Case Report Gastroenterology, Hepatology and Endoscopy Gastroenterol Hepatol Endosc, 2020 doi: 10.15761/GHE.1000203 ISSN: 2398-3116 Volume 5: 1-2 Ulcerative colitis associated with aplastic anemia and extra intestinal manifestations: Case presentation Maha M Maher 1 *, Fatma Adel 1 and Hazem M Rizk 2 1 Gastroenterology and Hepatology Unit, Masoura University, Specialized Medical Hospital, Egypt 2 London Northwest University Hospital NHS Trust, UK Abstract Association between infammatory bowel disease (IBD) and myelodysplastic syndrome, in particular aplastic anaemia was reported with possible share a common immune dysfunction pathway. Extra intestinal manifestations of IBD are also common and usually related to the activity of IBD. We report a case of active ulcerative colitis associated with aplastic anaemia, dermatological and thromboembolic extra intestinal manifestations. *Correspondence to: Maha Mohammad Maher, Gastroenterology and Hepatology Unit, Masoura University, Specialized Medical Hospital, Egypt, Tel: 00213 667 33 98 52; E-mail: wahibaguenif@yahoo.fr Key words: aplastic anaemia, immune dysfunction pathway, infammatory bowel disease Received: May 07, 2020; Accepted: May 22, 2020; Published: May 25, 2020 Introduction Ulcerative colitis (UC) is an autoimmune disease that mainly afects the mucosa of the colon. Haematological afection is commonly associated with UC. It can be due to multiple causes: blood loss, malabsorption, chronicity of UC, sepsis, associated myelodysplastic syndromes, or hemolysis [1]. Tere is a clinical association between infammatory bowel disease (IBD) and myelodysplastic syndrome, maybe they share an immune dysfunction and impairment of T-lymphocytes activities [2]. Extra intestinal manifestations of IBD are usually accompanied with activity of IBD. Case presentation We present a case of male patient 35 years old, complained of bloody diarrhoea more than 6 times / day. Patient has been diagnosed as ulcerative colitis for four years. On examination he was pale, average built, with slight diminution of vision. Tere was area of Pyoderma gangrenosum on extensor side of his right thigh. Patient had history of deep venous thrombosis for which he received warfarin for 6 months. His current therapy also included mesalamine 3 grams/day, 300 mg hydrocortisone was started afer his admission in Mansoura specialized medical hospital. Abdomen ultrasound and CT were free. His laboratory testing showed: Complete Blood Count: haemoglobin was 9.2 gm/dl, MCV: 77 f, Platelets: 42 /cmm 3 , WBCs:3 / cmm 3 , Reticulocyte count:1.2%, INR: 1, ferritin: 11.5 ng/ml, LDH :265 U/I (100-190), Creatinine: 0.9 mg/dl, uric acid: 4.8, Urinalysis: NAD. Serum calcium ionized 0.83 mmol/L(1.15-1.32), Serum albumin: 3.8 g/dl, serum bilirubin : 0.8 mg/dl (direct) 0.2 mg/dl, ALT: 13 mg/dl, AST: 13 mg/dl, alkaline phosphatase :228 U/L HBs-Ag, HBc -Ab IgM, HCV Ab, HIV Ab: all are –ve, CMV IgM -ve, Quantiferon TB:-ve. ESR: 30, CRP: 60, faecal calprotectin: 1000 ug/g, Coomb’s (direct) positive, (indirect) negative, ANA –ve, Prothrombin gene mutation: normal, Factor V Leiden: heterogenous gene mutation was detected. CBC was repeated serially due to pancytopenia. Haematological consultation advised bone marrow biopsy that showed marked hypo cellular bone marrow with 5-10% cellularity, the erythroid series is represented by few megakaryocytes and reduced myeloid series, with no detected abnormal deposits; picture suggestive of aplastic anaemia. He was advised to start Eltrombopag daily and epoetin alpha weekly with frequent substitution by transfusion of packed RBCs and platelets. Anticoagulant was started by recombinant hirudin 15 mg sc/12 hours. Tere was problem related to stating azathioprine as immune modulator due to his pancytopenia yet, anti TNF infiximab was started afer 2 weeks of his admission as well as cyclosporine by dose 300 mg daily. He showed improvement concerning the pyoderma gangrenosum and the activity of ulcerative colitis (Table 1). During his admission patient complained of more diminution of vision. Ophthalmological consultation ordered fuorescein angiography of the right eye that showed dilated capillaries of optic disc indicating disc edema and areas of haemorrhage giving impression of non- ischemic central retinal vein occlusion with difuse maculopathy. As for the lef eye there was mild retinal haemorrhage (impending vein occlusion) with increased central macular thickness and neurosensory detachment. He was advised to have frequent laser photocoagulation sessions that showed slight improvement (Figure 1). Start of ttt After 1 week 2 weeks 3 weeks 2 months 3 months 4 months Hb 10.8 10.1 8.7 8.6 7.9 6.2 8.9 Mcv 77 79 85 78 79 80 81 WBC 2.4 2.1 4.9 5.3 1.9 2.3 1.8 Neutrophils 23% 26% 20% 20% 20 20 7.5 Platelets 26 29 26 38 13 21 16 Table 1. Serial CBC