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.