Medical College of Georgia Philadelphia, PA, United States
Award: Presidential Poster Award
Michael Coles, MD1, Victoria Madray, MD1, Amit Hudgi, MD1, Pooja Mude, MD1, Rohan Mundkur, BSc1, Isaac E. Perry, DO1, Humberto Sifuentes, MD1, John Erikson Yap, MD2 1Medical College of Georgia, Augusta, GA; 2Medical College of Georgia at Augusta University, Augusta, GA
Introduction: Monoclonal antibody therapies, such as Ixekizumab, specifically targeting IL-17 have shown to be an effective treatment modality for Psoriatic Arthritis. IL-17 inhibition has been implicated in compromised mucosal integrity of the bowel, and specifically perforation as in the following vignette.
Case Description/Methods: A 53-year-old Caucasian male with seropositive psoriatic arthritis on Ixekizumab presented to the ED with severe pleuritic pain after eating a boneless ham sandwich. In triage, he was tachypnic with an oxygen saturation of 98%. Physical exam was remarkable for supraclavicular crepitus. Labs were unremarkable. A CT thorax with contrast demonstrated pneumomediastinum of the neck (Figure 1AB). A small defect was seen within the posterior wall of the mid-thoracic esophagus consistent with perforation. EGD demonstrated a 3 cm esophageal tear in the distal esophagus with a normal mucosa (Figure 1C). Prior to presentation, the patient denied any instrumentation, retching, emesis, reflux, NSAID/antibiotic/potassium/iron supplement use. Additionally, he had no other signs or symptoms suggestive of underlying infection, malignancy or connective tissue disease. A 22 mm x 12 cm fully covered self-expanding metal stent was placed across the tear and deployed proximal to the gastroesophageal junction. Follow up CT revealed resolution of pneumomediastinum. The stent (Figure 1D) was removed 4 weeks later without complication. Biopsies taken of the esophagus were significant only for reactive squamous mucosa, without eosinophilic infiltration.
Discussion: IL-17 has multiple roles specific to the gut mucosa including promotion of epithelial integrity by regulating tight junction proteins, stabilizing inter-cellular connections, and preservation of mucosal homeostasis. These potential mechanisms may explain why IL-17 antagonism could lead to compromised mucosal integrity of the bowel, and predisposition to perforation. Review of the Federal Drug Administration Adverse Events Reporting System (FAERS) yields over 23 instances of perforation within the gastrointestinal tract associated to the use of IL-17 blockers since 2016. Follow-up screening for gastrointestinal symptoms is needed for patients on IL-17 inhibitors. This report and the predicted side effects of IL-17 blockade should prompt careful monitoring to preempt the risk of associated infection as well as the rare but serious risk of GI tract perforation.
Figure: 1A: Axial view of computed tomography with contrast of the head and neck demonstrating left lateral esophageal mucosal tear, demarcated with red arrow, and associated esophageal wall and subserosal emphysema.
1B: Sagittal view of Computed Tomography with contrast of the head and neck demonstrating esophageal tear in left lateral esophageal wall, demarcated by red arrow. Perpendicular to the arrow is a red line, 80.6mm in length, tracing the resultant pneumomediastinum superiorly through the retropharyngeal and into the bilateral carotid spaces.
1C: Endoscopic view of mucosal tear in esophageal left lateral wall, representing the site of perforation approximately 8 cm below the upper esophageal sphincter. The esophageal mucosa otherwise appears grossly normal.
1D: Endoscopic view of proximal end of the fully covered self-expanding metal stent (FCSEMS) deployed across the esophageal tear, proximal clips noted to be in place. Complete visualization impacted by presence of food debris.
Disclosures: Michael Coles indicated no relevant financial relationships. Victoria Madray indicated no relevant financial relationships. Amit Hudgi indicated no relevant financial relationships. Pooja Mude indicated no relevant financial relationships. Rohan Mundkur indicated no relevant financial relationships. Isaac Perry indicated no relevant financial relationships. Humberto Sifuentes indicated no relevant financial relationships. John Erikson Yap indicated no relevant financial relationships.
Michael Coles, MD1, Victoria Madray, MD1, Amit Hudgi, MD1, Pooja Mude, MD1, Rohan Mundkur, BSc1, Isaac E. Perry, DO1, Humberto Sifuentes, MD1, John Erikson Yap, MD2. P2430 - Esophageal Perforation in a Patient With Psoriatic Arthritis on Ixekizumab, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.