Accelerated dose of ustekinumab for acute severe ulcerative colitis.

We read with interest Affendi et al. [1] report about a patient with severe ulcerative colitis who responded to an accelerated dose of ustekinumab. We have the following comments and concerns. The patient‘s endoscopic images do not show the typical Mayo score 3 appearances of colitis. Severe ulcerative colitis is characterized by diffuse, circumferentially affected, granular mucosa with superficial ulcerations that may coalesce. Figures from the case show discrete, deep, oval ulcers. Furthermore, it almost has a cobblestone appearance, more specific to Crohn‘s disease [2]. In addition to colon involvement in Fig. 1A, the small intestinal loops (possible ileal segments) are thickened and edematous in the right lower quadrant, distant from the cecum. There is also the appearance of fat stranding. In ulcerative colitis, involvement of intestinal segments distant from the cecum is not expected, being specific to Crohn‘s disease [3]. Due to the severity of the disease, a pancolonoscopy could not be performed; therefore, disease extension was described using computed tomography. Not exceeding splenic flexure, it was interpreted as left-sided colitis. According to his medical history, 3 grams of mesalazine was started three weeks prior to his admission. Mesalazine >2.4 g/dL enteral and 1-gram topical forms are recommended by the 2017 ECCO (European Crohn‘s and Colitis Organisation) guideline for left-sided ulcerative colitis. The remission induction rate at this dose is high when compared to placebo [4]. If the patient has left-sided ulcerative colitis, we anticipate a positive response to a sufficient dose of 5-acetylsalicylic acid preparation. Finally, the histopathological findings are not mentioned in the article. Although there are no pathognomonic features specific to ulcerative colitis, the presence of granulomas (which can be found in 15-36% of mucosal biopsies) could indicate Crohn‘s disease [4, 5]. LETTERS TO THE EDITOR