2774 Gastritis After Combination Ipilimumab and Nivolumab: A Rare Adverse Event After Immunotherapy

Abstract

INTRODUCTION: Immunotherapies are commonplace in the treatment of many neoplasms, and have an array of commonly reported toxicities. Among the reported gastrointestinal side effects, diarrhea and colitis are most frequently cited. However, there have only been a rare handful of reported cases of Immune-checkpoint modulator toxicity affecting only the upper GI tract. In this paper we report a case of Ipilimumab-Nivolumab associated Gastritis in a patient treated with these medications at our facility. CASE DESCRIPTION/METHODS: The patient is a 78-year-old male with Stage IV Melanoma who presented to the hospital with nausea, vomiting, weight loss, and reduced oral intake for two weeks. The patient had most recently received 2 rounds of Ipilimumab and Nivolumab for his Melanoma 2 weeks prior to his presentation to our hospital, concurrent with the start of his symptoms. There had been no history of NSAID usage during this time, and physical exam was notable for mild epigastric tenderness. A Computed Tomography scan of the Chest/Abdomen/Pelvis showed diffuse thickening of the stomach, compatible with gastritis. Upper Endoscopy revealed diffuse severely erythematous mucosa with bleeding on contact in the entire examined stomach, and patchy, mildly erythematous mucosa without bleeding was found in the duodenal bulb, with the second portion of the duodenum being normal. The pathology report revealed subacute gastritis with acute inflammatory exudate consistent with an area of mucosal ulceration, with other etiologies of gastritis ruled out. The patient was begun on glucocorticoid therapy, with rapid resolution of his symptoms. Repeat endoscopy 2 weeks later revealed resolution of the previously noted gastritis and inflammation. Pathologic examination of biopsies confirmed resolution of the inflammatory process. DISCUSSION: On review of the literature, gastritis resulting from immune-checkpoint modulators has rarely been reported on. Some common side effects associated with these immune modulating medications, colloquially called immune-related adverse events (irAEs), include diarrhea, colitis, and hepatitis. However, there are a few case reports concerning the development gastritis without enterocolitis after Nivolumab treatment alone. Approximately 3 case reports and 1 case series of 20 patients describe such a side effect, To date, there are no reported cases of a patient treated with both Nivolumab and Ipilimumab who developed gastritis as the only adverse event.