Reactions 1704, p206 - 2 Jun 2018
Acute inflammatory enterocolitis: case report
An 18-year-old man developed acute inflammatory
enterocolitis during treatment with ipilimumab for metastatic
melanoma [route not stated].
The man, who had been diagnosed with metastatic
amelanotic melanoma, was started on first-line therapy with
ipilimumab 3 mg/kg plus nivolumab 1 mg/kg every three
weeks. He tolerated the treatment well; however, he
developed mild hepatitis. The hepatitis was characterised by
grade 2 transaminase elevation. After four weeks of
methylprednisolone treatment, the hepatitis resolved. After
four doses of combination therapy, the metastases decreased
and he was started on maintenance therapy with nivolumab
3 mg/kg every second week. After two doses, the underlying
disease was progressed. He underwent adjuvant radiotherapy
and was started on high-dose ipilimumab 10 mg/kg every
three weeks. Five days after the second dose of ipilimumab, he
presented with abdominal pain, nausea, loss of appetite,
weight loss and vomiting. Therefore, he was hospitalised and
was started on IV fluid replacement. CT scans showed a
pronounced thickening of the ileum and jejunum walls with
contrast enhancement, which was consistent with an
inflammatory process. Therefore, he was treated with
methylprednisolone along with parenteral fluids and nutrition.
In spite of these treatments, his condition worsened with
persistent vomiting, nausea, weight loss and abdominal pain.
One week later, he developed severe diarrhoea. Repeated CT
scans showed an extension of the inflammatory changes to the
transversing and ascending colon. Punch biopsies taken from
the ileum, duodenum and colon revealed a
lymphoplasmocytic infiltration of the lamina propria and
intraepithelial neutrophilic granulocytes (cryptitis, crypt
abscesses), which confirmed a diagnosis of a severe acute
inflammatory enterocolitis-induced by high-dose ipilimumab.
He developed radiographic and clinical signs of paralytic ileus
with large intraluminal fluid retentions and reduced bowel
motility due to the prolonged severe inflammation.
The man’s condition improved slowly after the
administration of three doses of infliximab 5 mg/kg along with
high-dose corticosteroids. After seven weeks of
hospitalisation, he was discharged on methylprednisolone
with 10kg less weight loss. Six months later, he was well and
free of disease without further adjuvant therapy.
Author comment: "Thus, the high toxicity observed in the
reported case is most likely attributable to the high
ipilimumab dose of 10 mg/kg.""Herein, we report on a young
patient who developed a severe, life-threatening
gastrointestinal toxicity to high-dose ipilimumab."
Olischewsky A, et al. Dose-dependent toxicity of ipilimumab in metastatic
melanoma. European Journal of Cancer 95: 104-108, May 2018. Available from:
URL: http://doi.org/10.1016/j.ejca.2018.01.088 - Germany
Reactions 2 Jun 2018 No. 17040114-9954/18/1704-0001/$14.95 Adis © 2018 Springer International Publishing AG. All rights reserved