Ulcerative Colitis Associated with Aplastic Anemia; A Case Report
A 45-year-old man a known case of ulcerative colitis since 7 years ago was admitted to the hematology wardof our hospital with fatigue and high fever.\nAt the first (7 years ago) he presented with bloody diarrhea (up to 10 urgent trips to bathroom per day), tenesmus, emergency sensation, fever, abdominal pain, and weight loss (about 5-lb) to the emergency department for 7 days. He denied emesis or extra intestinal manifestations. Laboratory evaluation and abdominal radiographs were significant only for a hemoglobin level of 10.8 g/dl. He has had no history of medical illness or surgeries, recent antibiotic or nonsteroidal anti-inflammatory drug use, and no known sick contacts or exposure to tainted foods. He has had experienced increased emotional stress for several weeks due to tumultuous personal relationship. He is a lifelong nonsmoker.\nThe patient was admitted in the hospital and treated for presumed infectious enterocolitis for intravenous hydration, and empirical ciprofloxacin. Stool culture was negative for infection, but fecal leukocytes were present. After 48 hours with minimal response to therapy, he underwent a flexible sigmoidoscopy and biopsies were taken. Sigmoidoscopy (,), showed friable and erythematous mucosa in a diffuse circumferential distribution from the anal verge to the splenic flexure with petechial hemorrhage, shallow ulcerations surrounded by injected mucosa, and an abnormal vessel pattern in the sigmoid to descending colon. The changes involved a length of 50 cm from anal verge. There were no pseudomembranes. Histologic evaluation showed acute and chronic inflammation with crypt branching and irregularity of size and shape, with an increase in chronic inflammatory cells in the lamina propria (,,).\nUltimately the patient was diagnosed as a case of left sided UC. The bloody diarrhea resolved after 2 weeks of treatment with mesalazine (4g/day) and hydrocortisone intravenously (300mg/day). The steroid dose was reduced and eventually discontinued after 5 months of treatment.\nTwo years ago referred with relapse of UC, and was treated with mesalazine (4g/day) and prednisolone (30mg/day) for the exacerbation of UC. Despite his relief of his ulcerative colitis, the patient’s laboratory data showed a worsening of the pancytopenia without any gastrointestinal symptoms. His Laboratory findings revealed a hematocrit of 14.5%, and hemoglobin 11.9 g/dl with normocytic appearance (MCV; 94.1 fl & reticulocytes 9×109/liter), white blood cell count (WBC) of 2 ×109/liter, an absolute neutrophilcount (ANC) of 0.3× 109/liter, and a platelet count of 80 × 109/liter. Bone marrow biopsy was consistent with a diagnosis of aplastic anemia (AA). The patient’s medical history was negative for exposure to a myelotoxic agent, a recent infection, blood transfusion, sexual promiscuity, or acute hepatitis. The patient’s serum IgG and IgA concentrations and C3 complement were normal. Serum anti-nuclear antibody and anti-DNA antibody were also negative.\nIn the hospital course his hemoglobin level dropped to 5.9g/dl; WBC count was 3.1×109/liter; and platelets counts were dropped to 68×109/liter. A bone marrow aspirate and biopsy was done for patient that showed trilineage hypoplasia, and a diagnosis of aplastic anemia was made. Two units of blood were transfused, and treatment with Danazol was initiated. The dose of Danazol was adjusted between 250-300 mg/day. Three month after termination of Danazol, pancytopenia was relapsed and the treatment with cyclosporine (CyA; 300mg/day) was initiated. The dose of CyA was adjusted to maintain a trough concentration between 200~250ng/ml in the whole blood. The patient’s hemoglobin level had increased to 10.2g/dl, his WBC count raised to 5.4×109/liter, and his platelet count to 132×109/liter. The ulcerative colitis has remained in remission, and the patient’s blood counts remained stable in his follow up.