A195 A RARE CAUSE OF SEVERE REFRACTORY DIARRHEA IN A PATIENT WITH COMMON VARIABLE IMMUNE DEFICIENCY ASSOCIATED INTESTINAL ENTEROPATHY

Background

CVID is the most common type of severe antibody deficiency. Gastrointestinal manifestations affect approximately 20–50% of patients. Boland et al. described in a case series that 2/3 CVID patients were able to achieve clinical and endoscopic remission with Vedolizumab. This α4β7 integrin antagonist inhibits intestinal T cell translocation by blocking integrin interactions with mucosal vascular addressin cell adhesion molecule 1, reducing lymphocyte mediated inflammation. However, despite its novel use for this indication, limited data is available on the consequences of this therapy in patients with CVID.

Aims

To report on a case assessing the efficacy and outcomes of Vedolizumab for the treatment of CVID associated autoimmune enteropathy.

Methods

We present the case of a 50-year-old male presenting with severe refractory diarrhea and malnutrition. A colonoscopy demonstrated patchy ulceration and biopsies revealed ulcerated active colitis, negative for CMV. He was treated with Vedolizumab and Total Parental Nutrition (TPN). His diarrhea resolved, he gained 20 kg and he was weaned off TPN. In 2019, he re-presented with severe diarrhea. Subsequently endoscopic evaluation revealed patchy edematous colonic mucosa and biopsies demonstrated minimally active colitis, negative for CMV. He again responded to Vedolizumab re-induction, however shortly after, his diarrhea returned aggressively. CT enterography demonstrated active jejunal inflammation. Subsequently, an EGD revealed multiple duodenal ulcers and luminal narrowing. Biopsies of the small bowel were sent to histopathology.

Results

CMV superinfection was diagnosed on pathology (image 1). This patient’s diarrhea completely resolved with IV Gancyclovir and he was discharged on maintenance treatment with oral Valganciclovir.

Conclusions

This represents the first reported case of CMV enteritis secondary to Vedolizumab for the treatment of CVID associated autoimmune enteropathy. In this case, clinical and endoscopic remission was observed with Vedolizumab, however subsequently hampered by CMV reactivation. Hommel et al., published a positive correlation in a single centre retrospective cohort study of CMV reactivation in patients with ulcerative colitis treated with Vedolizumab. A large retrospective review of data from a multicenter consortium database of over 1000 Vedolizumab treated IBD patients reported CMV colitis in only 4 patients. CMV reactivation appears to be an exceptionally rare but important event in patients treated with Vedolizumab. Based on this report, patients with CVID associated enteropathy and refractory diarrhea should be carefully screened for CMV when treated with Vedolizumab. Further prospective data assessing the incidence of CMV reactivation in patients with Vedolizumab therapy is required to further define these findings.

Funding Agencies

None

A234 CLINICAL, ENDOSCOPIC AND HISTOLOGICAL IMPROVEMENT IN COMMON VARIABLE IMMUNODEFICIENCY DISEASE ASSOCIATED ENTEROPATHY WITH VEDOLIZUMAB

Background

Common variable immune deficiency (CVID) can be associated with autoimmune manifestations including enteric inflammation and diarrhea. Systemic immunosuppression used in patients with inflammatory bowel disease (IBD) may be associated with increased risk of infection in CVID.

Aims

We report a patient with CVID associated intestinal enteropathy who underwent clinical, endoscopic and histological improvement after treatment with vedolizumab (IgG1 monoclonal antibody to α4β7 integrin), as well as a concurrent systematic review (SR) of the literature.

Methods

Case report and systematic literature review. We searched EMBASE, Medline, Cochrane CENTRAL, clinialtrials.gov, and the International Clinical Trials Registry Platform without language restriction using key words to identify patients with CVID associated enteropathy treated with vedolizumab. Clinical, endoscopic and histological outcomes were extracted and safety data.

Results

A 32-year-old male presented with weight loss, anemia and hypoalbuminemia on a background of chronic diarrhea and recurrent sinus infections. Serology and genetic testing was not consistent with celiac disease. Pan-endoscopy showed complete villous atrophy in the duodenum and biopsies showed and intraepithelial lymphocytosis (IEL) in the duodenum and terminal ileum. CT abdomen showed pan-enteritis with extensive mesenteric lymphadenopathy which were reactive on lymph node excision, as well as bronchiectasis. Pneumococcal vaccination challenge to assess humoral response confirmed CVID. After suboptimal response with steroids and mercaptopurine, treatment was initiated with vedolizumab 300mg IV at weeks 0, 2, and 6, then 8 weekly. This led to normalization of stool frequency, weight gain as well as endoscopic and histological resolution within 6 months of treatment. The SR yielded 101 studies of which 3 case series were identified reporting a total of 7 patients with CVID. In 5 cases there was clinical improvement, 4 reported endoscopic improvement and 3 patients had histologic improvement. No safety concerns associated with vedolizumab were reported.

Conclusions

Vedolizumab, a selective leucocyte inhibitor to the gut, was able to induce either clinical, endoscopic or histological improvement in 8 published cases in the worldwide literature. Prospective studies are needed to determine whether this treatment could be included in the therapeutic armamentarium for this orphan indication.

Funding Agencies

None

A87 A NEW ERA: CIRCUMFERENTIAL ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY ESOPHAGEAL NEOPLASM AND BARRET’S ERADICATION

Background

Endoscopic submucosal dissection (ESD) has become increasingly important over the last few years as the treatment of choice for early gastrointestinal malignancies. Esophageal adenocarcinoma is among the most rapidly rising malignancies associated with a poor 5-year survival rate. ESD is emerging as a novel minimally invasive treatment for superficial esophageal neoplasms. However, with increasing circumference of dissection, the rate of stricture increases with over 90% stricture rate reported with complete circumferential ESD (cESD). Currently, for superficial Barrett’s neoplasms the dysplastic lesion is resected and subsequent eradication of remaining Barrett’s is with radiofrequency ablation over multiple sessions.

Aims

To report on a case of cESD for intramucosal carcinoma and Barrett’s eradication with one procedure with the application of prophylactic dual steroid treatment (DST) for prevention of stricture.

Methods

We present the case of a 62-year-old female with C1M5 Barrett’s esophagus with pathology confirming high grade dysplasia with a focus suspicious for intramucosal adenocarcinoma. Staging CT excluded metastatic disease. Repeat endoscopy with magnification revealed multiple areas with highly irregular vascular and surface patterns with premature loss of acetowhitening reaction consistent with multifocal at least high-grade dysplasia. Subsequently, the entire segment of Barrett’s was removed via cESD. Histopathologic analysis of the resected tissue confirmed multifocal high grade disease with margins negative for dysplasia or intestinal metaplasia. The patient was started on DST with oral prednisone and topical (swallowed) budesonide along with sucralfate as prophylactic measures to prevent luminal stricturing.

Results

During the re-epithelization period the patient required 2 prophylactic dilations. Five months post-ESD, full clinical, endoscopic and histopathologic healing had been observed. There was complete squamous re-epithelization with normal squamous mucosa without stricture. The patient remains on a yearly endoscopic surveillance protocol.

Conclusions

cESD represents a novel therapeutic strategy for the definitive histologic and endoscopic eradication of superficial esophageal neoplasms along with remaining Barrett’s. In this patient, there were no complications and significant stricturing was prevented with DST. Multiple prior studies have assessed single steroid therapy as a therapeutic option for strictures. In this report, DST represents a novel regime in preventing severe strictures post cESD. Longer term follow-up and further reports are needed to confirm these findings.

Funding Agencies

None