Exacerbation of ulcerative colitis

A 17-year-old girl with a history of ulcerative colitis and a recent pilonidal cyst excision was admitted to the hospital with fever, severe abdominal pain, and frequent, bloody diarrhea. The diagnosis of idiopathic ulcerative colitis was made 4 years before admission and was based on colitis symptoms, endoscopic pancolitis, and unequivocal histological changes. The patient was started on sulfasalazine and prednisone therapy but failed to achieve a complete remission. One year before admission she was having three episodes of bloody diarrhea daily. Her medications were prednisone, 30 mg daily, and sulfasalazine, 1 g t.i.d. She complained of intolerable mood swings due to prednisone, but tapering resulted in continuous diarrhea. Her colonic mucosa was edematous, erythematous, granular, and friable from the mid-descending colon to the rectum. The patient responded well to the addition of one 4-g mesalamine enema per day, and steroid therapy was tapered off completely over the next 8 months. She experienced a brief relapse 3 months before admission manifest by abdominal cramping and two to three blood-streaked, loose stools per day. The patient attributed this relapse to a viral upper respiratory infection she had contracted several days earlier. She observed that her colitis flared “every time she had a cold.” This relapse resolved with an increase in oral sulfasalazine and mesalamine enemas. When the patient was seen 10 weeks before admission she was in clinical and sigmoidoscopic remission, with no complaints of pain, diarrhea, or bleeding on a regimen of sulfasalazine, 2 g daily, and mesalamine enemas, 2 g daily. The patient was scheduled to have a pilonidal cyst excised. The case was discussed with the surgeon, who agreed not to use antibiotics perioperatively unless treating a specific infection because of the concern about provoking antibiotic-induced diarrhea or Clostridium dijjkile colitis. Several days before surgery the patient developed recurrent fevers and pharyngitis. Her examination showed tonsilar hyertrophy, but there was no significant adenopathy or splenomegaly. Her white blood cell count was elevated to 1300 with 78% lymphocytes, most of which were atypical. Results of a mono spot test were positive, and infectious mononucleosis was presumed to be the cause of the patient’s fevers. Surgery was performed 7 weeks before admission. The patient’s ulcerative colitis remained in clinical remission throughout her febrile illness and during the immediate postoperative period. However, 2 weeks after surgery (5 weeks before admission) she developed abdominal cramping, tenesmus, and bloody stools. Her symptoms became worse despite an increase in her sulfasalazine to 4 g daily and mesalamine enemas to 4 g daily. A flexible sigmoidoscopy performed approximately 2 weeks before admission revealed mucosal edema, erythema, granularity, and friability from the rectum to the descending colon. The hematocrit was 29.5%, the white cell count was 8100, the platelets were 625,000, and the erythrocyte sedimentation rate was 58 mm/h. The differential white blood cell count showed 16% segmented neutrophils, 16% banded neutrophils, 39% lymphocytes, 9% monocytes, and 20% eosinophils. Because of the patient’s eosinophilia and worsening condition, the sulfasalazine dosage was reduced to 2 g daily. Abdominal pain, stool frequency, and bleeding all continued to increase. The patient, complaining of progressive weakness, was admitted to the hospital after a syncopal episode during a phlebotomy. Physical examination revealed a pale, thin, and mildly diaphoretic female patient. Her temperature was 37.8”C, her heart rate was 100 per minute, and her systolic blood pressure was 100 mm Hg supine but fell to 90 mm Hg in the sitting position. She had no ocular or oral lesions, and the chest examination results were normal except for tachycardia. The patient had active bowel sounds, and her abdomen was soft and nondistended with mild, diffuse tenderness. There was no rebound, guarding, or liver or spleen enlarge-