Cardiovascular autonomic insufficiency in a patient with metastatic malignancy

A case of cardiovascular autonomic insufficiency is described in a cachectic 70-year-old man with widely metastatic small-cell tumor. The patient experienced disabling syncopal episodes in association with severe postural hypotension. Tests of cardiovascular autonomic insufficiency were abnormal. The introduction of fludrocortisone and the use of elastic stockings produced palliation of the symptomatology, but his condition deteriorated and he died. Autopsy demonstrated unexpectedly extensive tumor invasion of autonomic nervous tissue. Although cardiovascular autonomic insufficiency (CAI) has been described in association with malignancy and malnutrition, local tumor invasion of autonomic nervous tissue and radiation injury may have been other possible, albeit unusual, etiologic factors. This case illustrates the differential diagnosis of hypotension and CAI in patients with advanced metastatic malignancy and also emphasizes the need for autopsy studies when speculating as to the cause of CAI in this group of patients.