Case Presentation
A 42-year-old male Ethiopian patient presented to Yekatit 12 Hospital
Medical College with a two-day history of worsening of shortness of
breath, which followed multiple episodes of massive bilateral epistaxis.
He also noted light-headedness, dizziness, tinnitus, easy fatigability,
intermittent vomiting of ingested matter, generalized body swelling
which started from the legs, palpitation, orthopnoea and paroxysmal
nocturnal dyspnoea.
Further inquiry revealed history of bilateral nasal bleeding which
initially started 6 years back. Over time, the epistaxis became more
frequent and severe, sometimes bleeding up to 1 liter per episode. He
also had passage of black tarry stools for the last 7 months which was
first noticed after hospitalization. Before his current admission, he
was hospitalized 3 times in the last 2 years, with diagnosis of high
output heart failure secondary to severe anemia. On his last admission,
he received 5 units of packed red blood cells and was also given oral
iron, folic acid and proton pump inhibitors. His mother had epistaxis
through bilateral nostrils which started in her early adulthood. She
died of unknown cause at the age of 60.
Physical examination was significant for tachycardia (pulse rate of 106
beats per minute), pale conjunctivae and tiny erythematous lesions over
the dorsum of his tongue which blanch on pressure (Figure 1), bibasilar
lung rales, raised JVP, ejection systolic murmur at the apex, and
pitting leg edema.
Laboratory investigations revealed hemoglobin of 4g/dl (MCV 78fL), iron
studies revealed low serum iron level of 20ug/dl (reference range:
33-193ug/dl) and low ferritin level of 16.8ng/ml (reference range:
30-150ng/ml); liver enzymes and renal function tests which were with in
normal limits and normal coagulation profile. Peripheral blood smear
showed microcytic and hypochromic anemia. Chest x-ray revealed grade I
pulmonary edema and borderline cardiomegaly but echocardiography showed
signs of high output heart failure with ejection fraction of 70%. Upper
GI endoscopy showed multiple telangiectatic spots in the stomach and
duodenum oozing heme while colonoscopy showed pale mucosa with normal
vascular architecture (Figure 2). Abdominal ultrasound with doppler
study showed minimal bilateral pleural effusion and hepatic AV
malformations (Figure 3).