Acute myocardial infarction following thalidomide treatment for AIDS-related ulcers.

Abstract

Thalidomide has been successfully used for two decades in HIV-positive patients to treat oral and oesophageal ulcers [1]. Mechanisms of action likely involve immunomodulatory effects, probably relating to inflammatory cytokines such as tumour necrosis factor α [2]. Typical complications include dizziness, peripheral neuropathy and neutropenia [2]. In addition, an increased risk of thromboembolic events, mainly deep vein thrombosis, has been described in individuals treated with thalidomide for multiple myeloma, highlighting the need for early antithrombotic prophylaxis in such patients [3]. We present the case of a 33-year-old HIV-positive patient who received, after informed consent, thalidomide (Thalidomide; Celgene, Paris, France) 100 mg daily for recurrent, debilitating and painful oesophageal and oral ulcers, associated with a wasting syndrome. No malignant or infectious causes were identified after serial endoscopic oesophageal biopsies and empirical antiviral therapy with aciclovir and valganciclovir showed no improvement leading to the diagnosis of HIV-related ulcers. Patient viral load and CD4+ cell count were 64 copies/ml and 4 cells/μl, respectively. Twenty-two days after initiation of thalidomide, the patient presented a cardiac arrest due to ventricular fibrillation. After successful resuscitation and restoration of sinus rhythm, an electrocardiogram demonstrated signs of myocardial infarction with ST elevation. Coronary angiography revealed a unique subocclusive thrombotic mass in the proximal right coronary artery (Fig. 1) despite the absence of atherosclerosis. This was successfully managed with mechanical thromboaspiration and an implanted, absorbable, prosthetic stent.Fig. 1: Coronarography of the right coronary artery.Presence of a sub-occlusive thrombotic mass in the proximal portion of the artery.Patient's medical history showed a smoking history of 5–10 pack-years with no additional cardiovascular risk factors. Other medications at the time of the event were darunavir/ritonavir, amoxicillin-acid clavulanate (initiated 3 days before), fluconazole, pantoprazole, morphine sulphate, filgrastim and azithromycin. Trials on the effect of thalidomide on oral and oesophageal ulcers in HIV-positive individuals have historically been performed on relatively small numbers of patients. Data about safety of use in this population are scarce and date from several years ago [1], although there have been increasing off-label uses in the treatment of immune reconstitution inflammatory syndrome [4]. Moreover, chronic HIV infection itself is associated with a heightened risk of coronary heart disease [5]. The present case highlights that indications of thalidomide should be carefully considered in this population and that antiaggregation therapy should be considered when starting thalidomide treatment in HIV-positive patients, as usually recommended in patients with multiple myeloma [3]. Acknowledgements Conflicts of interest There are no conflicts of interest.