Case Presentation: A 42 year old African American male with a recent diagnosis of Ulcerative Colitis (UC) presented with recurrent bloody diarrhea, abdominal pain, fevers, chills, weight loss and was admitted for management of a presumed UC flare. On a previous admission 2 months prior, he had been diagnosed with UC with a colonoscopy and biopsy. He was started on oral steroids and discharged. Subsequently, the patient was readmitted 2 weeks later with ongoing bloody diarrhea and workup revealed suppressed TSH, elevated free T4 and T3 levels. No treatment was initiated for the hyperthyroidism and the patient was discharged on a steroid taper with outpatient follow up.
He continued to have unrelenting complaints for which he was admitted to an outside hospital, where intravenous steroids were initiated along with a single dose of intravenous infliximab. In the absence of significant clinical response, patient was transferred to our hospital for the current admission.
On exam, vital signs showed a HR of 113/min, and temperature of 37.2°C. Abdominal exam was significant for diffuse tenderness without guarding. Laboratory workup revealed was significatn for Platelets 431,000, ESR 86 mm/hr, CRP 12.4 mg/dl, TSH of 0.00, T4 2.9 ng/dl and T3 10.1 pg/dl. Thyrotropin antibodies were positive. Thyroid ultrasound revealed a diffusely enlarged thyroid gland confirming a diagnosis of Graves disease. CT scan of the abdomen with contrast revealed pancolitis consistent with severe acute UC. Stool antigen test was negative for Clostridium difficile.
Treatment for hyperthyroidism was initiated with propranolol, and methimazole. Interval repeat thyroid function tests confirmed improvement. For the UC flare, he was started on oral mesalamine along with intravenous steroids. Due to poor response, mesalamine enemas were added after a few days. Clinical improvement was gradual and the patient was eventually discharged with methimazole, propranolol, oral prednisone and mesalamine.
Discussion: Steroid refractory – UlC is defined as lack of meaningful clinical response to oral glucocorticoids (40-60 mg/kg/day of prednisone or equivalent) within 30 days or to intravenous steroids for 7-10 days. Steroid refractory- UC is a clinical dilemma that requires meticulous workup to re-evaluate for an underlying infection, alternative diagnoses such as Crohn’s disease or complications. However, physicians should also be aware of another reversible etiology for steroid refractory- UC i.e Hyperthyroidism and once recognized, should treat it rapidly to prevent high mortality and morbidity from this overlapping fulminant condition.
Hyperthyroidism can aggravate the symptoms of IBD and render it refractory to therapy and similarly untreated UC can set off hyperthyroidism. This case illustrates the high prevalence of autoimmune thyroid disorders with coexisting IBD (3.8% vs 1.3% for the general population). Hyperthyroidism is more common than hypothyroidism with the estimated incidence in UC reported at 0.8%-3.7%. Thyroid disease may follow the diagnosis of IBD but more often precedes the diagnosis of IBD. The incidence of thyroid disorders with concomitant Crohn’s disease is lower than that with UC.
Conclusions: The presence of coexisting thyroid disorders should especially be considered in cases of IBD that are refractory to initial glucocorticosteroid therapy. Early treatment of underlying hyperthyroidism or underlying coexisting precipitants can accomplish a more rapid control of UC symptoms and thereby prevent increased morbidity.