A Rare Case of Rheumatoid Arthritis with Tocilizumab-induced Intestinal Mucosal Injury

Multiple Ulcers with Perforations of the Small Intestine in the Acute Phase of CD19 Chimeric Antigen Receptor T-cell Therapy Possibly Associated with Tocilizumab Administration

CD19 chimeric antigen receptor (CAR) T-cell therapy is associated with potentially life-threatening immunological toxicities. We herein report an 81-year-old woman who experienced multiple perforations in the small intestine 8 days after tisagenlecleucel infusion for relapsed and refractory follicular lymphoma with no gastrointestinal involvement. A pathological examination of the resected small intestine revealed multiple ulcers that formed after resection but without lymphoma involvement. Based on these findings, tocilizumab used for cytokine release syndrome was considered to be associated with these lesions. This case illustrates a previously undescribed but serious sequela of CAR T-cell therapy, calling for relevant personnel to be vigilant about gastrointestinal symptoms.

Tocilizumab-induced mucosal injury in the terminal ileum mimicking intestinal Behçet's disease: A case report

RATIONALE

Tocilizumab, a humanized anti-interleukin-6 (IL-6) receptor monoclonal antibody, is used for the treatment of adult-onset Still disease (AOSD). Despite its efficacy in many clinical situations, concerns have been raised regarding intestinal mucosal injury in patients receiving tocilizumab.

PATIENT CONCERNS

A 64-year-old woman with a history of AOSD was admitted to our hospital with hematochezia. She had AOSD for 15 years and underwent treatment with biweekly tocilizumab 9 months prior to admission. Colonoscopy revealed a large punched-out ulcer in the terminal ileum. On pathological evaluation, nonspecific enteritis with lymphocytes and eosinophils were seen. Based on the location and shape of the lesion, we suspected intestinal Behçet's disease. However, the ulcer reduced in size over time by discontinuation of tocilizumab without additional drug treatment, indicating that it was a drug-induced ulcer.

DIAGNOSIS

The patient was diagnosed with tocilizumab-induced small intestinal ulcer.

INTERVENTIONS

The patient treated with the discontinuation of tocilizumab.

OUTCOMES

The discontinuation of tocilizumab resulted in ulcer scarring. There was no recurrence of hematochezia.

LESSONS

Tocilizumab can cause deep ulcerative lesions in the terminal ileum, which may resemble intestinal Behçet's disease. It is important to continuously monitor abdominal symptoms during tocilizumab therapy and aggressively perform colonoscopy when hematochezia or abdominal pain is observed.