An Unusual Cause of Headache in Ulcerative Colitis

Abstract

Introduction: A 21-year-old female with pan-colonic ulcerative colitis (UC) was admitted to our hospital with headache, abdominal pain, bloody diarrhea, and seizures. Two months prior to presentation, she was diagnosed with moderate UC and was initiated on oral and rectal mesalamine. On arrival to the ED, she had a seizure and was treated with anti-epileptics. Initial labs were notable for a WBC count of 24.3, platelets of 530, normal hemoglobin, sodium of 126, albumin of 2, and ESR/CRP of 40/15.5 respectively. A head CT showed left temporal hemorrhage with additional hemorrhage in the region of the sigmoid sinus. A subsequent MRI/MRV revealed thrombus in the left transverse sinus, sigmoid sinus, and jugular veins, as well as the cortical vein of Labbe. The patient was admitted to neurology and started on a heparin drip. The gastroenterology service was consulted for the bloody diarrhea. The patient was supposed to take oral mesalamine, but due to the pill burden, was non-compliant with therapy. A CT scan of abdomen/pelvis demonstrated pan-colitis with backwash terminal ileitis. C. diff and stool cultures were negative. The patient was restarted on oral and rectal mesalamine in addition to high-dose IV steroids. Her bloody diarrhea improved over a few days and she returned to regular, brown, formed bowel movements. The patient made a full neurologic recovery and was discharged on hospital day 9. Patients with IBD have been reported to have a 2- to 4-fold increase in lifetime risk of developing venous thrombosis (VTE). An estimated 1.3-6.4% of adults with IBD will develop cerebrovascular complications at some point in their lifetime. This increased risk can be attributed to factors such as inflammatory activity, hospitalization, medications (particularly steroids), and increased platelet number/activity. CVT almost invariably presents with headache as the major symptom, and approximately one-third of patients can experience generalized tonic-clonic seizures. IBD patients who develop CVT tend to be predominantly female, present at a younger age than the general population, and have active bowel disease at the time of presentation. CVT should be strongly considered in any IBD patient presenting with a new headache. MRI/MRA are the best imaging modalities for diagnosis and for follow-up. Prompt recognition and treatment is imperative in order to prevent mortality and neurologic sequelae. Thrombolytics and heparin are the treatments of choice in the acute period. Warfarin, low molecular weight heparin, and aspirin can be used for long-term prophylactic therapy.