SUNY Downstate Health Science University Brooklyn, NY
Tian Li, MD, MS, Mohamed Kahila, MD, Mouyed Alawad, MD; SUNY Downstate Health Science University, Brooklyn, NY
Introduction: Mycophenolate mofetil (MMF) is an immunosuppressive drug widely used in organ and bone marrow transplant recipients as well as in autoimmune disorders like systemic lupus erythematosus(SLE). Gastrointestinal side effects occur in about 45% of patients using MMF, manifesting as nausea, vomiting, diarrhea, and abdominal pain. Here we illustrate a case of diffuse colitis induced by MMF diagnosed by colonoscopy and histology.
Methods: 55-year old woman presented to hospital due to asymptomatic severe anemia. She reported having increased flatus and abdominal bloating for the past three weeks but denied any abdominal pain, weight changes, hematochezia, melena or hematuria. Past medical history were hypertension, diabetes mellitus, SLE and lupus nephritis requiring hemodialysis. One month prior to her presentation she experienced a flare of lupus nephritis that was managed with prednisone and MMF. Vital signs and physical exams were unremarkable. Complete blood count showed severe anemia with hemoglobin at 4.6 g/dL, normal MCV 86.9 fL and increased RDW 16.4% and normal white cells and platelet counts, indicative of normocytic anemia. Comprehensive metabolic panel were significant for increased BUN 41 mg/dL and creatinine 6.12 mg/dL with decreased total bilirubin level 0.2 mg/dL. Fecal occult blood test was negative and no blood in urine. Upper endoscopy showed chronic gastric ulcer and duodenitis without hemorrhage or perforation. Colonoscopy demonstrated the entire colon appeared inflamed, edematous and erythematous mucosa with loss of vascularity. Histopathologic exam revealed pan-colonic crypt architectural distortion with increased apoptotic bodies with endocrine cell hyperplasia and focal cryptitis (Figure A-B), which were indicative of MMF induced colitis. Subsequently, MMF was discontinued resulting in improvement and resolution of the patient’s symptoms. Discussion: MMF-induced colitis is an uncommon however debilitating complication with only few case reports and no current guidelines in the literature. Histologic features of MMF-induced colitis include crypt architectural distortion, inflammatory cell infiltration, lamina propria edema and increased crypt epithelial apoptosis, which can mimic ischemic colitis, inflammatory bowel disease or graft-versus-host disease. Colitis is seen in around 9% of patients on MMF. Discontinuing MMF leads to spontaneous resolution of symptoms.
Colonoscopy images showing the entire colon appeared inflamed; the mucosa was edematous and erythematous with loss of vascularity (A). Hematoxylin and eosin stain (original magnification x 400) showing crypt architectural distortion with increased apoptotic bodies (B: red arrows).
Disclosures: Tian Li indicated no relevant financial relationships. Mohamed Kahila indicated no relevant financial relationships. Mouyed Alawad indicated no relevant financial relationships.