Atypical Rapid Onset of Olmesartan-Induced Enteropathy with Recurrence After Rechallenging

Abstract

Background: Olmesartan-induced enteropathy is a rare complication of a widely used angiotensin II receptor blocker. Patients usually present with chronic diarrhea and weight loss. Histologically, villous atrophy and intraepithelial lymphocyte infiltrates within the duodenum confirm the diagnosis. The prognosis is usually good after withdrawal of the offending drug.

Case presentation: Here, we report the case of a 76-year-old woman who developed a severe form of Olmesartan-induced enteropathy complicated by acute kidney injury and acute recurrence after drug rechallenge. After definite cessation of the drug, the patient did not experience any gastrointestinal (GI) symptom recurrence after 6 months of follow-up. However, she experienced chronic kidney disease stage G3b. Histological analysis did not show any villous atrophy or intraepithelial lymphocyte infiltrates within the duodenum or the colon biopsy.

Discussion and conclusion: This case highlights the broad spectrum of clinical manifestations and histological findings in Olmesartan-induced enteropathy. It also highlights the importance of rapid diagnosis in order to limit organ damage such as chronic kidney disease.

Keywords: acute kidney injury; diarrhea; enteropathy; olmesartan.

Figure 1

Histological findings within the duodenum and the colon. Panel (A): Duodenal biopsy fragment (hematoxylin and eosin stain, 5× magnification), showing non-atrophic duodenal mucosa, without evidence of intraepithelial lymphocytosis or significant increase in the inflammatory infiltrate. Panel (B): Duodenal biopsy fragment (hematoxylin and eosin stain, 10× magnification), showing non-atrophic duodenal mucosa, without evidence of intraepithelial lymphocytosis or significant increase in the inflammatory infiltrate. White arrow shows the presence of Brunner’s glands outside the submucosa. Panel (C,D): duodenal biopsy fragment (hematoxylin and eosin stain, 10× magnification), showing non-atrophic duodenal mucosa, without evidence of intraepithelial lymphocytosis or significant increase in the inflammatory infiltrate. White arrow shows the presence of Brunner’s glands outside the submucosa. Panel (E): Colon biopsy (hematoxylin and eosin stain, 10× magnification) showing no significant increase in the inflammatory infiltrate colonic mucosa. A focal lymphoid aggregate is observed, which may be seen under physiological conditions depending on the biopsy site. There is no increase in intraepithelial lymphocytes and no thickening of the basement membrane.

Figure 2

Time course of serum creatinine levels (blue bars) in relation to exposure to olmesartan. The green area represents the normal serum creatinine range. Orange arrows represent the two hospitalization periods in the nephrology department.

Figure 3

Hypothetical pathophysiology of olmesartan-induced enteropathy.