The Journal of the Arkansas Medical Society Med Journal April 2020 | Page 17

Case Study
by Joseph W. Fong MD 1 , Latha M. Achanta MD 2
2.
1
Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Ark.
Department of Internal Medicine, Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Ark.
Use of Thalidomide for Gastrointestinal
Angiodysplasia – Not So Uncommon Anymore
Abstract
We report a 67-year-old African American female
with extensive proximal small bowel arteriove-
nous malformations who developed GI bleed-
ing refractory to endoscopic treatments. Her GI
bleeding resolved after initiation of thalidomide.
Thalidomide is a known teratogenic drug with
suppressive action on tumor necrosis factor al-
pha and an effective inhibitor of angiogenesis,
which was shown to be efficacious in treatment
of gastrointestinal vascular malformations re-
fractory to other interventions.
colonoscopy. She reports no significant family
history. Her daily medications include amlodip-
ine/valsartan, insulin glargine, regular insulin
sliding scale, cinacalcet, sevelamer carbonate,
levothyroxine, lubiprostone, and simvastatin.
Socially, she is not currently married and denies
any smoking, alcohol, or illicit drug use history.
Per outside hospital records, esophagogastrodu-
odenoscopy (EGD) and colonoscopy showed no
obvious source of bleeding and noted only some
erosion in the stomach. Tagged RBC scan was
clindamycin and linezolid. She was transferred to
our facility for further management of GI bleed
and consideration for capsule endoscopy.
Upon arrival to our facility, patient was afebrile,
normotensive, with normal heart rate, and on
room air. Her abdomen was soft with no ten-
derness to palpation and normoactive bowel
sounds present. She had a left internal jugular
Quinton catheter in place. Capsule endoscopy
was performed, which showed multiple areas
of angioectasia and bleeding AVMs in the prox-
imal small bowel (Figure 1), and
the patient underwent single bal-
loon enteroscopy with argon plas-
Case
ma coagulation of multiple AVMs.
We present a 67-year-old Af-
Infectious disease was consulted
rican American female who
for MSSA bacteremia and the pa-
initially presented to an outside
tient was switched to cefazolin for
hospital stating that she was
a total course of six weeks. She
intermittently having dark, tar-
underwent work up for bacteremia,
ry stools for several months
which included removal and replace-
and started having fevers,
ment of the Quinton catheter and
chills, fatigue, and malaise for
trans-esophageal echocardiogram
two weeks. She was found
that revealed a mitral valve vegeta-
to be febrile to 102° F and
tion and perforation with moderate/
hypotensive with a hemoglo-
severe mitral regurgitation. Cardiol-
bin of 4. She was transfused,
ogy and cardiothoracic surgery were
started on broad spectrum
consulted for evaluation for possible
antibiotics, and admitted for
valve repair. The patient, however,
workup of GI bleed and sepsis.
continued to have melena during
her preoperative workup, therefore
She has a past medical his- Figure 1: Extensive AVMs and angioectasia in the jejunum with
cardiothoracic surgery was unable
tory significant for recurrent active bleeding noted on serial small bowel enteroscopy studies to perform mitral valve replacement
diverticulitis with perforation (TOP). Angiodysplasia of the jejunum (BOTTOM).
since anticoagulation would be contra-
requiring hemicolectomy with
indicated with continued GI bleeding.
ostomy placement with subsequent reversal 30 performed, which showed hemorrhage in colon Our GI consultants recommended subcutaneous
years ago, hypertension, hypothyroidism, insu- but again no obvious source of bleeding. She octreotide 100 mcg BID to decrease need for
lin-dependent type 2 diabetes, obstructive sleep continued to have melanotic stools and she re- transfusions. Capsule endoscopy was repeated
apnea, and end stage renal disease on hemodi- quired transfusions almost daily. Blood cultures and showed active bleeding in small bowel most
alysis. She was noted to have multiple arterio- grew methicillin-sensitive Staphylococcus aureus likely from small bowel AVMs with poor local-
venous malformations (AVMs) on a previous (MSSA), and her antibiotics were switched to IV ization. Most of the lesions were noted to be in
Volume 116 • Number 10
April 2020 • 233