S2778 Ulcerative Colitis and Concomitant Pulmonary Sarcoidosis Leading to Colectomy: A Case Series

Abstract

Introduction: A recent analysis of 24 cases of ulcerative colitis (UC) with concomitant sarcoidosis found a common HLA serotype (Toshiyuki 2021), however its role in disease severity is unknown. We describe 2 pulmonary sarcoidosis patients with rapidly progressing refractory UC needing colectomy. Case Description/Methods: A 45-year-old male presented with 15-20 episodes of hematochezia a day with nocturnal bowel movements. He was diagnosed with UC and started on mesalamine and vedolizumab. He did not respond and was switched to multiple biologics including ustekinumab, adalimumab and infliximab. He ultimately underwent total colectomy within 1 year of diagnosis. He was diagnosed with pulmonary sarcoidosis 10 years prior, presenting with weight loss and chest pain. Prior to his UC diagnosis, he was not taking steroids for his pulmonary disease. His annual pulmonary function tests had been normal. A 52-year-old female presented with 3 months of hematochezia and anemia. She was treated for gastroenteritis but was hospitalized due to minimal improvement. Imaging, endoscopy, and histology confirmed colitis, thought to be Crohn’s disease (CD) but later reclassified as UC. She was started on infliximab but was a primary non-responder. After 1 year of therapy she was switched to vedolizumab but received 3 doses before switching to ustekinumab. Soon after induction, her symptoms warranted hospitalization, and colectomy was performed 3 years after diagnosis. She was diagnosed with pulmonary sarcoidosis 3 years prior to her UC diagnosis and had been on daily low-dose prednisone since then. (Figure) Discussion: Our patients were diagnosed with sarcoidosis well before their UC and had rapidly progressing disease despite biologic therapy requiring colectomy. Most studies address the link between CD and sarcoidosis. Increased CD4/CD8 ratios are specific for sarcoidosis with similar expansion of T cell subsets in patients with CD. Both have been observed more often among siblings and monozygotic twins suggesting a genetic component. A similar analysis has not been performed in UC patients. To date, there is only one case that found specific HLA serotypes associated with both UC and sarcoidosis. In addition, sarcoidosis was thought to lead to less penetrative disease and fewer colectomies. This contrasts with the cases presented here, which both progressed to colectomy within 3 years of diagnosis. Thus, more studies need to be conducted in patients with UC and sarcoidosis to further elucidate the prognosis and potential complications.Figure 1.: Diffuse severe inflammation characterized by erythema, friability and deep ulcerations of the rectum (Fig 1a. and 1b.). Less severe inflammation characterized by erythema of the sigmoid colon (Fig 2a. and 2b.).