Case Report A Case of Elderly-Onset Ulcerative Colitis with Large-Vessel Giant Cell Arteritis Treated Successfully with Tofocitinib

Introduction: Large vessel vasculitis, including Takayasu arteritis and giant cell arteritis (GCA), is a recognized extraintestinal manifestation of ulcerative colitis (UC), but its optimal management remains unclear. GCA is the principal systemic vasculitis in individuals aged over 50 years, and large vessel involvement may occur with or without cranial disease. We report a case of UC complicated by inflammation of the thoracic aorta and the proximal left subclavian and brachiocephalic arteries. Case Presentation: A 78-year-old man was diagnosed with proctitis-type UC. Mesalamine was switched to rectal budesonide enema plus azathioprine owing to intolerance. One month later, fever and neck pain appeared. Continuous linear hyperintensity on T2-weighted magnetic resonance imaging extended from part of the ascending aorta through the descending aorta, involving the aortic arch and the proximal left subclavian and brachiocephalic arteries and becoming less conspicuous distally. Corresponding images of contrast enhanced T1 weighted sampling perfection with application optimized contrasts using different flip angle evolutions with spectral pre saturation with inversion recovery demonstrated matching mural enhancement, consistent with large vessel GCA. Tocilizumab was administered, but UC relapsed, prompting adalimumab initiation, which later resulted in loss of response. Infliximab was attempted but was discontinued because of an infusion reaction. Prednisolone 10 mg/day resulted in improvement, and tofacitinib was introduced for steroid tapering. Conclusion: This case highlights the importance of considering large-vessel GCA in elderly-onset UC with unexplained fever and demonstrates the potential role of tofacitinib in achieving steroid-free remission and vascular inflammation, offering a potential novel therapeutic option for refractory overlap syndromes.