case_images: PMC10213227_01
case_images: Upper gastrointestinal endoscopic images showing (A) a deep, large mucosal ulcer in the angular incisure and (B) pyloric ring stenosis caused by a bleeding mucosal ulcer.
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case_images: Upper gastrointestinal endoscopy (UGE) revealed a severe ulcer in the angular incisure and antrum of the stomach ( Figure 1A ), which was treated with esomeprazole 20 mg/day. The endoscope could not pass through the duodenum due to ulceration-induced stenosis of the pyloric ring ( Figure 1B ).
case_images: Microscopic image (400x) of the gastric mucosa stained with hematoxylin and eosin (A) showing marked intraepithelial lymphocytosis with prominent apoptotic bodies:arrows. Microscopic image (400x) of the immunohistochemically stained gastric mucosa (B) showing CD8+ T cell infiltrates:arrowheads.
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case_images: Histopathology revealed lymphoplasmacytic infiltration into the fundic gland mucosa without evidence of infection or malignant neoplasia ( Figure 2A ). T cells ( Figure 2B ), suggesting pembrolizumab-induced gastritis. Therefore, pembrolizumab treatment was discontinued.
case_images: Time-course of immunosuppressant therapy (A). Pulse corticosteroid therapy with mPSL 1,000 mg/day was started 97 days after initiating corticosteroid therapy with oral PSL. After 3 doses of the latter therapy, oral PSL 2 mg/kg/day was administered in combination with MMF. Time-course changes in serum AST and ALT levels (B). Serum ALT levels increased despite co-treatment with PSL and MMF, which prompted the initiation of tacrolimus. Serum AST and ALT levels decreased after initiating tacrolimus administration. AST, aspartate aminotransferase; ALT, alanine aminotransferase; mPSL, methylprednisolone; PSL, prednisolone; MMF, mycophenolate mofetil.
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case_images: The oral prednisolone dose was slowly tapered under close blood monitoring ( Figure 3 ). The patient was discharged 60 days after hospitalization and had no indication of solid food dysphagia at 2 months after initiating tacrolimus treatment.