I suffered a clinical relapse of ulcerative colitis in January 2021.

In early January, my health seemed to be excellent – I had no symptoms, my energy levels seemed normal, and I had a good overall sense of well-being. I even managed a short business trip (two nights) to Kuala Lumpur without any trouble.

My last clinic appointment with my gastroenterologist was on January 19, 2021. On that day, my blood tests (full blood count, CRP, and ESR) were normal. And since I seemed to be doing fine, my gastroenterologist recommended that I continue taking oral mesalazine (Salofalk) at a dose of 2 grams daily, i.e. 1 gram of Salofalk twice a day.

General Symptoms

Things took a turn for the worse in late January. I developed non-specific symptoms initially:

  • A feeling of general unwellness.
  • Fatigue. I was feeling fatigued most of the day, with episodes of incapacitating fatigue, which lasted anything between half an hour and several hours, occurring randomly during my waking hours.
  • Feeling warm/hot most of the day (without ever having a recorded temperature above 37℃ on a thermometer), but especially at bedtime.
  • Night sweats. I had experienced excessive perspiration at night in the past but not to this degree and not for so many consecutive nights. I didn’t and still don’t think the hot and humid weather was the main reason. The distance of my runs had been steadily rising. In January, I was running between 13 and 13.5 km per day. Likewise, the time I spent on my erg (indoor rower) had been increasing. In January, I was rowing about 68 minutes per session. At that time, I presumed the sensation of whole body warmth was somehow related to the exercise.

These symptoms not only persisted but became progressively worse. They were not associated with any change in weight or appetite, and at least in January, I did not experience any specific or localizing symptoms. I had not altered my medications in the months preceding onset of this episode.

My symptoms didn’t immediately make me think the cause was a relapse of ulcerative colitis. Instead, I considered the following:

1. Excessive exercise

The duration of my exercise sessions had been climbing since I recovered from a sprained back in October 2020. Below are the total number of hours of exercise I had done each month, as recorded in Strava, in 2020 and in 2021 to date.

Hours of exercise per month, Jan 2020–May 2021

As the data indicate, the increase in exercise duration between October 2020 and January 2021 was gradual, and I had achieved a similar level of activity, or greater, in the first three quarters of 2020 (without issue). Therefore, I did not expect that that level of exercise would have induced fatigue or a prolonged feeling of unwellness.

Further, following my workouts, I expected to feel warmer than usual for perhaps a few hours but not most of the day! Likewise, the nocturnal sweating occurred consistently every night, regardless of time of day of my workout.

2. Infection (COVID-19?)

COVID-19 was something worth considering. However, this seemed unlikely for several reasons:

  • Exposure to transmission has been minimized and minimal – I don’t leave the safe confines of my immediate home environment except when necessary, and even when I do venture out (e.g. for a run around the neighborhood), I take evidence-based precautions.
  • I did not have other symptoms suggestive of COVID-19, e.g. cough, shortness of breath, sore throat, loss of taste or smell, etc.
  • My symptoms never went away, albeit without any treatment, even after two months. I didn’t expect the symptoms of COVID-19 to persist for that long.

Similarly, flu and or flu-like illness seemed improbable.

3. Hormone Disorder

An endocrine condition, e.g. hyperthyroidism, pheochromocytoma, or carcinoid syndrome, could have explained my symptoms. Though no tests to examine this possibility were done, I didn’t think this was likely.

4. Autonomic Neuropathy

Autonomic neuropathy was in the differential diagnosis, but again, there were no other specific symptoms or signs to support this.

5. Cancer

Some cancers may cause non-specific symptoms like mine, but I deemed the risk to be small.

Lower Gastrointestinal Symptoms in February 2021

Though I knew I wasn’t well, I couldn’t put a finger on the problem. So, I continued my usual routine and hoped to ride out whatever was causing my health woes.

In the third week of February 2021, about a month after the onset of general symptoms, I developed lower gastrointestinal (GI) symptoms:

  • Diarrhea – Type 6 on the Bristol Stool Scale, these episodes were occurring almost every day.
  • Abdominal pain – Colicky in nature, in the left lower quadrant.

I didn’t immediately link the diarrhea and abdominal pain with my general symptoms because I had experienced all of them, though not simultaneously, on rare occasions in the past, even on my best days.

The penny finally dropped in the second week of March, when I started having anal canal inflammation, i.e. anusitis, with the following symptoms:

  • Warmth
  • Swelling – a circumferential anal lump
  • Itching

At no time was there blood or mucus in stool. Neither was there pain on defecation.

These anal symptoms felt different to those of hemorrhoiditis, which I’ve had in the past. Furthermore, my hemorrhoids have not played up since I went on a high-fiber diet in late 2019. Hygiene of the area has been more than adequate and proper; as a matter of fact, it’s been immaculate, as has the rest of my body.

Self-Diagnosis and Treatment

I concluded that I had a relapse of ulcerative colitis. There was no obvious precipitant for this relapse. My daily routine, including meals and fiber intake, had remained the same for months. My stress levels felt no different to those at any other time in the past couple of years. In fact, the local pandemic-related lockdown lessened stress because travel out of town was not permitted and therefore not necessary; all my work was done from the comfort and convenience of my home office.

As planned with my gastroenterologist on my last clinic visit in such an event, I bumped up my dose of mesalazine (Salofalk) to 3 grams a day (from 2 grams a day) and also started taking a Salofalk suppository (500 grams) before bedtime.

My anal symptoms responded to the increased dose of mesalazine within a week. My abdominal pain and diarrhea were next to resolve – this happened in two or three weeks. The night sweats and warm/hot feeling also stopped within a couple of weeks.

Because my lower GI symptoms, especially those in my anus, had responded well to the increase in dose of Salofalk, I stopped the suppository after about three weeks.

Unlike my other symptoms, the fatigue has only recently improved to a state that is close to normal, i.e. about three months since I went back on the increased dose of mesalazine (3 grams per day). Sometimes it’s a struggle to get motivated due to the fatigue, but I have somehow managed.

In short, I’m much better than I was at the end of January, but probably not 100 percent yet.

Staying Productive During a Clinical Relapse of Ulcerative Colitis

Throughout this period, I maintained a satisfactory level of performance and productivity:

  • All my work commitments were met, if not exceeded – Zoom calls, education and training, written and oral reports, etc.
  • I generated more ideas for content for both in-person education and training, and our online platforms.
  • Several internal projects were completed in the first half of 2021, the most important of which was the acquisition (most of which from US sources) and installation of equipment for my home-based studio, where I live stream and create video content.

Conclusion

I probably experienced my first clinical relapse of ulcerative colitis in January 2021 since being diagnosed in March 2018. This presumed relapse seems to have responded to increasing the dose of oral mesalazine to 3 grams per day – the dose I had been on between March 2018 and July 2020 – and a short course of treatment with mesalazine suppository.

Things weren’t plain sailing during this episode of relapse; my fatigue created challenges at times. Those occasions of severe fatigue called for a fair degree of mental fortitude. Fortunately, I am blessed with an abundance of the latter.

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