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Communications to the Editor |

Carcinoid-Related Intrapulmonary Shunting May Be Associated With Increased Production of Nitric Oxide FREE TO VIEW

Shinji Teramoto, MD, FCCP; Takeshi Matsuse, MD; Yasuyoshi Ouchi, MD
Author and Funding Information

Tokyo University Hospital Tokyo, Japan

Correspondence to: Shinji Teramoto, MD, FCCP, Department of Geriatric Medicine, Tokyo University Hospital, 7–3-1 Hongo Bunkyo-ku, Tokyo, Japan 113-8655



Chest. 1999;116(6):1838. doi:10.1378/chest.116.6.1838
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To the Editor:

In a recent issue of CHEST, Lee and Lepler (April 1999)1 rationally discussed the mimicking of hepatopulmonary syndrome (HPS) by the severe intrapulmonary shunting that is caused by carcinoid syndrome.

HPS is caused by hypoxemia in patients with chronic liver diseases in the absence of intrinsic lung disease,2and so carcinoid-related intrapulmonary shunting and hypoxemia are not exactly the same as HPS. However, HPS may occur secondary to a functional right-to-left shunt because of intrapulmonary vascular dilatation.3Thus, the shunting in that situation may mimic the pathogenesis of HPS in carcinoid syndrome. Furthermore, recent evidence suggests that nitric oxide (NO) is an important mediator of impaired oxygenation in patients with cirrhosis (ie, HPS).5 The increased production of NO by metastatic carcinoid tumors in the lung may be another cause of extraordinary vasodilation and intrapulmonary shunting, resulting in severe hypoxemia in carcinoid syndrome.

Patients with carcinoid syndrome are known to produce the vasoconstrictor 5-hydroxytryptamine. However, NO, a major vasodilator, also may be produced in patients with carcinoid syndrome.6 Although carcinoid-related pulmonary shunting may be responsible for hypoxemia in the case of the patient reported by Lee and Lepler who has metastatic carcinoid tumors, the pathogenic mechanism of severe hypoxemia may not be simple in carcinoid syndrome. Because many neurohumoral vasoactive substances can be released by tumors, the complex regulatory mechanism may work in the lungs of the patients. Further analysis of vasodilators and vasoconstrictors may be important to elucidate the mechanism of hypoxemia in the carcinoid syndrome.

References

Lee, DF, Lepler, LS (1999) Severe intrapulmonary shunting associated with metastatic carcinoid.Chest115,1203-1206. [PubMed] [CrossRef]
 
Krowka, MJ, Cortese, DA Hepatopulmonary syndrome: current concepts in diagnosis and therapeutic considerations.Chest1994;105,1528-1537. [PubMed]
 
Whyte, MK, Hughes, JM, Peters, AM, et al Analysis of intrapulmonary right to left shunt in the hepatopulmonary syndrome.J Hepatol1998;29,85-93. [PubMed]
 
Teramoto, S, Matsuse, T, Ouchi, Y Nitric oxide and impaired oxygenation before and after liver transplantation [letter]. Ann Intern Med. 1999;;131 ,.:69. [PubMed]
 
Rolla, G, Brussino, L, Colagrande, P, et al Exhaled nitric oxide and oxygenation abnormality in hepatic cirrhosis.Hepatology1997;26,842-847. [PubMed]
 
Hansen, MB, Dresner, LS, Wait, RB Profile of neurohumoral agents on mesenteric and intestinal blood flow in health and disease.Physiol Res1998;47,307-327. [PubMed]
 

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Tables

References

Lee, DF, Lepler, LS (1999) Severe intrapulmonary shunting associated with metastatic carcinoid.Chest115,1203-1206. [PubMed] [CrossRef]
 
Krowka, MJ, Cortese, DA Hepatopulmonary syndrome: current concepts in diagnosis and therapeutic considerations.Chest1994;105,1528-1537. [PubMed]
 
Whyte, MK, Hughes, JM, Peters, AM, et al Analysis of intrapulmonary right to left shunt in the hepatopulmonary syndrome.J Hepatol1998;29,85-93. [PubMed]
 
Teramoto, S, Matsuse, T, Ouchi, Y Nitric oxide and impaired oxygenation before and after liver transplantation [letter]. Ann Intern Med. 1999;;131 ,.:69. [PubMed]
 
Rolla, G, Brussino, L, Colagrande, P, et al Exhaled nitric oxide and oxygenation abnormality in hepatic cirrhosis.Hepatology1997;26,842-847. [PubMed]
 
Hansen, MB, Dresner, LS, Wait, RB Profile of neurohumoral agents on mesenteric and intestinal blood flow in health and disease.Physiol Res1998;47,307-327. [PubMed]
 
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