INSIDIOUS COMPLICATION OF ULCERATIVE COLITIS - CLINICAL DETERIORATION DUE TO OCCULT AND UNEXPECTED EXTRAINTESTINAL COMPLICATION

Introduction: Thromboembolic disease, including venous thrombosis and pulmonary embolism, is a well-established extraintestinal complication of inflammatory bowel disease (IBD). The frequency of these potentially lethal events mandates improved vigilance in clinical practice. Case presentation: A 28-years old man with no prior medical history was admitted through our Emergency Room for the first flare of extensive ulcerative colitis of moderate-severe activity. Due to a complex disease course requiring prolonged hospitalization, he was started on low dose low-molecular-weight heparin as a primary prophylaxis of venous thromboembolism. He became febrile after four weeks reporting just slight chest discomfort with no other symptoms. The occurrence of fever coincided with the ongoing study at our Department that included measurements of levels of blood coagulation factors and fibrin degradation products. Laboratory findings were consistent with acute thrombosis and despite low probability of pulmonary embolism according to Wells' criteria, no signs of peripheral deep venous thrombosis and no known accountable predisposing factors, we decided to do pulmonary angiography that revealed pulmonary embolism. Discussion: In the presented case, suspicion of pulmonary embolism was raised merely by the accidental laboratory findings suggestive of acute thrombosis, since our patient's clinical symptoms were initially ascribed to a more probable hospital-acquired pneumonia. However, clinical presentation of pulmonary embolism is often nonspecific. Whether a high-grade fever was atypical presentation of pulmonary embolism or was due to obscure infectious complication remains difficult to determine retrospectively. Conclusion: Our case illustrates how most atypical and unexpected scenarios are possible in IBD patients with thromboembolic complications. It also raises the question of need to alleviate the diagnostic criteria for pulmonary embolism in this high-risk group of patients in order to reduce mortality by prompt diagnosis and therapy.