1. Curious Case of Wheezing: Carcinoid Heart Disease
Dhaval Desai, MD, M. Fuad Jan, MBBS, MD, Nataly Stenzel, APNP, Paul Werner, MD, A. Jamil Tajik, MD 
The American Journal of Medicine 
Volume 130, Issue 5, Pages e177-e180 (May 2017)
DOI: /j.amjmed
Copyright © 2017 Elsevier Inc. Terms and Conditions

2. Figure 1
(A) Transthoracic echocardiogram apical 4-chamber view showed thickened and retracted tricuspid valve leaflets in a semi-open position (arrowheads). (B) Right ventricular focused view shows mildly enlarged right ventricle. (C) Color flow imaging revealed severe tricuspid regurgitation toward the septal tricuspid valve leaflet. (D) Continuous-wave Doppler interrogation of tricuspid regurgitation revealed a peak velocity of 3 m/s with a rapid taper (white arrows) indicative of high right atrial pressures. Tricuspid in-flow velocities are increased (white arrowheads) with a gradient of 7 mm Hg due to fixed semi-open tricuspid valve leaflets and increased diastolic flow because of severe tricuspid regurgitation. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
The American Journal of Medicine  , e177-e180DOI: ( /j.amjmed )
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3. Figure 2
(A) Liver ultrasound was obtained to evaluate for sequelae of carcinoid heart disease. It revealed multiple, rounded, hyperechoic lesions (arrows). (B) Magnetic resonance imaging of the abdomen with contrast showed multiple solid lesions with spoke-wheel enhancement, raising the suspicion for metastatic carcinoid disease.
The American Journal of Medicine  , e177-e180DOI: ( /j.amjmed )
Copyright © 2017 Elsevier Inc. Terms and Conditions

4. Figure 3
(A) Fluorodeoxyglucose-positron emission tomography of the whole body was performed to help identify the primary location of the neuroendocrine tumor. Focal fluorodeoxyglucose accumulation of approximately 3.1 × 3.1 cm (arrow) was localized near the ileocecal valve (arrow). (B) Colonoscopy-directed biopsy of the mass near the ileocecal valve confirmed the diagnosis of neuroendocrine tumor. The pathology slide shows fragments of intestinal mucosa containing nests of bland cells in the mucosa and submucosa containing uniform, round nuclei with “salt and pepper” chromatin (arrowheads), morphologically consistent with a carcinoid tumor.
The American Journal of Medicine  , e177-e180DOI: ( /j.amjmed )
Copyright © 2017 Elsevier Inc. Terms and Conditions

5. Figure 4
(A) The patient underwent surgery for tricuspid and pulmonic valve replacement. An intraoperative image of the in situ pulmonic valve shows thickened and retracted leaflets (arrow). (B) An excised tricuspid valve shows thickened, rough leaflet that is pronounced more at the tips of the leaflet (arrow). (C) Hematoxylin and eosin stain of the valve leaflet shows the surface of the valve covered with a proliferation of bland spindle cells (stained blue), which are induced by the carcinoid tumor, consistent with myofibroblasts.
The American Journal of Medicine  , e177-e180DOI: ( /j.amjmed )
Copyright © 2017 Elsevier Inc. Terms and Conditions