A 68-year-old male presented to his family physician with a five-week history of nonbloody diarrhea, vomiting, and a 20 lb weight loss. Three days previously he had been seen by ophthalmology with new onset right eye pain, redness, and light sensitivity and diagnosed with severe right nongranulomatous anterior uveitis. He was treated with homatropine, dexamethasone, and prednisolone eye drops. He had no fevers, joint pain, skin changes, or recent travel. Past medical history included kidney stones, hypertension, and bioprosthetic aortic valve replacement three years earlier for severe aortic stenosis. He had been on olmesartan/hydrochlorothiazide 40/12.5 mg daily for 3-4 years. Other medications included ASA 81 mg twice weekly, vitamin C daily, multivitamin daily, cod liver oil daily, and acetaminophen as needed. Blood work ordered by his family physician included an elevated creatinine at 474 mumol/L. He was sent to the emergency department and admitted for an acute kidney injury presumably secondary to dehydration. Physical examination was unremarkable. He had normocytic anemia (hemoglobin 120 g/L), normal albumin (40 g/L), normal electrolytes, and nonanion gap metabolic acidosis. Creatinine improved to 77 mumol/L with intravenous fluids over 5 days. Stool was negative for culture, parasites, and Clostridium difficile. Anti-tissue transglutaminase (TTG) antibody was negative with normal immunoglobulin A levels. Biopsies of the distal duodenum and duodenal cap revealed marked villous blunting with near complete villous atrophy of the small intestinal mucosa in some areas (Figure 1). There was an increase in intraepithelial lymphocytes as well as neutrophils in the surface epithelium. The crypts had a prominent increase in apoptosis.
In hospital, his uveitis improved considerably and he was reassessed by ophthalmology. A diagnosis of idiopathic bilateral anterior and intermediate uveitis was confirmed after negative workup for syphilis, Lyme disease, sarcoid, and tuberculosis. The uveitis resolved at 16 weeks with a taper of prednisolone eye drops.
The patient's diarrhea resolved within 2 weeks of olmesartan discontinuation. His anemia improved to baseline and he returned to his previous weight within 3 months. Follow-up endoscopy 14 weeks later demonstrated complete resolution of the duodenal inflammatory changes and restoration of normal villous architecture (Figure 2).