Renegade
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Thirty-one year old female has a twenty year history of severe colonic Crohn's disease with strictures, fistulae, and intratability. 4 months ago she underwent total proctocolectomy + ileostomy and has been unmedicated since then. She gained weight, had good appetite, and normal output of ostomy even without medications. Three weeks ago she developed a few skin lesions on both arms. These were vesicles filled with pus which after six days ulcerated. Once ulcerated, the lesions persisted and slowly increased in size and depth. Over the next few weeks more lesions appeared near the ostomy, on the perineum, buttocks, vulva and legs. Has had DVT with IVC filter 1 year ago. Currently medicated with ibuprofen. No alcohol or tobacco use nor substance abuse; stable finances and family. Family History: SLE in grandfather; no family history of IBD.
a) Proceed with appropriate Crohn's medication is best next step
b) Family Hx is of great importance in this case
c) Final diagnosis of skin lesions may require previous Tx with methotrexate
d) Best next step would include blood works to access disease severity
e) When IBD is suspected, the diagnosis of Crohn's can be made if the skin lesions are present
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| nisha
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he he my turn to guess........A?
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| chemamr
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 , i go with A, too.
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| nisha
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it's scary......just like today.....Happy Halloween!!!
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| chemamr
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jejej, yeah, i guess so.
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| an
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i dunno the ans...but HAPPY HALLOWEEN guys...
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| ARJ
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IS it pyoderma gangrenosum..................So what would be the next step,,,,,,,,,,,
Probably a) Proceed with appropriate Crohn's medication is best next step
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| frontal
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I also think it's A. I don't quite understand option C. What about D? CRPs do help in assessing disease severity.
chemarm: have mercy on the poor boy's knee. By the way, do you use the pointed side of the hammer to elicit knee jerk?
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| chemamr
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, jejej. Yes, i use the pointed side, it´s better in my opinion.
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| frontal
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jejej?
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| chemamr
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 i decided to change it for a harmless one.
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| Renegade
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Congrats, a) was right answer 
The skin lesions represent Pyoderma Gangrenosum (PG). Having this or any other extra-intestinal manifestation of Crohn's increases the risk for all others. Inflammatory extra-intestinal manifestations occur more often in Ulcerative Colitis than in Crohn's disease and than in Crohn's limited to the small bowel. Even patients who underwent total colectomy can have PG, which often is a familiar tendency suggestive of genetic component (in this particular case, SLE in grandfather was of no influence). PG is a painful condition usually beginning with plaques/pustules that rapidly progress to ulcers with a purple border. The base is often necrotic with irregular borders. The lesions of PG can resemble fungal, mycobacterial or herpetic skin lesions, as well as squamous cell carcinoma; they can affect all areas mentioned, but vulvar lesions are very rare. No blood tests are helpful in the diagnosis. IBD-associated PG usually responds to treatment of the bowel disease itself; other cases (aproximately 30%) need PG-directed therapy, which consists of corticosteroids (intralesional or systemic, according to location of ulcers).
I really don't like corticosteroids, though they sometimes come handy. If regular treatment can take care of the skin lesions as well as IBD, so much for the better...
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