Dehydration Secondary to Acute Olmesartan Associated Enteropathy with Concomitant Lymphocytic Colitis

Abstract

Introduction: Olmesartan is an angiotensin II receptor blocker recently described to cause a spruelike enteropathy. Duodenal biopsies are identical to those of Celiac disease (CD), however the patient will be negative for transglutaminase. Unlike Olmesartan associated enteropathy (OAE), CD has been associated with lymphocytic colitis (LC). LC can cause significant diarrhea, although it typically does not cause dehydration. Case Report: 84-year-old Caucasian female with a past medical history of dementia and hypertension was hospitalized for diarrhea. She was noted to have an acute kidney injury (AKI) with a creatinine of 1.79 mg/dL. Her C. diff screen was positive and the patient was treated with oral vancomycin. Her AKI resolved with rehydration and she was discharged home. At home she began to have 20 liquid bowel movements daily and was taken to another local hospital. Repeat C. diff screening was negative; however, she was again treated with oral Vancomycin. She was discharged home despite still having diarrhea. Outpatient esophagogastroduodenoscopy and colonoscopy were performed for follow up evaluation. Further, she was noted to have been recently started on Olmesartan which was discontinued prior to endoscopic evaluation. Endoscopy revealed negative gross evaluation of the duodenum and biopsy revealed blunted villous architecture with increased intraepithelial lymphocytes and focal neutrophilic infiltrates. Colonic biopsies revealed lymphocytic colitis. Shortly after, the patient had altered mental status and hypotension and was sent to the emergency department. Initial vital signs were significant for temperature of 91.7 °F and a blood pressure of 72/57 mm Hg. Physical exam was unremarkable besides altered mentation. Initial bloodwork revealed an AKI with a creatinine of 7.74 mg/dL. She continued to have profound diarrhea and outpatient biopsy results were not immediately available. Repeat C. diff screening, stool cultures, Shiga toxins, and ova and parasites were checked and found to be negative. Computer tomography of the abdomen showed diverticulosis. With the duodenal biopsy results transglutaminase IgA and IgG were checked and were negative. The AKI resolved with rehydration and the diarrhea improved with budesonide. Discussion: Celiac sprue enteritis is associated with LC, OAE has not been described to be associated with it. Clinicians should suspect a concomitant process in patients with LC presenting with dehydration.