Journal of The Association of Physicians of India Vol.

63 November 2015

69

Atypical Bronchial Carcinoid Masquerading as Bronchial Asthma

V Rajendran1, Iqbal2, Vinod Kumar3
noted. Patients skin showed suggestion
of flushing though she was dark.

Abstract
A case study of 35-year-old woman with persistent breathlessness and wheezing
that had been unsuccessfully treated with inhaled beta 2-agonists and steroids for
about two years. Patient developed dry cough and haemoptysis, so investigated
further. Spirometry demonstrated a restrictive pattern. Chest CT demonstrated
well defined hyperdense lesion in right middle lobe. Biopsy taken from the mass
during bronchoscopy demonstrated the picture of atypical bronchial carcinoid.
In this case, due to the lack of awareness, diagnosis of carcinoid was delayed by
two years.

Introduction

arcinoid tumors are malignant

neuro endocrine tumors arising
from kulchitsky cell. Most common site
of carcinoid tumors is GI tract (64%)
next is being respiratory tract (28%).
Bronchial carcinoids accounts for 1-2
% of all lung malignancies. Male and
female are equally affected with mean
age of presentation is 40 years.
It is a very slow growing tumor
hence called cancer in slow motion.
Bronchial carcinoids are frequently
d i s c o ve r e d a s a l e s i o n o n a c h e s t
radiograph and 31% of the patients are
asymptomatic. Based on microscopic
appearance they are called typical
carcinoid when less than two mitosis
present after ten high power field
examination and without areas of
n e c r o s i s . At y p i c a l c a r c i n o i d s a r e
diagnosed when more than ten mitosis
detected after ten high power field
examinations or by the presence of
necrosis. WHO classification includes
four general categories: typical
carcinoid, atypical carcinoid, large

cell neuroendocrine carcinoma, small

cell carcinoma. Typical and atypical
categories are not related to tobacco
use but not the other two. Prognosis
is excellent for typical carcinoids and
poor for small cell carcinoma.

Case Report
A 35- year-old female admitted with
breathlessness and wheezing for about
two years, cough and 6 to 7 episodes
of haemoptysis for two months. This
wheezing had no correlation with
physical exertion. She was treated
as a case of Bronchial asthma with
bronchodilators and steroids, both oral
and inhaled.
On Physical examination patient
was found to be moderately built and
nourished, blood pressure was 130/80
mm Hg, Pulse rate was 86 per minute,
Respiratory rate was 18 per minute.
Breath sounds and vocal resonance
were decreased over right axillary and
infra-axillary areas. Bilateral wheeze

Fig. 2: CT showing tumor

Chest x-ray demonstrated a well

defined opacity in the right lower
zone (Figure 1). CT chest revealed a
mass lesion involving Right middle
lobe (Figure 2 and 3). Staging work up
done. No evidence of distant metastasis
detected.
Pulmonary function tests revealed
r e s t r i c t i ve p a t t e r n . B r o n c h o s c o p y
revealed right sided endobronchial
growth. Biopsied specimen
demonstrated atypical carcinoid tumor
by histopathological examination.
Patient underwent middle lobectomy
(Figures 4). Histopathological
examination of resected specimen
confirmed atypical carcinoid tumor
(Figure 5).

Discussion
Bronchial carcinoids accounts for
1-2% of primary lung tumors may be
located centrally as endobronchial
carcinoid and present asymptomatically
or produce wheeze, haemoptysis,
post-obstructive pneumonitis.
Peripherally located carcinoids occurs
asymptomatically or scarring in

Fig. 3: CT showing tumor

Associate Professor of Medicine, 3Post Graduate, Department of Medicine, KAPV Medical College and Mahatma Gandhi Memorial
Government General Hospital (MGMGH), Trichirapalli; 2Post Graduate, Department of Medicine, Thanjavur Medical college,
Thanjavur, Tamil Nadu
Received: 03.02.20914; Revised: 22.08.2014; Accepted: 23.09.2014
1

Fig. 1: Preoperative CXR

Hematological investigations
revealed haemoglobin 9.2 gms/dl, total
leucocyte count 12000 (P-66, L-30, E-4),
platelet count 2 lac/cu.mm, ESR 8 mm
at the end of one hour. Urea 34 mgs/
dl, creatinine 0.9 mgs/dl, random blood
sugar 112 mgs/dl.

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Journal of The Association of Physicians of India Vol. 63 November 2015

octreotide or lantreotide and interferon

alpha.

Conclusion

Fig. 4: Gross appearance

nature. Carcinoids may present as

multiple tumorlets producing airway
fibrosis leading to severe obstructive
lung disease. All carcinoid tumors
do not cause carcinoid syndrome.
The reason is even though high
level of neuropeptide and amine are
synthesized they may not be released
in enough high quantity or due to
defective chemical nature. Clinical
features of carcinoid syndrome includes
flushing, watery diarrhea, wheeze,
asthma-like symptom, pellagra-like
skin lesion and retroperitoneal fibrosis,
Peyronies disease commonly seen in
those with liver metastasis or tumors
outside the gastrointestinal tract like
ovarian or lung carcinoids.
In chest X-ray bronchial carcinoids
manifests as solitary pulmonary nodule

Fig. 5: Microscopic appearance

or calcified nodule in 40%, infiltrations

in 60% of cases. CT and somatostatin
receptor scintigraphy localizes
metastatic deposits in liver. MRI shows
high signal intensity in T2 weighted
images. Serum chromogranin-A level
correlates with tumor bulk. Plasma
NSE, platelet serotonin and urinary
5HIAA (typical carcinoid), 5HTP and
5HT (atypical carcinoid) supports the
diagnosis.
Typical carcinoids are treated by
surgical resection of tumour, atypical
carcinoids require lobectomy and
lymphnodal dissection. Cisplatin and
etoposide based chemotherapy used in
unresectable tumors. Liver metastasis
treated by chemo embolisation using
5-flurouracil, doxorubicin and cisplatin.
Carcinoid sy ndrome is t reat ed b y

This case is a good example of

masquerading of a rare disease as a
common illness. Extended clinical
diagnosis, including computed
tomography and bronchoscopy,
should be considered in all cases of
bronchial asthma or chronic obstructive
pulmonary disease which do not
respond to standard treatment.

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