Stricturing Crohn's disease-like colitis in a patient treated with belatacept

Abstract

Cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) modifying agents have been involved in the development of intestinal inflammation, especially therapeutic monoclonal antibodies directed against CTLA-4. Here we report the appearance of a severe stricturing Crohn's disease-like colitis in a patient with a kidney allograft who was treated with belatacept, a recombinant CTLA-4-Ig fusion protein.

Keywords: Belatacept; Colitis; Crohn’s disease; HHV-6; Inflammatory bowel disease.

Figure 1

Endoscopic finding before and after withdrawal of belatacept. The first colonoscopy showed the presence of disseminated ulcers on the colonic mucosa (A) with more severe lesions at the left colonic flexure (B). The patient was still on mycophenolate mofetil and belatacept. After mycophenolate withdrawal and continuation of belatacept, the second colonoscopy showed the persistence of disseminated ulcerations (C) and a worsening of lesions at the left colonic flexure with appearance of an inflammatory ulcerated stricture (D). Five months after belatacept withdrawal, follow up colonoscopy showed complete healing of disseminated ulcerations in the left colon (transverse and right colon were not visualized due to the stricture, (E) and healing of the left colonic flexure with persistence of a non-inflammatory stenosis (F) which did not allow passage of the colonoscope.

Figure 2

Histologic findings of belatacept-induced colitis. A: Histologic examination of colonic biopsies showed acute colitis with ulcerations, crypt abscesses, lymphocytes and neutrophil polymorphonuclear leukocyte infiltration. Neither crypt dystrophy nor granuloma was found; B: After belatacept withdrawal, colonic biopsies showed complete healing of the mucosa with no signs of chronic mucosal inflammation.