Gastrointestinal bleeding and cutaneous nodules

A 58-year-old man with a past medical history of hepatitis C and hypertension was referred to Baylor University Medical Center to evaluate occult gastrointestinal bleeding with double-balloon endoscopy. Before coming to Baylor, he complained of fatigue, shortness of breath, and noted melena. Upper endoscopy and colonoscopy were unrevealing. Capsule endoscopy at the outside hospital suggested a proximal bleed in the small bowel. Imaging included an ultrasound that showed a 6-mm common bile duct with cholelithiasis and an angiogram with findings of a proximal jejunal blush suggestive of the site of bleeding. At the outside hospital, he had an initial hematocrit of 23% and received 3 units of packed red blood cells. While his hematocrit rose with the transfusion, it further declined during treatment with a proton pump inhibitor, and he remained symptomatic. The patient's past medical history included a right carotid artery aneurysm resulting in a cerebrovascular accident that limited the use of his right arm, as well as a hiatal hernia, benign prostatic hypertrophy, chronic lower back pain, arthritis, Horner's syndrome, and a right knee surgery. His medications included ondansetron, pantoprazole, lisinopril, tramadol, docu-sate, and diphenhydramine. The family history was positive for strokes and diabetes. On physical examination, he was noted to have multiple cherry angiomas on his right arm, as well as a 5-cm hyperpig-mented cafe-au-lait macule on his right neck, axillary freckling, and palpable, nontender nodules on his abdomen and extremities. Suspecting neurofibromatosis 1 (NF1), multiple Baylor physicians inquired about a history of this disease, and he denied any previous diagnosis or family history.