OC34 Drug induced eosinophilic pneumonia in a child treated with ustekinumab for ulcerative colitis

• Published in: Frontline gastroenterology Vol. 14; no. Suppl 1; pp. A21 - A22
• Main Authors: Sandhu, K, P To, Balfour-Lynn, I M, Fell, JME, Thangarajah, D
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group LTD 01.07.2023
• Subjects: Drug dosages; FDA approval; Inflammatory bowel disease; Pneumonia
• ISSN: 2041-4137; 2041-4145
• DOI: 10.1136/flgastro-2023-bspghan.33

BackgroundUstekinumab is known to cause respiratory side effects, with eosinophilic pneumonia (EP) a rare adverse event only reported in the literature in a few adult cases. We report on an 11-year-old female with ulcerative colitis (UC) with drug induced EP secondary to ustekinumab.Methods/Case PresentationAn 11-year-old girl with UC who at 9 months from diagnosis was started on ustekinumab due to steroid dependency and anti-TNF failure. After a single loading dose of ustekinumab (6 mg/kg) and concurrent prednisolone 0.5 mg/kg, she presented within one week with dry cough, fever, night sweats and dyspneoa, raised inflammatory markers (CRP 167, ESR >120) and eosinophil count of 1.6 (range 0.9–1.3) and negative TB screen. CXR (figure 1) showed bilateral lung changes with tenting of diaphragm, antibiotics were started with no improvement after 1 week. After respiratory consult, CT (figure 2) was diagnostic of EP with reduced lung function, FEV1 (forced expiratory volume in 1 second) 52% and FVC (forced vital capacity) 48%. She was treated with 1.5 mg/kg of prednisolone for 5 days. 2 weeks later there was resolution of chest symptoms and normal X-ray with improvement in lung function (FEV1 70%, FVC 72%). Immunology consult excluded immunodeficiency and secondary autoimmune conditions. Further steroids given for her UC led to improvement to FEV1 91% and FVC 88% which was maintained for a further year.Abstract OC34 Figure 1CXR showing dense air space opacification[Figure omitted. See PDF]Abstract OC34 Figure 2Bilateral upper lobe in right lung and left upper zone with tenting of consolidation left hemidiaphragm[Figure omitted. See PDF]Results/DiscussionWe report the first paediatric case of ustekinumab induced EP. In the adult series similar presentation has been observed and with one case of patient had acute respiratory distress syndrome. Most cases occurred after prolonged use of ustekinumab, and fewer occurring after a single dose. It has been postulated the pathogenesis of EP is hypersensitivity reaction or upregulation of TH2 pathway due to ustekinumab blockade of IL-12 and IL-23.ConclusionEP is a rare and serious side effect of ustekinumab. We recommend avoiding further doses of ustekinumab, screening for opportunistic infections in the context of an immunosuppressed patient. In 2018, the food and drug administration approved a warning for ustekinumab highlighting the risk of non-infectious pneumonia. Our case highlights that children can present similarly to adults and resolved with a course of steroids.