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Minjung Kim1*, Jinmann Chon1†, Hee-Sang Kim1, Jong Ha Lee1, Dong Hwan Yun1, Yunsoo Soh1, Yong Kim1, Myung Chul Yoo1 |
Inflammatory bowel disease (IBD) is a chronic systemic inflammatory disorder and it includes ulcerative colitis and Crohn’s disease. Thromboembolic event or CNS vasculitis is a rare extraintestinal manifestation of IBD. Cerebrovascular disorders have been documented in 0.12 to 4% of all patients with IBD. Cerebral infarction in patients with IBD is related to cerebral vasculitis as an autoimmune-mediated mechanism. We report a case of 49-year-old patient with ulcerative colitis who had multiple recurrent ischemic infarction.
A 49-year-old man presented to an emergency room with left-side weakness. He was diagnosed with right parietal lobe infarction, ulcerative colitis, ankylosing spondylitis, hypertension and dyslipidemia. He was on medications including aspirin, mesalazine and prednisolone. He had a kidney transplantation for autosomic dominant polycystic kidney disease. Initial brain diffusion weighted imaging (DWI) showed high signal intensity in right corona radiata with chronic small infarction at right parietal lobe. The antibody tests especially ANCA, ASCA and ANA showed negative findings. Another findings showed that CRP was less than 0.5 and hemoglobin was around 8.0 g/dL. In vessel wall MRI, diffuse wall thickening, a typical finding of vasculitis or atherosclerotic change, was seen along the both middle cerebral arteries(MCA), right anterior cerebral artery(ACA) and left vertebral artery(VA). Steroid pulse therapy for 6 days was performed in accordance with vasculitis. The symptoms of motor deteriorated several times and the newly observed small acute infarctions was confirmed at right posterior basal ganglia, right medial frontal lobe and right posterior cingulate gyrus. He was hospitalized again for renal biopsy due to BK viremia and held taking aspirin for biopsy. Left side weakness recurred and a new lesion at anterior cerebral artery territory was seen in DWI. In follow-up brain vessel wall MRI, the vessel wall enhancement previously seen in MCA are not observed. Diffuse wall thickening on right ACA and left VA showed equivocal changes. These findings are closer to vasculitis. He takes mesalazine 3600 mg, prednisolone 5 mg, aspirin 100 mg and cilostazol 200 mg per day.
In this case, two possibilities can be considered: vasculitis and less likely atherosclerosis which was seen in vessel wall MRI associated with ulcerative colitis as pathophysiology, resulted in a cerebral infarction. This case was accompanied by anemia, which can be considered another risk factor for infarction.
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