Severe steroid refractory gastritis induced by Nivolumab: A case report

Table 1 Timeline

Time	Event	Findings
June 2018	Removal of mole on the right thigh at the general practitioner	Pathology showed malignant melanoma, 2.1 mm. Level IV
August	Re-excision of malignant melanoma and sentinel node biopsy	Stage IIIb malignant melanoma. (No open protocol for adjuvant treatment)
September	PET-CT	No metastases
December	Multidisciplinary team-conference	Referred to the oncology department
January 2019	Started adjuvant Nivolumab treatment
March	Nausea and stomach pain	Grade 1 hepatitis (ALT 129 U/L)
April	Ultrasound of liver because of elevated ALT	Normal
May	Decline in ALT (ALT 47 U/L), 6th dose of Nivolumab
June 21-24	First admission for 3 d with nausea, stomach pain, and vomiting; Cerebral MRI	Short prednisone treatment with initial effect. No brain metastasis
July 1	PET-CT (Figure 1)	FDG-uptake in the gastric wall
July 3	Second admission with vomiting, stomach pain, and nausea	ALT 85 U/L, albumin 23 g/L
July 4	EGD and EUS (Figure 2); Initiated methylprednisolone 80 mg iv.	Gastritis. Erythematous mucosa with severe, fibrinous erosions. Acute and chronic inflammation
July 10	First dose Infliximab
July 11	Discharged; continued prednisone
July 18	Initiated tapering of prednisone
July 24	Second dose Infliximab
August 8	EGD	Slight to moderate gastritis without ulcerations and fibrinous membranes. Improvement compared to the first EGD
September 17	PET-CT (Figure 4)	No FDG uptake in the gastric wall
September 26	Discontinued prednisone

ALT: Alanine transaminase; PET-CT: Positron emission tomography with computed tomography; EGD: Esophagogastroduodenoscopy; EUS: Endoscopic ultrasound; MRI: Magnetic resonance imaging; FDG: Fluorodeoxyglucose.