Case presentation
A 75-year-old male patient, with a prior medical history including
long-standing hypertension, recurring episodes of peripheral joint
arthritis, leg skin lesions reminiscent of erythema nodosum, and
persistent chronic diarrhea over the past two years, was recently
hospitalized at the rheumatology department of Imam Reza Hospital in
Tabriz. His admission was prompted by a worsening of diarrhea and the
development of polyarthritis in the peripheral joints. Furthermore, he
exhibited distinctive palm skin lesions (as depicted in Figure 1), along
with sensations of tingling and paresthesia in his extremities and an
increase in blood creatinine levels. Throughout the patient’s hospital
stay, a series of diagnostic assessments were conducted, encompassing
procedures such as colonoscopy (as shown in Figure 2), Electromyography
and nerve conduction studies (EMG-NCS), echocardiography, renal
ultrasonography, and standard hematological analyses (Table 1). Notably,
the colonoscopy result was: Multiple ulcers with congested
and erythematous and friable mucosa, prompting a subsequent intestinal
biopsy that yielded findings consistent with a diagnosis of ulcerative
colitis (Figure 3) . The result of the EMG-NCS was reported as follows:
moderate axonal sensory motor polyneuropathy with superimposed newly
onset left median and ulnar neuropathy compatible with mononeuritis
multiplex neuritis. In echocardiography EF (Ejection Fraction) 35-40%
with normal LV (Left Ventricular Size) and RV (Right Ventricular) size
was reported. Ultrasound of kidney and urinary tract did not reveal any
abnormalities and shape, size, and echogenicity of the kidneys were
reported as normal.
Based on a comprehensive array of diagnostic findings, encompassing both
colon and skin and nerve biopsies, the patient’s medical condition was
ascertained. The colon biopsy confirmed the presence of active
ulcerative colitis while excluding any associated vasculitis-related
indicators. Simultaneously, the skin and nerve biopsy yielded no
indications of vasculitis. Consequently, the patient received a formal
diagnosis of ulcerative colitis concomitant with mononeuritis
multiplex and underwent the following therapeutic regimen.
The initial phase of treatment involved the administration of
corticosteroid pulse therapy at a dosage of 1 gram per day, administered
consecutively for three days. Additionally, the patient received a 750
mg ampoule of cyclophosphamide as part of the prescribed therapeutic
protocol.
Pulse Corticosteroid : The treatment began with a high dose of
corticosteroids \ administered intravenously at 1 gram
per day for three consecutive days. This approach is aimed at rapidly
reducing inflammation.
Cyclophosphamide : On the same day, the patient received an
injection of cyclophosphamide at a dose of 750 mg. Cyclophosphamide is
an immunosuppressive medication often used to treat vasculitis by
suppressing the overactive immune response.
Mesalamine: Based on a consultation with a gastrointestinal
specialist, the patient was prescribed mesalamine
During the hospitalization, the patient’s diarrhea ceased, and their
hydration improved. Additionally, their creatinine levels
decreased(creatinine =1.1), indicating a positive response to treatment.
As a result, the patient was discharged from the hospital with the
following medications:
Prednisolone : The patient was prescribed prednisolone at a dose
of 20 mg three times a day (TDS).
Mesalasine : Mesalasine is another medication commonly used in
the treatment of IBD.
Cotrimoxazole and Monthly Cyclophosphamide Injection : The
patient received cyclophosphamide injections on a monthly basis.
In accordance with the patient’s recent follow-up conducted over the
past 20 days, it is notable that recurrent episodes of diarrhea have not
been reported. Additionally, the patient has shown substantial
amelioration in parathesis and tingling symptoms, and notably, the
previously evident arthritis has demonstrated complete resolution. These
observed clinical improvements signify a promising response to the
treatment and suggest a positive trajectory in the management of the
patient’s condition.