A 62-year-old retired machinist, known for his elaborate Christmas decorations, comes
to the emergency department after several weeks of unexplained flushing, pounding
palpitations, and watery diarrhea. His wife reports that in certain lighting - especially
when he is standing in front of the Christmas tree - his face and hands look greenish.
He has lost 5 pounds of weight since the onset of his symptoms. He states that his
flushing began the day after Thanksgiving and that the episodes have become more frequent,
now occurring nightly. He denies any recent travel, exposure to illness, or change
in his medications. He notes, however, that he has switched to a "festive herbal tea
blend" which he drinks four or five times a day during the holidays.
Pertinent findings on physical examination include a normal temperature, a heart rate
of 108 beats per minute, mild postural hypotension (BP changes from 134/80 sitting
to 102/68 mmHg standing), and a respiratory rate of 14 breaths per minute. His skin
is warm, dry, and exhibits a faint flushing. The remainder the examination is within
normal limits.
DIAGNOSIS: Carcinoid syndrome, worsened and unmasked by serotonin-rich holiday herbal tea.
This tea blend - sold as "Yuletide Harmony" contains stinging nettle, hibiscus, rosehip
and lemon balm. Two of these plants contain high levels of serotonin and serotonin
precursors. When he stopped drinking the tea and was placed on octreotide to treat
the tumor, which was suspected by documenting high levels of plasma serotonin and
24-hour urine 5-HIAA, and a CT of the abdomen showing a 1.8 cm enhancing mass in the
ilium. The tumor was surgically removed and confirmed histologically as a carcinoid
tumor. Following surgery and discontinuation of the tea, he became asymptomatic.