Case Presentation: A 21-year old female presented with fever, abdominal pain, diarrhea and hematochezia. Her past medical history was significant for ulcerative colitis and recurrent clostridium difficile infection. On exam, she had tender abdomen and erythematous tender nodules on legs. Her left eye was inflamed on the nasal sectorial area of sclera and conjunctiva with yellow, soft, tender and immovable 8×6 mm nodule (figure 1). Extensive infectious workup including blood cultures, stool studies, fungal and viral serology, was negative. CT abdomen and pelvis showed pancolitis. CRP was 23 mg/dL. She was diagnosed with ulcerative colitis exacerbation with associated erythema nodosum and anterior nodular scleritis. Flexible sigmoidoscopy showed congested, erythematous, eroded, friable, nodular and ulcerated mucosa. She was treated with intravenous steroids with significant improvement in her eye exam findings. No significant improvement in gastrointestinal symptoms was noted after steroid treatment. Due to persistent severe abdominal pain and profuse diarrhea she underwent partial colectomy.

Discussion: Extra intestinal and ocular manifestations of inflammatory bowel disease occur in around 10% cases. Common ocular complications are conjunctivitis (8.62%), blepharitis (6.9%), uveitis (5.17%), cataract (5.17%), and episcleritis (3.45%). Nodular scleritis is a rare condition and is seen in various autoimmune and infectious processes. Inflammation of anterior sclera is the underlying mechanism. It can be associated with herpes zoster, behcet’s syndrome, mycobacterium tuberculosis, takayasu arteritis, latent syphilis, sarcoidosis, chrohn’s disease and pyoderma gangrenosum. Medications like alendronate are also reported to cause nodular scleritis. Steroids and treatment of the underlying condition are the main modes of therapy.
To our knowledge, this is the first case report in the literature with the association of nodular scleritis with erythema nodosum in a patient with ulcerative colitis who ended up undergoing colectomy. This may suggest that nodular scleritis with erythema nodosum in a patient with ulcerative colitis indicates the severity of inflammation, and possible poor prognosis.

Conclusions: Hospitalists must be aware of ocular manifestations of inflammatory bowel disease. Whenever anterior nodular scleritis is associated with ulcerative colitis, poor response to medical therapy and poor prognosis may be predicted. Such cases need to be assessed for surgical intervention like for colectomy without delay.