S4905 An Uncommon Presentation of Aplastic Anemia in a Patient With Ulcerative Colitis

Introduction: Ulcerative colitis (UC) is a type of inflammatory bowel disease with numerous extraintestinal manifestations. Hematologic conditions associated with UC include iron deficiency anemia, myelodysplastic syndromes and leukemias. The pathophysiology is thought to be immune mediated. Few case reports have demonstrated aplastic anemia and associated UC. We describe a case of aplastic anemia in a patient with UC and highlight the diagnostic and treatment considerations. Case Description/Methods: A 48-year-old woman with UC, diagnosed 9 years prior to presentation, on mesalamine presented with hematochezia, bleeding gums, and pancytopenia found on outpatient labs. Physical exam showed ecchymosis. Laboratory studies showed a white count of 1.70 k/uL, hemoglobin 6.8 g/dL, platelet count 7 k/uL, and absolute neutrophil count 0.65 k/uL. Coagulation and nutritional studies, disseminated intravascular coagulation panel, direct antiglobulin test, and hemolysis labs were within normal limits. Gastroenterology was consulted, mesalamine was held, luminal evaluation was deferred given neutropenia and thrombocytopenia. Hematochezia resolved with optimization of platelet count. Hematology was consulted and recommended a bone marrow biopsy and dexamethasone. Serum protein electrophoresis showed no monoclonal peak, quantitative immunoglobulins were within normal limits, and bone marrow biopsy showed megakaryocytic aplasia. Genetic testing revealed a BCOR gene mutation which is associated with aplastic anemia. Intravenous immunoglobulin treatment was administered, and patient was started on cyclosporine. On gastroenterology clinic outpatient follow up, vedolizumab was initiated for UC management. However, patient experienced worsening thrombocytopenia in this timeframe, so vedolizumab was discontinued. Patient remains on cyclosporine therapy and antithymocyte globulin for aplastic anemia, which has been relatively stable. UC is in clinical remission as well, so luminal evaluation has been withheld. Discussion: This highlights a case of aplastic anemia in a patient with UC, rarely described in the literature. The importance of close follow up and laboratory monitoring are demonstrated, in case of possible adverse effects of treatments or novel diagnoses that may arise, as in this case. Immunomodulatory effects of cyclosporine therapy for aplastic anemia are likely contributing to current clinical remission of UC. Multidisciplinary care and approaches to treatment are necessary in cases of UC with underlying hematologic conditions.