Ben Byriel, DO, Megan J. Walker, MD, Monika Fischer, MD
Indiana University School of Medicine, Indianapolis, IN
Sclerosing Mesenteritis is a rare, non-neoplastic, inflammatory condition that affects the mesentery. It typically presents with a variety of gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and diarrhea, but is largely variable. It is often treated successfully with steroids, estrogen modulators, anti-purine metabolites, and other antineoplastic agents. However, due to the wide ranging side-effect profiles of these medications, treatment limitations can arise when these options are exhausted. This case is particularly interesting considering the depth of the treatment algorithm pursued, and the potential change in management of sclerosing mesenteritis for future patients.
A 45-year-old male presented with intermittent left upper quadrant pain with associated nausea, vomiting, and diarrhea. CT scan of the abdomen revealed diffuse central mesenteric stranding and lymphadenopathy. Histopathology of the mesentery revealed fatty necrosis and foamy histiocytes, consistent with a diagnosis of sclerosing mesenteritis. Over the course of years, the patient was treated with prednisone, azathioprine, colchicine, cyclophosphamide, and methotrexate, but had persistent symptoms and intolerable medication side effects. He was started on infliximab, enabling him to decrease his prednisone dose to 12.5 milligrams daily and had symptom free remission. Six months later, he developed mesenteric large B cell lymphoma and infliximab had to be discontinued. The patient went into remission after R-CHOP chemotherapy. Due to chronic prednisone use, he had developed osteoporosis, bilateral cataracts, and diabetes mellitus type 2. Faced with a lack of other pharmacologic options and concern for continued glucocorticoid usage, an off-label use of ustekinumab was pursued. The patient was induced with a 520 milligram dose IV and continued on 90 milligram dose SQ every 8 weeks, leading to complete resolution of his symptoms. The patient was able to be weaned to 10 mg of prednisone daily, his lowest in 15 years, and is continuing to wean the prednisone with help of endocrinology.
This case highlights successful utilization of infliximab and ustekinumab for steroid-dependent sclerosing mesenteritis. It may implicate the role of TNF-alpha and interleukins 12, 23 in the pathogenesis of the disease, and suggests alternative treatments to traditional pharmacologic therapy are available.
Citation: Ben Byriel, DO, Megan J. Walker, MD, Monika Fischer, MD. P0545 - SCLEROSING MESENTERITIS TREATED SUCCESSFULLY WITH USTEKINUMAB; AN OFF-LABEL USE OF INFLIXIMAB AND USTEKINUMAB. Program No. P0545. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.