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Author: Stephanie E. Dreifuss, University of
Pittsburgh School of Medicine, Class of 2014
We present a 64-year-old male with a past medical history of
hypertension who presented with diarrhea and 12 kilogram weight
loss over the preceding three months. He reported 3-10 daily
episodes of fatty, non-bloody diarrhea with associated abdominal
pain, bloating, and distention. He denied any changes in his diet
or medications (olmesartan 40mg daily and omeprazole 40mg daily)
within the last few years. He had a recent hospitalization for
prerenal acute kidney injury (AKI) secondary to intractable
Stool cultures, Clostridium difficile toxin, and stool ova and
parasites were negative. Stool osmolality, stool electrolytes,
serum gastrin, serum VIP, and urine 5-HIAA were within normal
limits. Fecal fat was elevated. A colonoscopy revealed no
abnormalities. Small intestinal biopsy revealed villous blunting
and intraepithelial lymphocyte infiltration. Based on the biopsy
results and fecal fat elevation, celiac sprue was suspected.
Therefore, the patient was instructed to begin a gluten-free diet,
and serologic studies were ordered. IgA, anti-endomysial, and
anti-tissue transglutaminase antibodies returned within normal
limits, while the patient reported no improvement in his
He was admitted to the hospital three weeks later with
dehydration, AKI, and orthostatic hypotension. Given his blood
pressure of 83/48, olmesartan was discontinued. At a two week
follow-up, he reported complete resolution of his diarrhea. He was
gaining weight, having only one formed bowel movement daily, and
beginning to reintroduce gluten into his diet. Amlodipine was
started in place of olmesartan. Two months later, he reports having
We report this case for two important reasons. First, we aim to
alert clinicians of an unusual entity to include in the
differential diagnosis of chronic diarrhea. The clinical features
of this enteropathy include gastrointestinal symptoms (chronic
diarrhea, weight loss, steatorrhea), negative serology (IgA tissue
transglutaminase or endomysial antibodies), histologic evidence of
enteropathy (villous atrophy and intraepithelial lymphocytosis),
lack of improvement in symptoms with a gluten-free diet, exclusion
of other causes of enteropathy, and evidence of improvement after
discontinuing olmesartan. The findings in this case are similar to
another case series in the literature (Mayo Clin Proc 2012;87:732).
Our second objective is to emphasize the potentially dramatic
consequences of drugs we prescribe. In this case, our patient
endured three months of repeat hospitalizations, invasive tests,
and weight loss before the offending drug was discontinued.
Further investigation is needed to elucidate the specific
mechanism of olmesartan-associated enteropathy and to determine
whether other ARBs elicit similar adverse reactions. Until these
questions are answered, it is important for clinicians to maintain
a high index of suspicion for olmesartan, and potentially other
ARBs, as precipitants of a celiac sprue-like picture.
December/January Issue of IMpact