The versatility of autoimmune pathology in inflammatory bowel diseases. A case report

Multisystem nature is characteristic for inflammatory bowel diseases (IBD), which is considered a predictor of unfavorable course. According to the European Crohn’s and Colitis Organisation (ECCO) extraintestinal manifestations (EIMs) are defined as "an inflammatory pathology in a patient with IBD that is located outside the gut whose pathogenesis is either dependent on extension/translocation of immune responses from the intestine, or is an independent inflammatory event perpetuated by IBD or that shares a common environmental or genetic predisposition with IBD". Data from several studies indicate that EIMs may affect 50-60% of patients. This report describes a case of HLA-B27-positive ankylosing spondylitis (AS) diagnosed prior to the confirmation of ulcerative colitis (UC) with subsequent development of idiopathic chronic pancreatitis. At onset, elevated acutephase reactants were revealed. MRI demonstrated active bilateral stage III sacroiliitis and active spondylitis of all lumbar vertebrae. Sulfasalazine was initiated. Subsequently given the absence of peripheral manifestations of AS, a decision to initiate therapy with upadacitinib 15 mg daily was made. Several years later a diagnosis of UC was established. Consequently, the upadacitinib dose was increased to 30 mg daily, achieving control of AS and clinical and endoscopic remission of UC. Later, contrast-enhanced abdominal computed tomography (CT) was performed due to abdominal pain. Chronic calcific pancreatitis was revealed. The patient's history of alcohol and smoking was negative. Laboratory investigations ruled out hypertriglyceridemia, elevated IgG levels, antinuclear antibodies. There were no autoimmune pancreatitis-specific CT features and histopathological findings. While the autoimmune pancreatitis is considered unlikely, it cannot be definitively ruled out due to the absence of all diagnostic criteria, including IgG4 subclass evaluation. Therefore, maintaining a high level of suspicion for immune-mediated pathology increases the chances of an accurate diagnosis for both IBD and EIMs. This facilitates the selection of effective targeted therapy.

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