a comprehensive search of two major databases of biomedical publications was performed during the last week of august 2013 . all of the adult and pediatric cases reports and series reporting uc associated with itp were included . a comprehensive search of two major databases of biomedical publications was performed during the last week of august 2013 . all of the adult and pediatric cases reports and series reporting uc associated with itp were included . cases of itp associated with uc were first reported in 1963 ( 1 ) . since then , a total of 40 cases ( including the above - mentioned case ) were identified , seven of them being of pediatric age group . fifty six percent of cases were male and the median age of presentation was 27 years ( interquartile range 1442 years ) . median age of presentation was higher in females ( 41 vs. 22 years ) but the difference was not statistically significant ( p = 0.0718 ) . as shown in table 1 , 52% of patients were white , 45% were asian ( mostly of japanese origin ) . summary demographics and treatment in reported cases itp : immune thrombocytopenic purpura ; ivigg : intravenous immunoglobulin g ; sulfa : sulfasalazine ; uc : ulcerative colitis . in the majority of cases , ivigg or anti - d antibodies were used in 15 cases ; response was adequate and lasting in 11 of them . amongst the remaining four patients , one responded dramatically to 5-asa ; in two cases , itp was resistant to both ivigg and splenectomy and required a colectomy ; and in one case , colectomy and splenectomy were performed together , which improved the itp . ten patients underwent a colectomy ; one of them had a colectomy some years prior to the development of itp ( 2 ) . of the remaining nine cases , eight responded well but one patient continued to have recurrent itp despite colectomy ( 3 ) . in one case , itp resolved with h. pylori eradication ( 4 ) . the development of itp adds complexity in the clinical course of uc flare as the number of bloody bowel movements is one of the important criteria to assess disease severity . rarity of occurrence limits methodologically sound studies to establish causal relationship between the two disorders . in disease epidemiology , sir austin bradford hill proposed criteria for causation , also knows has hill 's criteria for causation ( 5 ) . results of this systematic review elicit multiple interesting observations to generate a hypothesis of causal relationships between uc and itp . 1 ) in most cases , uc preceded itp , which demonstrates a temporal relationship between uc ( exposure ) and itp ( effect ) . only three cases have been reported where itp preceded uc ( 6 , 7 ) . in two of the cases , this could be a result of delay in diagnosis or subclinical disease , which is not uncommon in uc . in another case , itp preceded uc by 18 years , which appears to be a result of random concurrence of the two disorders . 2 ) platelet count was lowest during the flare of uc , demonstrating a biological gradient . 3 ) in most cases , treatment of uc resolved itp , analogous to the removal of exposure leading to reversal of effect . biological plausibility in itp development in patients with uc is hypothesized to be due to antigenic mimicry between platelet surface antigen and luminal antigens , including bacterial surface antigen . this is also postulated for the association of itp with crohn 's disease ( 8) . the results of our systematic review suggest that peak age for this association is in the third decade of life with a trend towards earlier occurrence in males . we report the first case in the african american population . in the management of this coexistence , treatment of uc is the corner stone . in severe cases of thrombocytopenia , ivigs or anti - d antibodies in combination with 5-asa and/or steroids are effective in most cases . we are reporting a second case where a colectomy was avoided by using anti - tumor necrosis factor therapy ( 9 ) . in conclusion treatment of underlying uc flare is the cornerstone in managing the condition and in severe cases of itp , ivigs is effective . though colectomy has been proposed as a definitive treatment option , the use of biological agents is an acceptable alternative in a steroid - resistant case of uc associated with itp . the authors have not received any funding or benefits from industry or elsewhere to conduct this study .
over 100 extraintestinal manifestations are reported in ulcerative colitis ( uc ) . 
 a commonly reported hematological manifestation is autoimmune hemolytic anemia . on rare occasions , immune 
 thrombocytopenic purpura ( itp ) has been reported with uc . 
 the presence of thrombocytopenia can complicate the clinical scenario as the number of bloody bowel movements is an important indicator of disease activity in uc . a proposed theory for this association 
 is antigenic mimicry between a platelet surface antigen and bacterial glycoprotein . 
 we are reporting a case of uc and associated itp managed successfully with anti - tnf therapy . 
 we also performed a systemic review of case reports and a case series reporting this association .