Case and Research Letter
Olmesartan Associated Enteropathy as an Inflammatory Bowel Disease Mimicker in a Patient With Hidradenitis Suppurativa
Enteropatía asociada a olmesartán, un simulador de enfermedad inflamatoria intestinal en un paciente con hidradenitis supurativa
F.J. Melgosa Ramos
, R. García Ruiz, A. Mateu Puchades
Corresponding author
Department of Dermatology, University Hospital Doctor Peset of Valencia, Valencia, Spain
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Melgosa Ramos, R. García Ruiz, A. Mateu Puchades" "autores" => array:3 [ 0 => array:2 [ "nombre" => "F.J." "apellidos" => "Melgosa Ramos" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "García Ruiz" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Mateu Puchades" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731024002801?idApp=UINPBA000044" "url" => "/00017310/0000011500000006/v1_202406021150/S0001731024002801/v1_202406021150/es/main.assets" ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letter</span>" "titulo" => "Olmesartan Associated Enteropathy as an Inflammatory Bowel Disease Mimicker in a Patient With Hidradenitis Suppurativa" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "607" "paginaFinal" => "608" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F.J. Melgosa Ramos, R. García Ruiz, A. Mateu Puchades" "autores" => array:3 [ 0 => array:4 [ "nombre" => "F.J." "apellidos" => "Melgosa Ramos" "email" => array:1 [ 0 => "javimelgo2017@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "R." "apellidos" => "García Ruiz" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "Mateu Puchades" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, University Hospital Doctor Peset of Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enteropatía asociada a olmesartán, un simulador de enfermedad inflamatoria intestinal en un paciente con hidradenitis supurativa" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hidradenitis suppurativa (HS) is a chronic inflammatory, disfiguring and difficult-to-treat disorder of the terminal pilosebaceous-apocrine unit characterized by the development of multiple deep-seated nodules, abscesses, draining sinus tracts and scars.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> HS and its comorbidities have a devastating impact on quality of life.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> HS is associated with higher overall comorbidity burden than exists for healthy populations.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> HS and inflammatory bowel disease often coexist and they may also share overlapping cytokine signatures with response to corresponding targeted therapies.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> It has been reported that the risk of Crohn's disease (CD) among patients with HS is 3 times greater.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> The risk of ulcerative colitis (UC) in patients with HS it is also increased compared to healthy populations,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,3</span></a> so screening of inflammatory bowel disease is mandatory in patients with HS who present with chronic diarrhea. It is widely known that patients with HS had also a significantly higher prevalence of arterial hypertension, diabetes, and dyslipidemia,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> which require treatment. Olmesartan is a commonly prescribed angiotensin <span class="elsevierStyleSmallCaps">II</span> receptor blockade antihypertensive drug recently associated with a seronegative sprue-like enteropathy. Patients typically present with severe diarrhea and weight loss.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Discontinuation of the drug leads to a dramatic recovery and hence, dermatologist and other physicians involved in HS patient's care need to be aware of olmesartan associated enteropathy (OAE) to avoid unnecessary testing.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Therefore, in patients with HS who present with chronic diarrhea, OAE should be considered in the differential diagnosis specially with inflammatory bowel disease, coeliac disease, and antibiotics-associated diarrhea.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 65-year-old man with HS (Hurley stage <span class="elsevierStyleSmallCaps">III</span>), treated with doxycycline 50<span class="elsevierStyleHsp" style=""></span>mg daily for 1 year, with an optimal disease control, was admitted to the hospital referring an intractable chronic non-bloody diarrhea, and considerable weight loss for 2 months. Medical history was notable for hypertension being treated with olmesartan for 6 months. Workup for all potential infectious causes and coeliac disease was negative. A computerized tomography (CT) scan was performed and did not reveal any malignancy. Colonoscopy and ileocolonic biopsies ruled out both inflammatory bowel disease and microscopic colitis, and revealed mild villous atrophy. An upper endoscopy was performed, and was also normal. Based on these results, and after a detailed review of the patient's drug intake, the possibility of OAE was considered. Olmesartan was stopped and the symptoms completely resolved.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Olmesartan is an angiotensin receptor blocker widely used for the treatment of arterial hypertension. In the last few years olmesartan has been linked to rare instances of severe sprue-like enteropathy called OAE.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,5</span></a> The enteropathy typically presents with moderate to severe diarrhea and weight loss with variable degrees of asthenia, nausea and abdominal pain a few months after the drug onset. Small intestinal histological findings resemble those of coeliac disease with flattening and atrophy of the duodenal villous.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6–8</span></a> However, serologic antibodies of coeliac disease are negative, there is little or no response to a gluten-free diet, and unlike CD, granulomas are not observed in the biopsy. Some cases OAE were also accompanied by serum aminotransferase elevations and fatty liver, which, along with the diarrhea, resolved drug withdrawal. Although the pathogenesis of OAE has not been completely determined yet, the involvement of cell-mediated immunity has been suggested.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">To conclude, diarrhea can be a frequent symptom in patients with hidradenitis suppurativa, and despite the high association with inflammatory bowel disease and antibiotic-associated diarrhea, OAE and, olmesartan withdrawal must be considered in patients with HS and arterial hypertension complaining of chronic diarrhea and taking this drug, before proposing more invasive tests.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Author's contribution</span><p id="par0025" class="elsevierStylePara elsevierViewall">All authors have contributed to this research.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Author's contribution" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hidradenitis suppurativa: an update on epidemiology, phenotypes, diagnosis, pathogenesis, comorbidities and quality of life" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T.V. 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