Wright Center for Graduate Medical Education Scranton, PA, United States
Khalid Ahmed, MD1, Ayla Benge, DO1, Abdul Ahad Ehsan Sheikh, MD2, Mohammad Asim Amjad, MBBS, MD1, Mladen Jecmenica, MD2, Beshir Saeed, MD1 1Wright Center for Graduate Medical Education, Scranton, PA; 2Wright Center for GME, Scranton, PA
Introduction: Immune checkpoint inhibitors (ICPI) are effective anti-cancer drugs that allow for better T-Cell mediated killing of cancer cells. ICPIs can be associated with immune-related adverse events (irAE). We present a case of celiac duodenopathy after initiation of Pembrolizumab which is scarcely reported in literature.
Case Description/Methods: A 79-year-old male with metastatic melanoma to the left distal humerus, on therapy with Pembrolizumab presented with nausea, vomiting and fatigue. The patient reported a sweet taste with dry mouth, hesitancy to swallow solids, loss of appetite and weight loss over a week. The symptoms began when he started Pembrolizumab. Initial labs were notable for TSH of 59 mIU/L, otherwise unremarkable. Anti-Thyroid Peroxidase antibody was negative. The patient was started on Synthroid 50 mcg daily. He eventually underwent an esophagogastroduodenoscopy (EGD) for persistent symptoms. EGD showed diffuse mucosal edema and scalloping-like erosions in the duodenum, with severe esophagitis and mild gastritis. Duodenal biopsy revealed lymphocytic infiltration of the small bowel mucosa associated with atrophy and blunting of the villous border at the lumen of the bowel mucosa, suggestive of celiac enteropathy. TTG and IgA antibodies were negative. The patient was started on steroids, and a gluten-free diet for suspected Celiac disease on biopsy findings resulting in improved symptoms.
Discussion: Cytotoxic T-lymphocyte antigen 4 (CTLA-4) and Programmed Cell Death 1 (PD-1) receptors are immune checkpoint receptors that inhibit T cell function. The advent of targeted pharmacotherapy against these receptors demonstrated efficacy in treating many cancer subtypes. Toxicities are related to autoimmune phenomena, termed “immune-related adverse events'' (irAEs). Studies illustrate that ICPIs cause systemic syndromes. Association between celiac disease and the use of Ipilimumab; a monoclonal antibody against CTLA-4 has been described in literature. Pembrolizumab, a monoclonal antibody to PD-1 receptors, has been shown to potentiate antitumor responses in patients with advanced melanoma. It has been revealed to cause abnormal thyroid functions. To our knowledge, there has not been a specific association between Pembrolizumab and Celiac disease, although T-cell and macrophage infiltration and antibody deposition has been hypothesized. We suspect that the use of Pembrolizumab potentiated the clinical presentation of Celiac disease without positive serological evidence.
Disclosures: Khalid Ahmed indicated no relevant financial relationships. Ayla Benge indicated no relevant financial relationships. Abdul Ahad Ehsan Sheikh indicated no relevant financial relationships. Mohammad Asim Amjad indicated no relevant financial relationships. Mladen Jecmenica indicated no relevant financial relationships. Beshir Saeed indicated no relevant financial relationships.
Khalid Ahmed, MD1, Ayla Benge, DO1, Abdul Ahad Ehsan Sheikh, MD2, Mohammad Asim Amjad, MBBS, MD1, Mladen Jecmenica, MD2, Beshir Saeed, MD1. P3027 - An Unusual Etiology of Celiac Duodenopathy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
