We present the case of a 72-years-old female with a history of paroxysmal supraventricular tachycardia and myelodysplastic syndrome (sideroblastic anemia) with iron overload. She was treated with bisoprolol and deferasirox for three years. She was admitted to our gastroenterology department for abdominal pain in the lower right quadrant and chronic watery diarrhea. An abdominal CT scan with intravenous contrast revealed a cecal and terminal ileum wall thickening (Fig. 1A). Blood test showed a normocitic anemia (Hb 8.5g/dl) and ferritin>1500. Stool cultures were negative for bacteria, virus and parasites. Thus, a colonoscopy was scheduled and revealed a diffuse ileitis with large superficial and geographic ulcers in the terminal ileum (Fig. 1B) The surrounding mucosa showed particularly atrophic mucosa and villis. Also, small erosions were observed in the right colon with a surrounding edematous mucosa with unremarkable mucosa in the rest of the colon. Multiples biopsies were taken and showed neutrophilic, eosinophilic and lymphocytic infiltration with non-specific microscopic features (Fig. 1C).
A: notice the right colonic wall thickening. B: Diffuse ileitis with large superficial and ulcers in the terminal ileum. C: Pathological study revealed non-specific features with neutrophilic, eosinophilic and lymphocytic infiltration. D: A second colonoscopy 4 months later showing mucosal healing in the terminal ileum.
The differential diagnosis included infectious ileocolitis, drug-induced ileocolitis and Crohn's disease. So, after multidisciplinary consensus, deferasirox was withdrawn. Rapid clinical improvement within days was noticed. A colonoscopy was repeated 4 months later showing mucosal healing and some scarce edematous mucosa without any ulcer neither erosion (Fig. 1D).
NSAIDs have been proposed as a clear risk factor for small bowel induced damage, with a prevalence of mucosal breaks in around 50% in chronic users.1 Other drugs as antihypertensives, digoxin, enteric-coated hydrochlorothiazide with potassium, ergotamine and oral contraceptives have been described as conditions related development of terminal ileitis.2
Deferasirox is an oral iron chelator commonly used in thalassemia. Some gastrointestinal side effects as diarrhea have been described, including duodenal and gastric ulcers.3,4 Although, terminal ileitis and colitis has not been previously described for deferasirox. After proper differential diagnosis and according to the WHO UMC causality categories, this case could be classified as possible due a second endoscopic procedure confirming the healing of the mucosa after drug withdrawal but the rechallenge was considered too risky.5 Moreover, gastric and duodenal ulcers have been described as adverse events in patients taking deferasirox. In this setting, the use of deferasirox should be discontinued, due to risk of perforation. This reason motivated the drug withdrawal in our case and after the repeated endoscopic procedure we choose to not resume.
As conclusions, a wide differential diagnosis should be mandatory in ileocolitis including pharmacological etiology as possible agent.
Conflict of interestThe authors declare that there is no conflict of interest.
