P0617 - Cutaneous Crohn’s Disease After Complete Proctocolectomy for Medically-Refractory Colonic Crohn’s Disease: A Case Series

Gabriel Marrero-Rivera, MD¹, Itishree Trivedi, MD, MS², Kyle Amber, MD^3
1University of Illinois at Chicago, Chicago, IL; ²University of Illinois at Chicago College of Medicine, Chicago, IL; ³Rush University Medical Center, Chicago, IL

Introduction: Cutaneous Crohn’s disease (CCD) is a rare extraintestinal manifestation of Crohn’s disease, and consists of granulomatous lesions of the skin that may be non-contiguous with the inflamed gastrointestinal tract. Studies on treatment options for CCD are lacking. Onset of CCD in patients without active gastrointestinal Crohn’s is a particularly understudied phenomenon. Here, we present a case series of patients with a documented history of medically-refractory luminal Crohn’s colitis who underwent complete proctocolectomy and subsequently developed CCD in the post-operative setting.

Case Description/Methods: Case 1: 49-year-old African American female with long-standing, severe medically refractory Crohn’s ileocolitis and perianal hidradenitis suppurativa who eventually underwent total proctocolectomy 7 years ago and in stable clinical remission on infliximab therapy. She presented with new “knife-cut” linear ulceration in the gluteal cleft consistent with CCD. Case 2: 26-year-old Hispanic male with severe Crohn’s pancolitis disease with rapidly progressive course needing urgent abdominal colectomy with diverting ileostomy 5 years ago. Despite infliximab and azathioprine therapy, patient continued to have persistent severe rectal inflammation. Patient developed new “knife-cut” linear ulceration in gluteal cleft consistent with CCD that initially responded to high dose steroid therapy. Then, he underwent completion proctectomy with recurrence of gluteal cleft lesions. Case 3: 35-year-old African American female with long-standing, severe, medically-refractory Crohn’s pancolitis with anal strictures and perianal fistulae who underwent diverting ileostomy 8 years ago. Despite infliximab therapy, continued to have progressive colonic disease with impassable stricture formation. She underwent proctocolectomy with end-ileostomy and two months after surgery, presented with new “knife-cut” linear ulceration in the gluteal cleft and perineum, consistent with CCD.

Discussion: CCD is an uncommon presentation and has a broad differential diagnosis upon presentation (Table 1). Given its rare presentation, the incidence of CCD is currently unknown. Moreover, studies are warranted to better understand this presentation in absence of any demonstrable GI inflammation while on biologics in order to elucidate what is the best multidisciplinary approach for this condition in the post-operative setting.


Figure: Erythematous, fissured plaques with purulence in the gluteal cleft consistent with Cutaneous Crohn's Disease.

Neutrophilic dermatosis Leukocytoclastic vasculitis Hidradenitis suppurativa Anti TNF-associated skin lesions Sweet Syndrome Granulomatous small vessel vasculitis Pyodermatitis-pyostomatitis vegetans Pyoderma gangrenosum Erythema nodosum Erythema multiforme Squamous cell carcinoma of the skin Sexually transmitted diseases (syphilis, lymphogranuloma venereum, granuloma inguinale) Cutaneous sarcoidosis Mycobacterial infections (TB) Schistosomiasis Erysipelas Foreign body reaction Impetigo Allergic contact dermatitis Cutaneous lesions secondary to nutritional deficiencies Cutaneous Rosai-Dorfman disease Necrobiosis lipoidica

Table: Differential Diagnosis of Cutaneous Crohn's Disease


Disclosures:
Gabriel Marrero-Rivera indicated no relevant financial relationships.
Itishree Trivedi indicated no relevant financial relationships.
Kyle Amber indicated no relevant financial relationships.


Gabriel Marrero-Rivera, MD¹, Itishree Trivedi, MD, MS², Kyle Amber, MD³. P0617 - Cutaneous Crohn’s Disease After Complete Proctocolectomy for Medically-Refractory Colonic Crohn’s Disease: A Case Series, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.