LAUSR

A 28-year-old man with a history of ulcerative colitis (UC) underwent specialist consultation in order to determine the appropriate medical therapy needed to optimally treat his disease. His UC diagnosis occurred 4 years prior to referral, when he developed abdominal pain and bloody diarrhea. Colonoscopy revealed proctosigmoiditis with a normal terminal ileum. Oral and rectal mesalamine given as inductive and maintenance therapy improved his symptoms for 8 months, although he never achieved true clinical remission. Approximately 1 year later while on a trip in South America, he developed a disease flare with no evidence of infection. Symptoms resolved after initiation of prednisone. He was then tapered off prednisone and continued on mesalamine oral and topical therapy. Two years later, his symptoms worsened requiring hospitalization. A flexible sigmoidoscopy revealed severe leftsided colitis (Mayo endoscopy score of 3) with the presence of deep ulcerations and spontaneous mucosal bleeding. He received intravenous infliximab at a dose of 5 mg/kg that was repeated 1 week later for a total of two doses. His baseline serum albumin at the time of admission was 4.5 g/dl. He was discharged receiving prednisone 40 mg/day with plans to continue infliximab as an outpatient, but he was rehospitalized 2 weeks later with persistent severe diarrhea passing ten bowel movements/day despite prednisone 40 mg/day. Repeated flexible sigmoidoscopy with biopsies demonstrated histologic changes consistent with cytomegalovirus (CMV) colitis. After therapy with ganciclovir, infliximab was increased to 10 mg/kg dosing and methotrexate was initiated at a dose of 25 mg subcutaneously once a week with concurrent folate 1 mg/day. Overall, his UC symptoms were much improved although he did have episodes of herpes zoster and Molluscum contagiosum. At this time, the patient transitioned his care to our providers.