Conclusion and Results (Outcome and Follow-Up)
Over the span of 2.5 years, the patient received multiple intratympanic steroid injections and prolonged tapering courses of high-dose prednisolone. Figure 2 shows a summary of the treatments he received and highlights the extensive number of steroid courses he had. It was also noted that the patient would no longer respond to prednisolone 40mg in the later course of his presentation and would see improvement only when 60mg (tapered over 12 weeks) was prescribed (Figure 3a-3b ). Whilst clinical and audiometric improvements were noted with steroid therapy, his hearing loss and symptoms would worsen when he was on lower doses or off steroids, with relapses occurring as early as 3 days after discontinuation. This, alongside the fluctuating nature of his symptoms, was very frustrating for him and prompted him to research specialist centres and ask for a second opinion.
The patient’s case was discussed in a multidisciplinary team (MDT) meeting by the specialist centre, with an outcome to consider methotrexate or anti-tumour necrosis factor α (anti-TNFα) treatment as steroid-sparing therapy. He was started on methotrexate by the local Rheumatology team, with guidance from Gastroenterology in the management of his UC. He was determined to start anti-TNFα therapy but there were barriers to acquiring this treatment for AIED as it required an individual funding request (IFR) to be funded by the National Health Service (NHS). Unfortunately, the IFR was rejected, which was very upsetting to the patient and his family. The specialist centre MDT advised that AIED is a rare manifestation or complication of UC, so an alternative option was explored to acquire anti-TNFα therapy via this pathway. Despite treatment with azathioprine and multiple high-dose steroid courses, remission had not been achieved for his UC, so his case was discussed in inflammatory bowel disease (IBD) MDT and was approved to start treatment with infliximab.
The patient was commenced on infliximab infusions 2.5 years after his initial presentation. He reported that his hearing has remained stable after two loading doses of infliximab (Figure 3c ), along with improvement in his bowel habits and symptoms of UC. The infliximab is well-tolerated, though the patient initially complained of non-specific elbow and wrist pain with no associated morning stiffness or swelling three months into the treatment, when approaching the next infliximab dose. He also reported an area of numbness on the left thigh above the superolateral aspect of knee that has persisted since starting the first infliximab infusion. Considering the nature of this numbness and his background of sitting for prolonged periods of time for his office job, this was thought to be meralgia paraesthetica. Nerve conduction studies were requested to exclude other causes. After a 24-month follow-up with audiograms, the patient’s hearing remained stable, his UC is in remission, and he has not required further courses of steroids.