Vedolizumab: A Peek into the Future of Autoimmune Enteropathy

Abstract

Autoimmune enteropathy (AIE) is characterized by protracted diarrhea and malnutrition. Vedolizumab; a humanized monoclonal antibody that inhibits adhesion and migration of leukocytes into the gastrointestinal tract and has never been used to treat autoimmune enteropathy in the past, but in this case has given us glimpse of a new modality that can be further established with research. We present to you a case of a 72-year-old Caucasian male with history of bilateral inguinal hernia repair. He was admitted to an outside hospital with diarrhea and weight loss for 6 months, without a recognizable etiology. He reported having 10-15 watery bowel movements daily along with small amount of blood and mucus associated with diffuse abdominal pain. Physical examination showed cachectic appearing male with normal vital signs, hyperactive bowel sounds and mild diffuse tenderness on deep palpation. Pertinent laboratory work showed: hemoglobin of 10 g/dl; ESR 19 mm/hr; albumin 2.7 g/dl and antinuclear antibodies with a titer of 1:320. Comprehensive stool studies were negative for enteric pathogens. Serological tests for celiac disease were also non contributory. Esophagogastroduodenoscopy demonstrated normal stomach, duodenum and proximal jejunum with unremarkable biopsies. Evidence of ileitis and right sided colitis was found on colonoscopy. Due to concerns for Crohn's disease he was initially started on mesalamine, azathioprine, prednisone to which his symptoms didn't respond. Later Infliximab was added only to worsen his condition. He presented to our hospital for further evaluation after significant weight loss. Repeat colonoscopy showed severe inflammation of terminal ileum, ascending and transverse colon. Random biopsies from terminal ileum and colon suggested changes consistent with autoimmune enteropathy or graft versus host disease. It was decided to switch infliximab to Vedolizumab in hope to treat his refractory symptoms. To our pleasant surprise one month on treatment he started showing signs of improvement. In three months on Vedolizumab, his stool frequency reduced to one bowel movement daily with documented weight gain with overall clinical improvement. Autoimmune enteropathy is exceedingly rare, treatment options are still being explored. Vedolizumab, which was used to treat this disorder for the first time has shown a very promising result. Further research with this drug would give us more insight into this immune milieu.