Clinical presentation

A 26-year-old man was diagnosed with a 4-month history of ulcerative colitis. At the time of diagnosis, an abdominal CT showed a thickened colorectum (figure 1A) and a normal liver (figure 1B). He was started on mesalazine 4 g/day and received this for approximately 2 months without therapeutic benefit. He clinically deteriorated and was admitted to the hospital with a fever of up to 38.5°C daily, abdominal pain and diarrhoea. Laboratory findings revealed significantly elevated white blood cells (13.86×10⁹/L), C reactive protein (69.5 mg/L) and elevated liver enzymes: aspartate aminotransferase 245 U/L, alanine aminotransferase 368 U/L (normal <50 U/L), γ-glutamyltransferase 672 U/L (normal <60 U/L) and alkaline phosphatase 418 U/L (normal range 40–129 U/L). There was no evidence of a recent infection with malaria, Lyme disease, hepatitis A, B, C or …