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Ipilimumab/nivolumab Haemorrhagic gastritis: case report

A 37-year-old woman developed haemorrhagic gastritis during treatment with ipilimumab and nivolumab for stage-IV metastatic melanoma [routes, doses, duration of treatments to reaction onset and outcome not stated]. The woman, who had stage-IV metastatic melanoma of the lung, liver, bone and brain, had previously received unspecified chemotherapy, followed by a single-agent nivolumab with disease progression. These was followed by combination therapy with ipilimumab and nivolumab, after which she presented to clinic with complaints of nausea, vomiting and inability to tolerate oral intake. She had received a total of four doses of nivolumab monotherapy with unspecified systemic chemotherapy every 4 weeks. Then, she was switched to combination therapy of nivolumab and ipilimumab every 4 weeks and received a total of two doses of combination therapy prior to the symptom onset. She also had mild epigastric discomfort. The woman received treatment with ondansetron, lorazepam, and prochlorperazine, which led to mild improvement of symptoms. She was not receiving any proton pump inhibitor and had never previously had an upper endoscopy or colonoscopy. Family history was unremarkable for GI malignancy. Her vital signs and physical examination were within normal limits. Laboratory testing was within normal limits without evidence of anaemia or leucocytosis. Abdominal and pelvic CT scan showed no inflammatory process or obstructive bowel pattern to explain her symptoms. Upper endoscopy showed a normal-appearing oesophagus, patchy haemorrhagic and inflamed mucosa with exudate in the gastric antrum and prepyloric region and normalappearing duodenum. A pathological review of the gastric biopsies showed gastric mucosa with severe chronic active gastritis with increased intraepithelial lymphocytosis with evidence of increased apoptotic activity consistent with checkpoint inhibitor-induced gastritis (haemorrhagic gastritis). Helicobacter pylori and viral immunostaining were negative. She started receiving prednisone with resolution of symptoms at the follow-up. She continued receiving prednisone taper. A repeat upper endoscopy 66 weeks later showed significant improvement with resolution of antral and prepyloric inflammation. Bazarbashi AN, et al. Combination checkpoint inhibitor-induced hemorrhagic gastritis. ACG Case Reports Journal 7: No. 6, Jun 2020. Available from: URL: http:// doi.org/10.14309/crj.0000000000000402

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Reactions 21 Nov 2020 No. 1831