Olmesartan-Associated Enteropathy Without Chronic Diarrhea: An Atypical Presentation of a Difficult Diagnosis

Abstract

Olmesartan-associated enteropathy (OAE) is a recently identified sprue-like enteropathy and clinical syndrome that presents primarily with chronic diarrhea and significant weight loss accompanied by abdominal pain, nausea, vomiting, bloating or fatigue. This report describes an atypical clinical presentation of olmesartan-associated enteropathy. An 82-year-old woman presented to clinic with approximately 5 months of poor appetite followed by sudden onset of frequent nausea, vomiting, epigastric abdominal pain and 40-pound weight loss. She had no diarrhea. She had several previous admissions at other hospitals with extensive work-up that was ultimately unrevealing (included multiple abdominal CTs, multiple EGDs, and colonoscopy). Olmesartan was on her home medication list but had been replaced by another hospital formulary angiotensin receptor blocker (ARB) on admission. While endoscopically unrevealing, duodenal biopsy at this admission demonstrated marked villous blunting and chronic inflammation. Serologies for celiac disease were negative, which was consistent with OAE. All ARBs were discontinued and the patient's nausea and abdominal pain improved. This case differed from the clinical pattern of symptoms noted in prior reports of OAE as the patient was entirely without diarrhea. A literature review identified numerous cases with nausea, vomiting and abdominal pain in addition to diarrhea and weight loss, but to our knowledge this is the first described case of OAE without symptoms of diarrhea (although constipation is not uncommon in celiac disease). Additionally, this case calls attention to a standard practice that influences the potential for missed diagnoses related to medication side effects. The admission process of substituting medications to comply with hospital formularies creates an opportunity for medications, such as olmesartan, to be overlooked. This case emphasizes the importance of thorough medication reconciliation at the time of a new hospitalization. Rubio-Tapia, Alberto, et al. “Severe spruelike enteropathy associated with olmesartan.” Mayo Clinic Proceedings. Vol. 87. No. 8. Elsevier, 2012. Marietta, E. V., et al. “Immunopathogenesis of olmesartan-associated enteropathy.” Alimentary pharmacology & therapeutics 42.11-12 (2015): 1303-1314. Burbure, Nina, et al. “Olmesartan associated sprue-like enteropathy: a systematic review with emphasis on histopathology.” Human Pathology (2015).Figure 1