Olmesartan Associated Sprue-Like Enteropathy and Colon Perforation

We are reporting a unique case of olmesartan associated severe sprue-like enteropathy in a 52-year-old woman who presented to our hospital complaining of severe abdominal pain and nausea. At the emergency department she suffered from a cardiac arrest and was found to have a colon perforation. The patient was treated conservatively without surgical intervention and olmesartan was discontinued. After one month, she had complete resolution of her symptoms. 1. Introduction Olmesartan is an angiotensin receptor blocker (ARB) approved for the treatment of hypertension in 2002. FDA reported olmesartan associated sprue-like enteropathy via a MedWatch alert in July 2013 after a case series of 22 patients was reported by Mayo Clinic [1]. Since that time only very few literatures discussed this adverse effect [2–4]. To our knowledge, this is the first reported case of olmesartan associated sprue-like enteropathy to present with colon perforation possibly secondary to the severity of the enteropathy. 2. Case Description A 52-year-old woman presented to our hospital complaining of severe abdominal pain and nausea. She reported recurrent mild abdominal pain, bloating, nausea, occasional vomiting, and severe nonbloody diarrhea with 20 evacuations a day for one year. She had a 45 pound weight loss within six months. She denied any other symptoms suggestive of local or systemic infections, recent travels or sick contacts, changes in her diet habit, or medications within the last year. Vital signs were within normal range. Physical exam revealed generalized abdominal tenderness with guarding and signs of dehydration. At the emergency department, the patient suffered from a cardiac arrest. She was successfully resuscitated and admitted to the intensive care unit. Laboratory investigations showed potassium 2.9？mMol/L, bicarbonate 17？mMol/L, blood urea nitrogen 7？mg/dL, creatinine 0.9？mg/dL, white blood count 12.1 × 103/μL, hemoglobin 13.8？gm/dL, and albumin 2.4？gm/dL. CT scan of the abdomen showed ascending colon inflammation and evidence suggestive of perforation (Figures 1 and 2). She was treated conservatively without surgical intervention. A repeat abdominal CT scan revealed improving of the colonic inflammation and sealing of the perforation. Figure 1: Contrast-enhanced CT abdomen showing wall thickening in the ascending colon with pericolonic stranding pattern and adjacent free air (circle) suggestive of colon perforation. Figure 2: Contrast-enhanced CT abdomen showing wall thickening in the ascending colon with pericolonic stranding pattern and adjacent tiny foci of