Introduction: Small intestinal villous atrophy and inflammatory infiltrates with negative celiac serologies, also known as sprue-like enteropathy, presents a diagnostic challenge. The differential diagnosis for this finding is broad, including autoimmune enteropathies, malignancies, infections, and immunodeficient disorders. Extensive evaluation of these patients often fails to identify an etiology, diminishing patients’ quality of life. A 69-year-old woman presented to our hospital system with weight loss, post-prandial emesis, volume depletion, and electrolyte abnormalities. Her medical history was remarkable for hypertension with blood pressure controlled using metoprolol, amlodipine, and olmesartan. Upper endoscopy (EGD) was performed, with gross scalloping throughout the duodenum. Biopsies of the duodenum showed villous blunting and intraepithelial neutrophilic infiltrates. Labs revelaed a normal IgA (204mg/dL), negative tissue transglutaminase IgA (<3U/mL), positive HLA-DQ2, and negative DQ8. A strict gluten-free diet for 2 months did not help, and she was empirically treated with prednisone given the severe inflammatory infiltrates of the small intestine. Symptoms improved rapidly, but recurred when the prednisone was weaned. She was started on azathioprine as a steroid-sparing medication with successful cessation of steroids. Repeat EGD showed persistent villous blunting similar to the previous biopsy, asymptomatic on prednisone and azathioprine. Due to financial constraints, the anti-hypertensive regimen was adjusted, with olmesartan switched to losartan. Following reports of sprue-like enteropathy linked to olmesartan, azathioprine was discontinued while she was kept on all other medications. EGD 6 months later showed normal histology with normal villous architecture and no inflammatory infiltrates. She continues to feel well on losartan at 12 months. Sprue-like enteropathy associated with olmesartan generally presents with diarrhea, vomiting, normocytic anemia, and low albumin. As in our case, steroids ameliorate symptoms in 95% of the cases. In our case, azathioprine and prednisone offered clinical relief, but did not restore histological changes. Replacing olmesartan with losartan provided both clinical and histologic improvement, exemplifying that sprue-like enteropathy is not a class effect with ARBs, but rather specific to olmesartan. Disclosure - Dr. Corral - no financial relationships to declare. Dr. Yarur - no financial relationships. Dr. Diaz - no financial relationships. Dr. Garcia-Buitrago - no financial relationships. Dr. Sussman - Consultant: ExactSciences. Research support: Bankhead-Coley Team Science (2BT02), Olympus America Inc., American Cancer Society (IRG-98-277-13), and Sylvester Comprehensive Cancer Center.