CASE STUDY:

A 40 years old gentleman with the known case of systemic hypertension for 5 years on treatment with Telmisartan and Metoprolol, presented with semisolid consistency of stools 5 to 6 episodes per day for past 1 year. Initially he was treated with the Anti diarrheal, Luminal antibiotics in the first two OPD reviews. He was suggested to do stool tests including Stool routine microscopy, Fecal calprotectin and baseline bloods includes CBC, LFT, Thyroid profile and Serum electrolytes which were normal. CT abdomen revealed no abnormalities. Hence he was suggested to undergo endoscopy and colonoscopy as there was no symptomatic relief. OGD revealed mildly edematous mucosa in the D2. D2 biopsy was taken and sent for HPE reports. D2 biopsy revealed increased Intraepithelial lymphocytosis and partial villous blunting in D2 mucosa. Colonoscopy was normal.

In view of Sprue like histology patient was asked to do serum IgA Anti Tissue Transglutaminase Enzyme (TTG) test done to rule out celiac disease and it was negative. On reviewing the regular medication list patient was suggested to withhold Telmisartan. After cardiac consultation Calcium Channel Blockers were initiated in place of Telmisartan, patients’s diarrhoea improved over 1 month. He was able to tolerate gluten diet during this period. Hence, the diagnosis was Telmisartan associate sprue like enteropathy was concluded.

DISCUSSION:

Case reports have shown that the Angiotensin Receptor Blockers (ARB) induced Sprue Like Enteropathy (SLE) is a condition present with diarrhoea due to mucosal malabsorption. It affects both men and women equally. In general SLE presents with the symptoms like chronic diarrhoea associated with the weight loss in most cases and the other symptoms may include fatigue, nausea, vomiting, abdominal pain.

Increased CD8 + T cells and IL – 15 over expression in the duodenal epithelial cells has been noted to represent immune mediated injury (reference 1)

Immune injury is postulated to be the cause of Sprue Like Enteropathy as symptoms onset has a latent period of month to years after drug initiation. Insidious immune injury to the villi has been postulated as cause for delayed onset symptoms.

Upper GI scopy suggestive of villous atrophy has been noted in previous case reports (Eg : Scalloping which improves with withdrawal of drug ) (reference 2)

Duodenal histology in sprue like Enteropathy due to Angiotensin Receptor Blockers has been characterized to have increased Intestinal Intraepithelial lymphocytosis in 71% cases, Eosinophilic infiltrates in 50% cases (reference 3)

Increased number of cases of Sprue Like Enteropathy secondary to Angiotensin Receptor Blockers based therapies other than Olmesartan suggest that this adverse event is a class effect of sartans rather than a individual drug.

Discontinuation of treatment is most effective way to treat symptoms and also helps to confirm diagnosis.

ENDOSCOPIC FINDINGS IN OUR PATIENT

Image 1 : Mild edematous mucosa noted in the 2nd part of duodenum

Image 2 : Colonoscopy showed no significant abnormalities in mucosa upto terminal Ileum

PHOTOMICROGRAPHS – DUODENAL HPE

Image 3 : Increased Intraepithelial lymphocytes in D2

Image 4 : Partial villous blunting in the D2

CONCLUSION:

All sprue may not be celiac or tropical sprue. Drug induced Sprue need to be kept in the mind. Every prescription of the patient must be clearly scrutinized to find the possible offending agents in the case of Chronic diarrhoea.

This case report illustrates a dramatic improvement in the diarrhoea once Telmisartan was stopped.

Careful drug history helps in the diagnosis and treatment of Drug Induced Diarrhoea.

REFERENCES:

1. Cyrany J, Vasatko T, Machac J, Nova M, Szanyi J, Kopacova M. Letter: Telmisartan-associated enteropathy – is there any class effect? Aliment Pharmacol Ther. 2014;40(5):569–570. Doi: 10.1111/apt.12850. [PubMed] [CrossRef] [Google Scholar]
2. Solano-Iturri G, García-Jiménez N, Solano-Iturri JD, et al.. Olmesartan-associated sprue-like enteropathy: an emerging cause of drug-induced chronic diarrhea. Rev Gastroenterol Mex 2018;83:71–2. 10.1016/j.rgmxen.2017.03.009 [PubMed] [CrossRef] [Google Scholar]
3. Marhne Costett et al duodenal histology in SLE to ARB ,Italy, Diarrhoea and liver disease Journal, volume 53,issue 10,Oct 2021,Page 1262 – 1267

AUTHOR:

DR.M.A.Aravind,
Senior Consultant, Medical Gastroenterologist
Kauvery Hospital, Alwarpet,
Chennai

CO – AUTHOR:

A.Jennithau Joan of Arck,
Bsc.Physician Assistant intern,
Kauvery Hospital, Chennai