Ergotomine-Induced Ulcerative Colitis

Abstract

Migraine headaches are commonly treated with ergotamines. Serotonin-1 5-hydroxytryptamine (5-HT 1) receptor agonists are first line agents for migraines. Intravenous dihydroergotamine (DHE) is sometimes used for refractory migraines. Previously published case report have suggested an association between 5-HT 1 receptors and onset of ulcerative colitis, however, this was dismissed as an unlikely cause. We report a case of a new diagnosis of ulcerative colitis associated with intravenous DHE use for refractory migraine. A 45-year-old female with a past medical history of severe migraines presented with a two month history of bloody diarrhea and abdominal pain. Her home medication regimen included naproxen and naratriptan. She was admitted to the Dartmouth-Hitchcock Medical Center (DHMC) a month prior for intractable migraines, where she received seven treatments of IV dihydroergotamine (DHE). During her second infusion of DHE, she developed severe abdominal cramps with associated bloody diarrhea. Infectious workup including stool for C. Difficile was negative. She was subsequently treated for infectious colitis with ciprofloxacin/metronidazole and discharged home. Two month post-discharge, she represented to DHMC for ongoing symptoms of abdominal pain, and bloody diarrhea (10-12 bloody bowel moments daily). In the Emergency Department she had a hemoglobin of 11 and C-reactive protein of 18.5 without an associated leukocytosis. An extensive infectious stool evaluation was negative. Sigmoidoscopy was performed and showed mild to moderate colitis extending from anal-rectal verge to 40 cm (the extent of the examination). The mucosa was characterized by diffuse erythema, edema, complete loss of the normal vascular pattern, granularity, contact friability and superficial ulceration (figure 1). Histopathology confirmed mildly active chronic colitis consistent with ulcerative colitis, without evidence of infection (Figure 2). She was treated with hydrocortisone 100mg IV q8hr with a rapid dramatic improvement in her symptoms. She was subsequently transitioned to prednisone with a planned taper and mesalamine 4.8g daily. Repeat colonoscopy four months later showed complete mucosal healing (Figure 3).Figure 1Figure 2There has being one case report of ergotamine induced ulcerative colitis in the literature. Since ergotamines are used wildly for the treatment of migraines, it is important to understand if there is a true association with inflammatory bowel disease. The mechanism of ergotamine inducing ulcerative colitis is not completely understood. However, the hypothesis is that vasoconstriction leads to ischemia triggering a pro-inflammatory state. We report this case to raise awareness of this possible association so that it can be identified and studied further in the future.Figure 2