A 53-year-old male with a history of hypertension and smoking for up to two months.
She was admitted for presenting diarrhea and rectal bleeding for three weeks, with progressive intensity.
In recent days he reported numerous bloody stools with abdominal discomfort and fever (38oC).
Physical examination showed a patient with acceptable general status, normal skin and mucous coloration, normal cardiorespiratory auscultation.
TA: 102/62.
Heart rate: 82 s/m.
The abdomen was painless and not distended.
Laboratory tests revealed elevated C-reactive protein (152.2 mg/dl), decreased total protein (4.7 g/dl) and cholesterol (70 mg/dl).
Hemoglobin levels, number of leukocytes and general and hepatic biochemistry were normal.
Coprocultive agents were isolated from stools and negative serology for cytomegalovirus.
Abdominal X-ray shows the colon full of air, with signs of wall edema and distortion of the pattern of haustra.
In rectosigmoidoscopy, data on severe ulcerative colitis were obtained.
Histology was compatible with this diagnosis, with no data of cytomegalovirus infection.
Treatment was established with absolute diet, parenteral nutrition, intravenous methylprednisolone.
(1 mg/kg) and antibiotics.
The patient, after a slight improvement in the first 48-72 hours, again presented numerous stools with increased rectal bleeding, decreased hemoglobin (7.5 g/dl) and haematocrit (21%), with a biochemical increase of reactive C.
Abdominal X-ray showed changes similar to those described at the time of admission.
The lack of response to steroid treatment is proposed with infliximab (5 mg/kg).
Cyclosporine is dismissed due to low cholesterol levels and difficulty in controlling serum levels.
Chest X-ray showed no abnormalities and Mantoux intradermal reaction was negative.
Abdominal X-ray, on the same day as the beginning of treatment with infliximab, showed choledocholithiasis absence, with loss of distraction and a transverse colon diameter of 8-9 cm.
Abdominal computed tomography showed neither pneumoperitoneum nor abdominal free fluid.
Toxic megacolon was diagnosed and it was decided, according to the patient, to assess the response to infliximab treatment with maximum medical-surgical surveillance.
The same clinical situation persists in the first 24 hours, but improvement is evident 48-72 hours later, with a decrease in the number of stools, rectal bleeding and absence of abdominal dyspnoea.
Progressive remission of radiological and laboratory abnormalities was observed.
Two weeks later, when the patient presented only 2-3 bloodless stools, a new dose of infliximab was administered, which was repeated at 6 weeks, and the patient was asymptomatic.
Steroid dose was progressively reduced, infliximab was discontinued and the patient was included in a treatment program every 8 weeks with infliximab.
Endoscopic control was performed at 6 months. The patient was asymptomatic, numerous pseudopolyps and had no inflammatory activity.
