S2313 A Rare Presentation of an IL-12/23 Antagonist in Crohn’s Disease and Development of Sarcoidosis

Abstract

INTRODUCTION: Anti-tumor necrosis factor (anti-TNF) therapy has been studied for use in inflammatory conditions such as IBD. There is a growing awareness of paradoxical reactions during treatment with this biologic agent. These can be defined as the development or exacerbation of a pathological condition which is triggered by the biologic agent being used. Commonly reported reactions include skin or joint manifestations, colitis or ileitis, or vasculitis. Paradoxically anti-TNF biologics have been reported to be useful to treat sarcoidosis and have been reported to cause sarcoidosis. Ustekinumab an IL-12/23 antagonist has been reported to cause sarcoidosis in 2 patients with psoriasis. We report the first case of a patient developing sarcoidosis during ustekinumab therapy for Crohn’s disease. CASE DESCRIPTION/METHODS: A 49 year-old female with history of breast carcinoma status-post mastectomy and adjuvant chemotherapy presented to clinic with abdominal pain and rectal bleeding. Prior colonoscopy on 6/26/17 only revealed pan-colonic diverticulosis. Colonoscopy on 10/12/18 revealed non-bleeding internal hemorrhoids, left-sided diverticulosis, sigmoid erythema/inflammation, and a normal terminal ileum. Sigmoid biopsies revealed chronic active colitis. She was started on Lialda with symptom resolution. The patient relapsed and was subsequently started on prednisone. Given the improvement with corticosteroids and suspicion of IBD, the patient was started on ustekinumab with a steroid taper and symptoms remained improved. Follow-up positron emission tomography scan for her breast cancer revealed uptake along the esophagus with development of mediastinal and bilateral hilar lymphadenopathy. Since there was concern for cancer, an EGD was performed, revealing only reflux esophagitis. Biopsies by pulmonology of her lymphadenopathy (EBUS) revealed noncaseating granulomatous sarcoidosis without evidence of malignancy. Ustekinumab was discontinued and the patient was restarted back on prednisone and Lialda with improvement. DISCUSSION: Side effects of ustekinumab, a monoclonal antibody to interleukin 12 and 23, can include cancers or serious infections. Our case describes a rare development of sarcoidosis in a Crohn’s Disease patient on ustekinumab therapy. The mechanism for this reaction remains unclear. The case does highlight the importance of knowing that all lymphadenopathy is not due to cancer even in patients with a cancer history and ustekinumab can cause sarcoidosis in patients with inflammatory bowel disease.