P096 Successful vedolizumab therapy in an elderly patient with ulcerative colitis and refractory immune thrombocytopenic purpura
Authors: Bruno Silva , Carolina Sacramento , Felipe de Campos , Maria Dias 
Published: July 2019

BACKGROUND:
Extraintestinal manifestations (EIM) are common in inflammatory bowel disease (IBD) patients and may occur before or after the diagnosis of IBD. In general, the most common EIM usually affect joints, skin and eyes. However, less often other systems can also be affected. The occurrence of immune thrombocytopenic purpura in IBD patients is rare and poorly described in the literature.

CASE:
A 61-year-old man was admitted with a history of diarrhea. Admission laboratory tests showed anemia and iron deficiency. There were also mild thrombocytopenia. The patient reported a history of ulcerative colitis (UC) diagnosed 7 years ago (pancolitis). There were several clinical recurrences, with episodes of severe anemia, requiring hemotransfusion in some occasions. He used 5-ASA without improvement. He reported different courses of prednisone 40 mg per day, with clinical remission. He used azathioprine for about 6 months, but there was no clinical remission free of corticosteroids. Colonoscopy showed a suggestive aspect of UC (pancolitis), with severe endoscopic activity (Mayo ES 3). The patient underwent corticosteroid therapy. He presented clinical remission and was discharged in order to initiate biological therapy on an outpatient basis. After discharge, the patient suspended steroid therapy on his own and did not return to the office for follow-up. Two months later, he developed a new UC relapse and was hospitalized again. Laboratory tests showed a significant worsening of thrombocytopenia (5,000 per mm3 platelets). Prednisone was performed again. The patient achieved clinical remission but maintained severe thrombocytopenia. The diagnosis of Immune thrombocytopenic purpura (ITP) refractory to corticosteroids was considered. Then, the patient underwent different immunoglobulin infusion sessions. He presented a temporary improvement in platelet count (20,000 to 50,000 per mm3), but in a few weeks he returned to severe thrombocytopenia (< 5,000 per mm3). Patient was then treated with rituximab. After the third dose, he developed septic shock. It improved after meropenem use. Due to the severe infectious episode, rituximab therapy was discontinued and romiplostim treatment was initiated. There was partial improvement of the thrombocytopenia and the patient maintained the weekly use of the medication. In August 2017, the patient started vedolizumab. After 14 weeks he evolved with clinical remission free of corticosteroids. The patient remained in clinical remission without corticosteroids in the first 12 months of treatment with vedolizumab. Colonoscopy performed 11 months after the beginning of the biological therapy showed mucosal healing (Mayo ES 1). He was maintained throughout this period with progressive improvement of the platelet count, with weekly doses of romiplostim. After the eleventh month of treatment with vedolizumab, there was a reduction in the dose of romiplostim due to improved thrombocytopenia (>200,000 per mm3).

DISCUSSION:
Physicians should be alert to the occurrence of severe thrombocytopenia in a IBD patient. ITP is considered a rare extraintestinal manifestation and appears to be related to the activity of IBD. In the case reported, clinical and endoscopic remission induced by vedolizumab seems to have been a decisive factor for the gradual improvement of thrombocytopenia, including the partial weaning of romiplostim.