Case Presentation: Ulcerative Colitis

Ulcerative Colitis: A Man With Ulcerative Colitis and Axial Spondyloarthritis

Simon Hong, MD | NYU Langone, NY

A 29-year-old man presents to your office with left-sided ulcerative colitis (UC), which had been diagnosed 10 months ago. At diagnosis, his index colonoscopy showed active colitis from the rectum to the descending colon, which was graded Mayo 2 in severity. He was treated with a prednisone taper and was started on mesalamine PO 4.8g daily with mesalamine rectal enemas with only a partial clinical response. He was then started on adalimumab every 2 weeks. 

The patient now presents to your office with continued rectal bleeding and urgency, is showing low drug levels with high antibodies to adalimumab, and is inquiring about biologic therapies. On further review of systems, you elicit that in the last 2 months the patient has noticed back pain that is worse in the morning, improves with activity, and occasionally wakes him up in the middle of the night, requiring him to walk around. You arrange for further testing and find that he is positive for HLA-B27; an MRI of the spine shows active sacroiliitis.

Extraintestinal manifestations (EIMs) occur in up to 50% of patients with inflammatory bowel disease (IBD), and symptoms involving the rheumatologic system are the most common type.1 This patient has axial spondyloarthritis (subtype: ankylosing spondylitis), the diagnosis of which is based on the presence of inflammatory back pain, serologic and radiologic evidence of axial joint inflammation and confirmation by a rheumatologist.2