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 quick business trip (two nights) to Kuala Lumpur with no trouble.

My last clinic appointment with my gastroenterologist was on January 19, 2021. On that day, my blood tests (complete blood count, CRP, and ESR) were normal. And since I seemed to do fine, my gastroenterologist recommended 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 felt fatigued most of the day, with episodes of incapacitating fatigue that lasted 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), especially at bedtime.
• Night sweats. I had experienced excessive nocturnal perspiration, 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) increased. In January, I was rowing for about 68 minutes per session. I presumed the exercise caused the sensation of whole-body warmth.

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

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

1. Excessive exercise
2. Infection (COVID-19?)
3. Hormone disorder
4. Autonomic neuropathy
5. Cancer

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 hours of exercise I had done each month, as recorded in Strava, in 2020 and 2021.

Hours of exercise per month, Jan 2020–May 2021

As the data show, 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 doing about 25 hours of exercise in a month would induce 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 the time of day I did my workouts.

2. Infection (COVID-19?)

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

• Exposure to transmission has been minimal – I don’t leave the safe confines of my immediate home environment unless necessary. Even when I 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 with no 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 I did not have any tests to examine this possibility, I didn’t think this was likely.

4. Autonomic Neuropathy

Autonomic neuropathy was in the differential diagnosis, but 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 negligible.

Lower Gastrointestinal Symptoms in February 2021

Though I knew I wasn’t well, I couldn’t put the 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 occurred almost daily.
• Abdominal pain – Colicky and in the left lower quadrant.

I didn’t immediately link my diarrhea and abdominal pain with my general symptoms because I had experienced all of them on rare occasions, 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

I did not see blood or mucus on my stools. There was no pain in defecation.

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

Self-Diagnosis and Treatment

I concluded 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 from those at any other time in the past couple of years. In fact, the local pandemic-related lockdown lessened stress because the local Movement Control Order did not permit me to work out of town; I did all my work 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). Also, I 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 in two or three weeks. The night sweats and warm 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 the dose of Salofalk, I stopped the suppository after about three weeks.

Unlike my other symptoms, the fatigue has only recently improved to a close-to-normal level, i.e., about three months since I went back to the increased dose of mesalazine (3 grams per day). Sometimes it’s a struggle to get motivated because of 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.

I met all my work commitments – 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.

I completed several internal projects in the first half of 2021, the most important of which was acquiring and installing 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. My presumed relapse seems to have responded to increasing the dose of oral mesalazine to 3 grams per day and a short course of treatment with mesalazine suppositories.

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