Document resource
Background Ocrelizumab is a humanised anti CD20 monoclonal antibody. Thirty nine cases of ocrelizumab associated colitis are reported in literature and adverse event databases. The majority describe onset within months of ocrelizumab initiation. We herein report a case of severe ocrelizumab induced colitis following five years of therapy.Case presentation A 68-year-old male presented with four weeks of non-bloody diarrhoea and generalised abdominal pain. Pertinent medical history included primary progressive multiple sclerosis, on 6 monthly ocrelizumab for the proceeding five years. Stool testing identified Blastocystic species but was otherwise negative. Colonoscopy demonstrated deep ulcers in the left colon and near complete denudation of the right colon. Biopsy revealed extensive ulceration with focal ischaemic changes and an inflammatory infiltrate characterised by an absence of B cells. CMV was excluded by serology and biopsy.No improvement occurred following 48 hours of empirical intravenous antibiotics. Budesonide and intravenous methylprednisone were commenced for severe drug induced colitis. Prednisone was initiated at 60mg daily. On day 17 of prednisone therapy the patient experienced worsening abdominal pain. Inflammatory markers were newly up trending. They received a three-day course of methylprednisone and tofacitinib was commenced. Clinical and biochemical improvement was achieved. Three months later the patient remained well, with normalisation of biochemical parameters. Budesonide and prednisone were weaned. Tofacitinib continues.Conclusions CD20+ cells play a regulatory and protective role in the gastrointestinal system. Variable responses to treatment of ocrelizumab induced colitis are evidenced in case reports. This is the first case employing tofacitinib to achieve disease control.