Introduction: The last European guidelines for the ma-nagement of atrial fibrillation (AF) endorses new oral anticoagulants (NOAC)’s net clinical benefit and their major prognostic impact but at the same time points out the value of periodic follow-ups and the importance of patient-tailored management. Sometimes NOAC therapy brings to light a hidden pathology which can initially be a real issue but by early diagnosis can lead to a satisfactory medical outcome.
Methods: We present the case of a 78 year old female patient with post-partum hysterectomy, a favorable background for the early onset of autoimmune thyroiditis, osteoporosis, arterial hypertension and years later AF with ventricular extrasystoles (VE). Patient was admitted for persistent fatigue and dizziness, symptoms with onset approximately a week earlier.
Results: Clinical exam shows tachycardic arrhythmic heart beats and a lumbar ulcerated pigmented tumor. Arterial tension: 160/100 mmHg. The electrocardio-gram shows AF with high ventricular rate, left ventricular hypertrophy and ventricular bigeminism, doublets, triplets and 2 episodes of nonsustained ventricular tachycardia, completely asymptomatic. We initiate antiarrhythmic, antihypertensive and anticoagulant the-rapy. At home patient was discharged on Dabigatran. Two months later the patient presents to emergency room with ongoing lower gastrointestinal bleeding and rectal tenesmus. Clinical exam shows active bleeding from the lumber ulcerated tumor and the digital rec-tal exam identifies a near-circumferential tumor and fresh blood. Colonoscopy shows an infiltrative-ulcera-ted lesion that requires differential diagnosis between chronic inflammatory process and malignant rectal tumor. Anatomopathological exam determines chronic proctitis. The anatomopathological exam of the lumbar tumor reveals basal cell carcinoma. Repeated medical history explains the etiology of both rectal and lumbar lesions: overdose radiation therapy subsequent to post-partum hysterectomy. We reinitiate NOAC therapy with Apixaban due to its lower gastrointestinal blee-ding rate, with good outcome.
Conclusions: In our patient, with multiple comorbidities, each of them with chronic individual progress, without major breakdowns, symptoms came out after a necessary therapeutic action for an asymptomatic patient with AF. The odds for the independent evolution of 2 pathologies (chronic radiation proctitis and basal cell carcinoma), initially considered as both malignant and related because they were simultaneously triggered by the same factor (NOAC), are very low but it reflects the unpredictable evolution of a patient undergoing NOAC.