A 61-year-old woman with multiple previous hospital admissions for episodes of gastrointestinal bleeding, with a history of mitral valve disease with prosthetic valve replacement and on treatment with acenocoumarol. In April 2011, she was admitted for intestinal bleeding of unaffiliated origin and severe iron deficiency anaemia, a gastroscopy and capsule endoscopy were performed without significant findings, after which it was decided to reduce the INR range to 2.5-3. Two months later, he presented a new episode of intestinal bleeding, after which a capsule endoscopy was performed again, showing the existence of intestinal angiodysplasias in the duodenal antrum, proximal jejunum and terminal ileum, with no evidence of bleeding from any other cause. He was subsequently admitted three times for the same reason, requiring multiple units (U) of red blood cell concentrates. Enteroscopy was performed orally up to the middle jejunum, during which no angiodysplasias were found, and it was impossible to assess the existence of ileal angiodysplasias.
At the last admission she had a haemoglobin of 10.5 g, with a haematocrit of 0.340 L/L and a mean corpuscular volume of 25.7 pg. After this new episode, and the episodes of bleeding persisted, with no clear lesions to perform other measures such as electrofulguration or surgery, it was decided to use thalidomide, at a dose of 50 mg daily, as a drug for compassionate use, following the patient's handwritten authorisation. The patient was asymptomatic for three months, with haemoglobin levels of 124 g/L and a negative faecal occult blood test over time.
After this period, she was admitted for a significant deterioration of her general condition, with dyspnoea on minimal effort, orthopnoea, malleolar oedema and no chest pain. Urgent echocardiography was requested and was reported as severe pulmonary hypertension with a PSAP (pulmonary artery systolic pressure) of 100mmHg, (prior to the start of thalidomide treatment, the patient had a PSAP of 26mmHg measured by ultrasound) and a study was performed to rule out pulmonary thromboembolism, with negative D-dimer and angiographic tomography.
There was no evidence of other causes for the elevated PSAP, so the drug was discontinued and treatment was started with monthly lanreotide.