Gastrointestinal: An unusual rectal finding in a patient with ulcerative colitis

A 67‐year‐old man, with an acute flare of severe ulcerative colitis, on therapy with azathioprine for steroid‐dependent disease for 6 years was referred to our Inflammatory Bowel Disease Unit in 2015 because of severe anal pain and bloody diarrhea. Rectosigmoidoscopy showed multiple inflammatory pseudopolyps, erosions, and, close to the anal verge, a large ulceration of about 5 cm with irregular border (Fig. 1). Histology of the lesion showed a framework compatible with active severe ulcerative colitis. He underwent a pelvic magnetic resonance imaging, which excluded the presence of complications (i.e. abscess or neoplasia). Thereafter, after a negative screening (hepatitis B virus DNA load in the blood was lower than 1000 copies/mL with negative Epstein–Barr virus [EBV] immunoglobulin M), infliximab 5 mg/kg i.v. was started. However, the patient was admitted to the Neurology Department because of neurological changes (psychomotor retardation, confusional state, asthenia, and tremors). A diagnosis of postinfectious encephalitis from EBV reactivation (EBV‐DNA 2378 copies/mL; microbiological investigations on liquor were negative) was performed, and acyclovir therapy was started with rapid resolution. Infliximab was stopped, and due to the severe persisting condition, a proctocolectomy was performed. The histological report was positive for a typical complication associated to inflammatory bowel disease (IBD) patients on thiopurine treatment that is colorectal lymphoma (Fig. 2).