P0248 - Double Whammy: A Case Report of Immune Checkpoint Inhibitor Colitis and Concomitant CMV Colitis in a Patient on Nivolumab for Metastatic Melanoma

Vinay Jahagirdar, MD¹, Himil Mahadevia, MD¹, Ronald Palmen, MD¹, Kimberly Sanders, MD¹, John Campbell, MD¹, Pamela B. Sylvestre, MD², Rajiv Chhabra, MD³, Wendell Clarkston, MD³, Sreeni S. Jonnalagadda, MD^3
1University of Missouri-Kansas City, Kansas City, MO; ²Saint Luke’s Health System of Kansas City, Kansas City, MO; ³University of Missouri-Kansas City School of Medicine, Saint Luke’s Hospital of Kansas City, Kansas City, MO

Introduction: Immune checkpoint inhibitors (ICI) are the standard of care for numerous malignancies. They are associated with immune-related adverse effects, with the GI tract being most commonly affected. Agents including nivolumab and ipilimumab have been shown to cause diarrhea due to colitis and/or enteritis in up to 40% of patients.

Case Description/Methods: A 66-year-old male with a history of melanoma of the left face s/p Mohs surgery 7 years ago, presented to the ED with diarrhea. 6 months prior he was diagnosed with recurrent melanoma and cerebral metastasis, underwent resection, and was started on ICI therapy with ipilimumab/nivolumab and radiotherapy. After 2 cycles of ICI, he developed grade 2 diarrhea (4-6 stools/day). ICI was held and he was started on prednisone with suspicion for immune-mediated diarrhea.

After an initial response to steroids, diarrhea recurred, with ≥ 7 stools/day. Stool PCR was positive for Yersinia and colonic biopsies showed neutrophilic infiltrate, suggestive of active colitis of infectious etiology. The patient clinically improved after a course of ciprofloxacin.

Nivolumab was resumed, and 4 days later he presented to the ED with diarrhea that rapidly progressed to ~20 stools/day (severe/grade 4). Stool GI PCR panel and C. difficile PCR was negative. IV methylprednisolone was started. Repeat colonoscopy showed pan-colonic diffuse congestion, and erythema. A 5 mm sessile descending polyp was snared. Histology revealed active chronic colitis with mononuclear infiltrate and attenuation of the colonic epithelium, supporting the diagnosis of ICI colitis. Low-grade CMV colitis was detected by IHC, with presence of CMV-positive cells within the colon biopsy and polyp specimens.

The patient was started on a 3-week course of IV ganciclovir and Bactrim for PJP prophylaxis. He was discharged on a tapering course of prednisone 40 mg with plans to repeat sigmoidoscopy in 4-6 weeks to assess healing.

Discussion: Infectious etiology of diarrhea must be excluded before starting therapy for suspected ICI colitis. ICI colitis should be confirmed endoscopically before starting high-dose steroids. Systemic immunosuppression poses a risk of opportunistic infections and we found Yersinia and CMV in our patient on 2 different admissions. We wish to highlight the importance of excluding infectious etiologies before considering steroid failure in these patients. Infliximab and vedolizumab can be used in steroid-refractory cases, though caution must be employed in the setting of active infection.



Disclosures:


Vinay Jahagirdar, MD¹, Himil Mahadevia, MD¹, Ronald Palmen, MD¹, Kimberly Sanders, MD¹, John Campbell, MD¹, Pamela B. Sylvestre, MD², Rajiv Chhabra, MD³, Wendell Clarkston, MD³, Sreeni S. Jonnalagadda, MD³. P0248 - Double Whammy: A Case Report of Immune Checkpoint Inhibitor Colitis and Concomitant CMV Colitis in a Patient on Nivolumab for Metastatic Melanoma, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.