Letter to the Editor
Sprue-like enteropathy associated with valsartan
Enteropatía sprue-like asociada a valsartán
Adolfo del Val
, María García Campos, Natalia García Morales
Corresponding author
Sección de Gastroenterología, Hospital Universitario y Politécnico la Fe, Valencia, Spain
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Olmesartan is an angiotensin II receptor antagonist (ARA-II) used in the treatment of arterial hypertension. We recently published a series of patients with SLEO.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> However, until then, only one case of <span class="elsevierStyleItalic">sprue-like</span> enteropathy associated with another ARA-II had been reported, that of valsartan.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 77-year-old man who presented with a 2-year history of chronic diarrhoea. He reported around 7 liquid stools per day, some also nocturnal, without pathological products, associated with abdominal pain in the form of cramping and weight loss of more than 9<span class="elsevierStyleHsp" style=""></span>kg. His personal pathological history included hypertension treated with valsartan 80<span class="elsevierStyleHsp" style=""></span>mg for 37 months, diabetes mellitus type 2 treated with sitagliptin and chronic lower limb ischaemia treated with cilostazol and clopidogrel. A complete blood test was performed, with a chronic diarrhoea profile, showing a mild anaemia with haemoglobin 10.8<span class="elsevierStyleHsp" style=""></span>g/dl and CRP 29<span class="elsevierStyleHsp" style=""></span>mg/dl. Stool culture and faecal calprotectin were normal. Colonoscopy was performed with diverticulosis of the left colon. Two descending colon polyps were removed, one of 13<span class="elsevierStyleHsp" style=""></span>mm (Paris 1p) and the other 6<span class="elsevierStyleHsp" style=""></span>mm (Paris 1s) both were tubulovillous. Serial biopsies of each segment of the colon ruled out microscopic colitis. The abdominal-pelvic CT scan showed no pathological findings. Gastroscopy revealed signs of chronic atrophic gastritis that was confirmed in the pathological study with the presence of complete intestinal metaplasia. The endoscopic appearance of the duodenum was normal, biopsies showed partial villous atrophy, increased intraepithelial lymphocytes (IEL) and hyperplasia of the crypts, findings consistent with Marsh IIIa celiac disease. Sprue serology had been negative. The clinical symptoms and the histopathological findings were identical to the SLEO cases already described.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Therefore, valsartan discontinuation was recommended to the patient. In the following weeks there was a gradual clinical improvement with remission of diarrhoea, recovery of lost weight and lab results improvement. At 6 months the duodenal biopsies were repeated, the villous atrophy had disappeared, although there was an increase in IEL and hyperplasia of the crypts.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Since the first case of SLEO in 2013, we have treated a considerable number of patients with this serious condition in our unit. In a Spanish registry study in which we collaborated, the incidence was low, between 0 and 22 per 10<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> treated patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> In recent years, numerous SLEO cases or case series have been published but their occurrence in association with another ARA-II is considered very rare. In fact, there is only one case reported associated with irbesartan,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> collected in a French national-based study,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and the Mayo Clinic group, which described the SLEO, has recently reported the first case due to valsartan.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Our case is very similar to the latter, the clinical improvement and the existence of seronegative villous atrophy prompted us to suspect an antihypertensive agent participation. It was decided to repeat the biopsies 6 months after discontinuation, as this had been the average time interval used in our SLEO patients. The histological improvement was only partial because the time elapsed was only short. In the previously described case, biopsies were repeated every year. After having made a literature review through PubMed, from 2011 to the present we only found one case for valsartan, so this would be the second one. This scenario suggests that other ARA-II could be involved. In fact, any patient in treatment with any ARA-II who presents with chronic watery diarrhoea should be assessed to rule out a <span class="elsevierStyleItalic">sprue-like</span> enteropathy, discontinue the drug treatment to verify if there is clinical improvement and subsequent duodenal biopsies to verify histological improvement.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: del Val A, García Campos M, García Morales N. Enteropatía sprue-like asociada a valsartán. Med Clin (Barc). 2018;150:329.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe sprue-like enteropathy associated with olmesartan" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Rubio-Tapia" 1 => "M.L. Herman" 2 => "J.F. Ludvigsson" 3 => "D.G. Kelly" 4 => "T.F. Mangan" 5 => "T.T. 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