2071 Rare Case of Ulcerative Colitis with Autoimmune Hemolytic Anemia

INTRODUCTION: Inflammatory Bowel disease (IBD) encompasses Ulcerative colitis (UC) and Crohn’s disease. UC is a chronic inflammatory process causing inflammation limited to the mucosal layer of the intestine. Anemia can occur due to multiple reasons in UC - iron deficiency anemia, anemia of chronic disease and rarely autoimmune hemolytic anemia. Here, we present an UC patient with rare manifestation of autoimmune hemolytic anemia (AIHA). CASE DESCRIPTION/METHODS: Report: 42-year-old male with significant past medical history of UC was admitted because of diarrheal episodes, jaundice for one week. He discontinued mesalamine two months prior to presentation. His vital signs were unremarkable and physical exam were was significant for pallor. Pertinent labs include hemoglobin: 5.7 g/dl, WBC count: 11.8 k/mm3, MCV: 113 fl, RDW 20.8%., Total Bilirubin: 4.1 mg/dl with direct of 2.7 mg/dl, LDH 592 U/L, and Haptoglobin was 8 mg/dl and reticulocyte count: 14.3%. On further studies cold agglutinin were found to be positive. Peripheral smear showed significant polychromasia, anisopoikilocytosis, macrocytes, mild agglutinated RBC. Stool studies were negative as well. Patient was transfused two units of blood. Colonoscopy with biopsy confirmed active colitis throughout cecum, ascending colon, transverse colon, sigmoid colon and rectum. Colonoscopy didn’t reveal any bleeding. Subsequently, patient was started on mesalamine, which lead to improvement of his symptoms. Hemoglobin level remained stable. Patient was discharged on maintenance dose and to follow up with hematology and gastroenterology as outpatient. DISCUSSION: AIHA is a rare complication of UC. It occurs in less than 1 % of UC cases. It is associated with acute flare up of UC. AIHA is caused by presence of warm agglutinins present in the blood that’s mostly IgG which reacts with the proteins on RBC membrane at particular temperature and causing hemolysis. There are several mechanisms causing AIHA in UC, IgG autoantibodies targeted against the RBC, modification of RBC when they pass through the colon and absorption of the antibodies from the colitis lesions. The treatment includes steroids and mesalamine. For resistant cases, immunotherapy and splenectomy can be considered and the last resort being colectomy. It is important to keep AIHA as a differential for secondary causes of anemia in patient with UC. Further studies are needed for the pathogenesis and treatment of the same.