Talal Alkayali, MBBS, Ahmed I. Salem, MD, Juan Ricardo, MD, Bahaa Amer, MD, Cynthia L. Harris, MD
Florida State University / Sarasota Memorial Hospital, Sarasota, FL
Introduction: Pembrolizumab induces immune checkpoint inhibition of programmed cell death protein-1 (PD-1 inhibitors) in various malignancies. Toxicities have been described, including but not limited to, inflammatory reaction in any system, and infusion related side effects. We report a rare case of symptomatic lymphocytic gastritis after pembrolizumab treatment of vocal cord squamous cell carcinoma.
Case Description/Methods: 70 year old female with history of right true vocal cord squamous cell carcinoma status post excision and chemoradiation with cisplatin. Recurrence in 1 year to the anterior vocal cord prompted treatment with pembrolizumab. Patient suffered complete esophageal occlusion requiring multiple EGDs with dilatation, gastric tube placement, morphine and transcutaneous fentanyl analgesia. During pembrolizumab treatment she developed new onset nausea and vomiting, intolerance to feeding regimen for 3 weeks, and a 10 pound weight loss in 1 week but no change in bowel movements, melena, abdominal pain, or fever. Physical exam was significant for cachectic female, LUQ G-tube in situ with no erythema/discharge, no abdominal tenderness, rigidity, or organomegaly, normal bowel sounds, and normal rectal exam. Lab work up was not significant. EGD was performed showing diffuse erythematous mucosa in the entire examined stomach. Biopsy showed lymphocytic gastritis negative for metaplasia, dysplasia, or neoplasia with no H-Pylori or other infectious organisms. Patient was started on prednisone 60mg daily with slow taper, metoclopramide, ondansetron PRN, and pembrolizumab was stopped. GI symptoms improved significantly with resolution of emesis.
Discussion: Lymphocytic gastritis (LG) is a rare subtype linked with H-pylori infection, celiac, lymphoma, and medication side effect. Patient might be asymptomatic or exhibit dyspepsia, nausea, vomiting or weight loss. Work up includes EGD; however, endoscopic appearance can be nonspecific as patients might have erythema, erosions, nodules or normal appearing mucosa. Diagnosis is made when biopsies show intraepithelial lymphocytes with more than 25 in 100 epithelial cells. Recommended treatment is based on etiology and included removing the offending agent, H-pylori eradication and/or gluten free diet. Steroids are not usually considered in the treatment of LG, but they are proposed as first line therapy in treatment of PD-1 inhibitor related side effects (enteritis, colitis, etc). Our patient had good response to steroids as her LG was induced by PD-1 inhibitor.
Citation: Talal Alkayali, MBBS, Ahmed I. Salem, MD, Juan Ricardo, MD, Bahaa Amer, MD, Cynthia L. Harris, MD. P0898 - NOT YOUR USUAL GASTRITIS: A CASE REPORT OF PEMBROLIZUMAB-INDUCED LYMPHOCYTIC GASTRITIS. Program No. P0898. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.