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.