Clinical Image

Metastatic Crohn’s disease: A case of a rarer IBD-related entity at initial presentation

Christopher Kim¹

Paul Guzik¹

F Parker Hudson¹

Kavitha Kumbum¹

¹ Department of Internal Medicine, Dell Medical School at the University of Texas at Austin, 1701 Trinity Street, Austin, Texas 78712, USA

Address correspondence to:

Christopher Kim

MD, Department of Internal Medicine, University of Texas at Austin Dell Medical School, 1701 Trinity Street, Austin, Texas 78712,

USA

Access full text article on other devices

Access PDF of article on other devices

Article ID: 101145Z01CK2020

doi: 10.5348/101145Z01CK2020CI

How to cite this article

Kim C, Guzik P, Hudson FP, Kumbum K. Metastatic Crohn’s disease: A case of a rarer IBD-related entity at initial presentation. Int J Case Rep Images 2020;11:101145Z01CK2020.

ABSTRACT

No Abstract

Keywords: Abdominal pain, Crohn’s disease, IBD

Case Report

A 68-year-old woman presented to the hospital with acute left-sided abdominal pain. Six months prior to admission she developed watery diarrhea up to 8 bowel movements daily, and she reported over 70 pounds of weight loss. On examination she had a painful 20 cm ulcer within her intergluteal fold extending toward the anus (Figure 1). She had similar lesions in her intertriginous areas under her breasts and abdominal pannus (Figure 2 and Figure 3). Punch biopsy of the ulcer showed non-caseating granulomas and was negative for mycobacterial or fungal organisms. Colonic mucosal biopsies from lower endoscopy and serologic testing were consistent with a diagnosis of metastatic Crohn’s disease (MCD) (Figure 4). The patient was started on mesalamine 1000 mg by mouth four times daily, prednisone 20 mg twice daily, and triamcinolone 0.1% topical ointment twice a day. She was seen in clinic two months after hospital discharge and reported significant improvement of both her gastrointestinal (GI) symptoms and cutaneous ulcerative lesions.

Figure 1: Clinical view of a sharply demarcated ulceration within the intergluteal fold extending to the anus.

Figure 2: View of ulceration across the lower abdominal pannus.

Figure 3: Ulceration visualized at the right inguinal area.

Figure 4: Lower endoscopy findings were notable severe edema, friability, and diffuse ulceration with cobblestoned edema.

Discussion

Metastatic Crohn’s disease is a rare cutaneous manifestation of Crohn’s disease in which skin involvement is non-contiguous with the GI tract and characterized by non-caseating granulomas on histopathology. Up to 44% of patients with Crohn’s disease may have some skin manifestation; however, as few as 100 cases of MCD have been described in the literature [1]. The GI disease typically precedes skin involvement by at least six months, although the manifestation of skin disease process may be the first sign of underlying Crohn’s disease [1]. Plaques, crusting, and nodules may be cutaneous manifestations appreciated on physical exam; notably, “knife-like” ulcerations may be also seen. Interestingly, the cutaneous lesions have a heterogenous symptom presentation, as some lesions are completely asymptomatic while others present as significantly painful [2]. Exclusion of other granulomatous diseases that could mimic MCD including sarcoidosis, mycobacterial, and fungal infections is required to confirm the diagnosis. Other cutaneous findings such pyoderma gangrenosum and erythema nodosum should be excluded as they are more common dermatological manifestations of Crohn’s disease [3].

While there are no formal guidelines for management of MCD, immunosuppressants such as oral and topical glucocorticoids are effective forms of induction treatment and are often combined with antibiotics, most often metronidazole. Biologic therapies with tumor necrosis factor inhibitors and immunomodulators such as azathioprine may be used for sustaining remission [4]. Early recognition of this disease may spare unnecessary tests or treatments.

Conclusion

Metastatic Crohn’s disease is a rare extraintestinal manifestation of Crohn’s disease that requires a thorough evaluation for a diagnosis. Its wide spectrum of clinical presentation presents a diagnostic challenge, and ultimately requires specific pathologic findings and ruling out other disease processes for a diagnosis. In this case, the woman was diagnosed with MCD at initial presentation and responded well to both topical and systemic steroid therapies.

REFERENCES

Bender-Heine A, Grantham JT, Zaslau S, Jansen R. Metastatic Crohn disease: A review of dermatologic manifestations and treatment. Cutis 2017;99(6):E33–40. [Pubmed] Back to citation no. 1

Schneider SL, Foster K, Patel D, Shwayder T. Cutaneous manifestations of metastatic Crohn’s disease. Pediatr Dermatol 2018;35(5):566–74. [CrossRef] [Pubmed] Back to citation no. 1

Aberumand B, Howard J, Howard J. Metastatic Crohn’s disease: An approach to an uncommon but important cutaneous disorder. Biomed Res Int 2017;2017:8192150. [CrossRef] [Pubmed] Back to citation no. 1

Kurtzman DJB, Jones T, Lian F, Peng LS. Metastatic Crohn’s disease: A review and approach to therapy. J Am Acad Dermatol 2014;71(4):804–13. [CrossRef] [Pubmed] Back to citation no. 1

SUPPORTING INFORMATION

Author Contributions

Christopher Kim - Substantial contributions to conception and design, Acquisition of data, Analysis of data, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

Paul Guzik - Substantial contributions to conception and design, Interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published

F Parker Hudson - Substantial contributions to conception and design, Analysis of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published

Kavitha Kumbum - Substantial contributions to conception and design, Acquisition of data, Interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published

Data Availability Statement

The corresponding author is the guarantor of submission.

Consent For Publication

Written informed consent was obtained from the patient for publication of this article.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Competing Interests

Authors declare no conflict of interest.

Copyright

© 2020 Christopher Kim et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.