SHM Converge Scientific Abstract ePoster Gallery-Not Your Typical Rash, a Case of Cutaneous Crohn's Disease

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This case describes a 71-year-old woman who presented with months of severe pain and a worsening erythematous rash involving the abdominal wall and labia. She had tried topical antifungal treatment without benefit and had no personal or family history of inflammatory bowel disease or autoimmune disease. Her history included a prior cecal perforation during colonoscopy prep, resulting in an end ileostomy and subtotal colectomy in 2017.<br /><br />On exam, she had an erythematous intertriginous rash, and labs showed anemia and hypoalbuminemia. CT imaging suggested a possible colovaginal fistula. Dermatology performed a punch biopsy of the abdominal lesion, which showed diffuse inflammation with noncaseating granulomas, fibrosis, edema, and plasma cells, consistent with cutaneous Crohn’s disease. Because metastatic cutaneous Crohn’s disease (MCD) can occur without direct continuity with the bowel, further evaluation was performed. CT enterography showed no active or chronic inflammatory bowel disease, and colonoscopy revealed only mild changes in the remnant rectum felt to be postsurgical rather than true Crohn’s disease. Ileal biopsies were normal.<br /><br />Cutaneous MCD is a rare extraintestinal manifestation of Crohn’s disease and can present before any intestinal involvement. It is defined by noncaseating granulomas in skin lesions not connected to the gastrointestinal tract or a fistula. In this patient, the rash caused significant morbidity and intractable pain.<br /><br />Because there are no randomized trials to guide treatment, management is based on case reports and series. Reported therapies include TNF-alpha inhibitors, azathioprine, systemic steroids, and metronidazole. This patient was started on infliximab and metronidazole and discharged for outpatient follow-up.<br /><br />The key clinical message is that cutaneous metastatic Crohn’s disease should be considered in patients with painful erythematous intertriginous rashes, even in the absence of intestinal Crohn’s disease, because prompt diagnosis can relieve suffering and guide treatment.

Asset Subtitle

Melanie Vargas

Meta Tag

Author List Bradley Schuler, Charlotte Chaiklin, Jacqueline Nguyen, Melanie Vargas, Nicole Gilreath, Ryan DeGroff

Category Clinical Vignettes

Concept Cutaneous Metastatic Crohns Disease

Concept Skin Biopsy

Concept Crohn Disease

Concept Fistulizing Disease

Concept CT Imaging

Distinguished Non-Finalist

Presenter Organization University of Florida College of Medicine

Presenting Author Melanie Vargas

Track Adult

Keywords

cutaneous Crohn's disease

metastatic Crohn's disease

noncaseating granulomas

erythematous rash

intertriginous rash

infliximab

metronidazole

extraintestinal manifestation

colovaginal fistula

abdominal wall

Cutaneous Metastatic Crohns Disease

Skin Biopsy

Crohn Disease

Fistulizing Disease

CT Imaging