Metastatic Crohn's disease

Crohn disease: before and after 1932 year

The article describes the historical milestones in the study of Crohn's disease from the time of its original description in the 17th century, the revolution in the medical community after the landmark paper in 1932, to the present day. The history of Crohn's disease testifies to the discoveries of the past years, which open up to us the advantages of a scientific approach to the diagnosis and treatment of this disease.

[Metastatic Crohn's disease of the umbilicus: An exceptional location]

INTRODUCTION

Cutaneous manifestations of Crohn's disease are frequent and include metastatic lesions. These are separated from the digestive tract and affect particularly the limbs and major folds. Umbilical involvement is exceptional.

CASE REPORT

A 93-year-old woman followed for 6 years for Crohn's disease, in remission on infliximab, 5mg/kg every 8 weeks, consulted for a fissured and painful omphalitis. Histology revealed epithelioid granulomas without necrosis in the dermis, leading to the diagnosis of umbilical cutaneous metastasis of Crohn's disease. Infliximab intensification every 6 weeks led to a positive outcome.

CONCLUSION

We report a unique case of umbilical metastatic localization of Crohn's disease occurring during treatment with anti-TNF alpha. The diagnosis was based on skin biopsy and histology which found epithelioid granulomas without caseous necrosis.

Ear Involvement in Inflammatory Bowel Disease: A Review of the Literature

Inflammatory bowel disease (IBD) is a multisystemic disease. The ear is a rare but recognized site of extraintestinal manifestations of IBD. In external ear, the more common manifestations of IBD are pyoderma gangrenosum, metastatic Crohn’s disease and relapsing polychondritis and the treatment includes corticosteroids and anti-TNF agents. Sensorineural hearing loss (SNHL) is the most common ear disease in IBD and especially in patients with ulcerative colitis. In most cases of IBD patients with SNHL, the hearing loss is attributable to autoimmune inner ear disease (AIED). Diagnosis of AIED is based on clinical presentation, the demonstration of a progressive sensorineural hearing loss in periodic audiological tests, a response to immunosuppressive drugs and exclusion of other causes of SNHL. The only diagnostic test that is available for clinical use is the Otoblot test (Western blot for antibodies against 68 kD protein-inner ear antigens). Initial therapy is usually steroids, with a step up to anti-TNF-a therapy and cochlear implantations with failure of treatment. Furthermore, Cogan’s syndrome, a chronic disease characterized by deafness, vertigo keratitis and aortitis, has been associated with IBD and mainly with Crohn’s disease.

Metastatic Crohn's Disease: An Approach to an Uncommon but Important Cutaneous Disorder

Objective. To provide physicians with a clinical approach to metastatic Crohn's disease (MCD). Main Message. Metastatic Crohn's disease, defined as skin lesions present in areas noncontiguous with the gastrointestinal tract, is the rarest cutaneous manifestation of Crohn's disease. MCD lesions vary in morphology and can arise anywhere on the skin. MCD presents equally in both sexes and across age groups. Cutaneous findings may precede, develop concurrently with, or follow gastrointestinal involvement. A detailed history and thorough physical examination including a full-skin exam may help to exclude other dermatoses, as MCD can mimic other common disorders. A biopsy is required for a definitive diagnosis. Treatment options for MCD remain underwhelming due to the lack of randomized control studies and varying responses of reported therapeutic methods. Topical, intralesional, and systemic corticosteroids, antibiotics, traditional immunosuppressants, and surgery have shown mixed results. Recently, biologics have shown promise, even with refractory cases of MCD. Conclusion. MCD is an important cutaneous manifestation of this inflammatory disorder. Although a rare entity, early recognition can provide opportunity for successful therapeutic intervention.

Mycobacterium avium subspecies paratuberculosis causes Crohn's disease in some inflammatory bowel disease patients

Crohn’s disease (CD) is a chronic inflammatory condition that plagues millions all over the world. This debilitating bowel disease can start in early childhood and continue into late adulthood. Signs and symptoms are usually many and multiple tests are often required for the diagnosis and confirmation of this disease. However, little is still understood about the cause(s) of CD. As a result, several theories have been proposed over the years. One theory in particular is that Mycobacterium avium subspecies paratuberculosis (MAP) is intimately linked to the etiology of CD. This fastidious bacterium also known to cause Johne’s disease in cattle has infected the intestines of animals for years. It is believed that due to the thick, waxy cell wall of MAP it is able to survive the process of pasteurization as well as chemical processes seen in irrigation purification systems. Subsequently meat, dairy products and water serve as key vehicles in the transmission of MAP infection to humans (from farm to fork) who have a genetic predisposition, thus leading to the development of CD. The challenges faced in culturing this bacterium from CD are many. Examples include its extreme slow growth, lack of cell wall, low abundance, and its mycobactin dependency. In this review article, data from 60 studies showing the detection and isolation of MAP by PCR and culture techniques have been reviewed. Although this review may not be 100% comprehensive of all studies, clearly the majority of the studies overwhelmingly and definitively support the role of MAP in at least 30%-50% of CD patients. It is very possible that lack of detection of MAP from some CD patients may be due to the absence of MAP role in these patients. The latter statement is conditional on utilization of methodology appropriate for detection of human MAP strains. Ultimately, stratification of CD and inflammatory bowel disease patients for the presence or absence of MAP is necessary for appropriate and effective treatment which may lead to a cure.

Metastatic Crohn's disease: a review and approach to therapy

Metastatic Crohn's disease (CD) is a rare cutaneous manifestation of CD that was first described nearly 50 years ago. Many subsequent reports have defined its most common clinical and histopathologic features. The pathogenesis underlying metastatic CD is unknown but various hypotheses exist. An established standard therapy is lacking. Owing to its rarity and nonspecific clinical presentation along with the diversity of inflammatory skin disorders that often complicate CD, the diagnosis of metastatic CD may be overlooked. This report highlights the salient features of this disorder to facilitate recognition and management of this rare dermatosis.

Anti-tumor necrosis factor-α induced systemic lupus erythematosus in a patient with metastatic Crohn's disease--what is the role of anti-TNF antibody?

Biological therapies are supposed to trigger the development of autoimmune diseases. We report a case of a 27-year old woman presenting with drug induced systemic lupus erythematosus (SLE) associated with infliximab therapy. The development of paradoxical inflammation in immune-mediated inflammatory diseases patients treated with anti TNF-α suggests that an unknown inflammatory pathway may be provoked by inhibiting TNF-α. We suppose that in our case a cross reactivity between anti-infliximab antibodies and autoantibodies may lead to the development of TNF-induced immune disease.

Surgical management of gluteal metastatic cutaneous Crohn's disease

Metastatic cutaneous Crohn's disease is a rare entity first described by McCallum et al. in 1976. It is diagnosed when histologically characteristic granulomata are seen at a site not contiguous with inflammatory disease in the gastrointestinal tract. We herein report presentation, diagnosis and management of a 28 year old lady with disabling, symptomatic cutaneous Crohn's of the buttocks and natal cleft refractory to Infliximab therapy. To the best of our knowledge only four other adult cases have been reported in the literature of metastatic cutaneous Crohn's disease of the buttock area distant from a flexure or area of skin apposition. The differential diagnosis in this case was Hidradenitis Suppurativa. A good cosmetic result and excellent symptom control were achieved with extensive debridement, wide local excision, vacuum assisted closure and delayed skin grafting.

Vulvar inflammation as the only clinical manifestation of Crohn disease in an 8-year-old girl

Recognition of Crohn disease in children who present with cutaneous vulvar lesions as their initial clinical manifestation is often difficult. We report here the case of an 8-year-old girl with chronic vulvar edema, which on biopsy revealed granulomatous inflammation of the vulva. Further investigation and biopsy of the terminal ileum demonstrated similar findings and was consistent with a diagnosis of Crohn disease.

Sellar inflammatory mass with inflammatory bowel disease

Inflammatory bowel disease may be associated with different intracranial disorders. An inflammatory sellar mass is very rare but includes a variety of noninfectious causes including lymphocytic hypophysitis, granulomatous inflammation and Wegener's granulomatosis. A 32-year-old man was diagnosed with an inflammatory sellar mass associated with an extensive colonic inflammatory process clinically characteristic of Crohn's disease. The concurrent onset of these inflammatory disorders in distinctly separate sites may reflect their common embryological origin or represent an unusual form of metastatic Crohn's disease. Further studies are needed to determine if less overt or focal sellar inflammatory processes occur in inflammatory bowel disease, particularly in Crohn's disease because their occurrence may be critically relevant for long-term management.

Cutaneous Crohn's disease in the pediatric population

Three healthy children with an anogenital skin eruption, all of whom had undergone extensive medical evaluation and treatment, had undetected intestinal Crohn's disease. Biopsy of the skin showed noncaseating granulomas consistent with cutaneous Crohn's disease. Inflammatory bowel disease should be in the differential diagnosis of persistent nontender, erythematous papules, nodules, and plaques in the anogenital region.

Metastatic cutaneous Crohn's disease in children: case report and review of the literature

Metastatic cutaneous Crohn's disease is a rare complication of Crohn's disease, especially in the pediatric population, and can present a diagnostic dilemma. Most of the reported cases of metastatic cutaneous Crohn's disease in childhood have concurrent gastrointestinal symptoms and/or perianal disease to aid in the diagnosis. We present a case of a 13 1/2-year-old girl whose initial symptom of Crohn's disease was asymptomatic labial swelling. An overview of metastatic cutaneous Crohn's disease in childhood is also provided.

Perineal metastatic Crohn's disease: a case report and review of the literature

Metastatic Crohn's disease is an uncommon complication of Crohn's disease defined as granulomatous inflammation not contiguous with inflammatory disease in bowel. We report on the presentation and management of a 36-year-old man, who had undergone panproctocolectomy 11 years ago, with complex fistulous disease in his perineum, which demonstrated granulomas histologically after resection. We review six similar case reports. Optimal treatment would appear to be by surgical debridement.

A diagnostic algorithm for male genital oedema

Male genital oedema can be defined as swelling or the appearance of swelling of the scrotum and/or the penile shaft and prepuce. Despite the various causes of genital oedema reported in the published work, a concise approach to the evaluation and management has not been sufficiently addressed.

Treatment of vulval Crohn's disease with infliximab

Anti-tumour necrosis factor-alpha therapy of Crohn's disease (CD) with infliximab has proved a major advance in the treatment of patients with difficult disease. We report our experience of the use of infliximab in a patient with recalcitrant vulval CD. The introduction of infliximab has improved disease control, although a search for an optimum remittive dosing schedule is ongoing.

Metastatic cutaneous Crohn's disease of the nipple: report of a case

A case of cutaneous Crohn's disease involving the right breast and presenting as multiple periareolar fistulas in a 46-year-old female is reported. The lesion had initially been diagnosed and treated as a simple abscess. She had a 26-year history of Crohn's disease with numerous hospitalizations for bowel resections and control of diarrhea. Histopathologic examination following excision of the fistulas and total duct excision, however, showed well-defined granulomas containing multinucleated giant cells characteristic of extraintestinal Crohn's disease.

Crohn's disease manifesting in the head and neck

Crohn's disease may present to the head and neck surgeon with symptoms and signs attributed to the disease. Many clinical presentations, both specific and non-specific, have been recorded in the oral cavity, nose and larynx. Some of these clinical manifestations have been found to be consistent with Crohn's disease, but most have been attributed to Crohn's disease without histologic confirmation of the presence of non-caseating granulomas, which is pathognomonic of Crohn's disease. Lesions, when present without an associated diagnosis of Crohn's disease, should be ascribed the diagnosis of orofacial granulomatosis, until a diagnosis of intestinal Crohn's disease has been confirmed.

Rapid response of severe refractory metastatic Crohn's disease to infliximab

A case is described of a middle-aged female who developed an aggressive form of biopsy-proven metastatic Crohn's disease involving the inguinal, perineal and submammary areas. Her condition had been unresponsive to topical and systemic corticosteroids, antibiotics, immunosuppressives, and repeated surgical debridement. Administration of infliximab resulted in a rapid clinical response with subjective improvements in pain and general well-being, and an objective decline in exudate, erythema and size of the lesions. Infliximab may be a suitable therapeutic option in patients with metastatic Crohn's disease.

The history of Crohn's disease

Although it is likely that cases of what we know as granulomatous inflammatory bowel disease (Crohn's disease) may have been recorded as early as 1769, this illness is basically a disease of the 20th century. This historical review traces the development of our understanding of the disease and the evolution of its operative management.

Giant cells in pyoderma gangrenosum

It has been claimed that pyoderma gangrenosum (PG) lesions may contain granulomatous foci when associated with Crohn's disease. To test this assertion, we obtained clinical histories and archived cutaneous biopsies from 34 PG patients. Thirteen of these patients had inflammatory bowel disease (IBD). Immunostaining with PGM1, a macrophage marker, revealed well-formed giant cells with three or more nuclei in biopsies from 6 of 13 patients with IBD. Five of the 6 biopsies came from patients with Crohn's disease and one from a patient with ulcerative colitis. Two were peristomal. In the 21 patients who had PG without IBD, no giant cells were seen. Thus, PGM1+ histiocytic giant cells within a PG lesion may be indicative of associated IBD (p = 0.006), particularly Crohn's disease.

Metastatic Crohn's disease: case report of an unusual variant and review of the literature

PURPOSE

Metastatic Crohn's disease is a rare complication of Crohn's disease that has been infrequently reported in the literature. We report a case where submammary, inguinal, and perineal disease was observed in a patient many years after a proctocolectomy. The proliferative and polypoid morphology of the cutaneous lesions has not been previously described. In addition, this case describes severe cutaneous metastatic Crohn's disease in the absence of active gastrointestinal disease, which to our knowledge has not been reported in the literature.

RESULTS

A 55-year-old female with a 25-year history of Crohn's disease was investigated and treated over a 12-month period for metastatic Crohn's disease involving the submammary, inguinal, and perineal areas. These proliferative lesions with erythema and ulceration were histologically consistent with metastatic Crohn's disease. Gram and Ziehl Nielsen stains revealed no pathogenic organisms. The use of topical solutions, antibiotics, immunosuppression, and surgery failed to produce any significant benefit. A review of 42 cases of metastatic Crohn's disease in the literature is reported.

CONCLUSION

Cutaneous metastatic Crohn's disease has an extremely variable macroscopic appearance and may be a source of considerable morbidity. It can be present without other significant symptomatology, although it more commonly parallels gastrointestinal disease activity. There are no trials to guide current treatment, which is mainly based on anecdotal reporting.

Genital cutaneous Crohn disease: two cases with unusual clinical and histopathologic features in young men

Cutaneous Crohn disease, sometimes called metastatic Crohn disease or Crohn disease with cutaneous involvement, is a rare complication of Crohn disease in which granulomatous lesions involve skin separated from gastrointestinal lesions by normal tissue. We report two cases of cutaneous Crohn disease presenting in young males with erythematous, nontender swelling of the scrotum. One of the young males presented erythematous, nontender swelling of the penis as well. In one case, cutaneous Crohn disease represented the primary presentation. The original biopsy in this case showed unusual areas of degeneration of dermal connective tissue forming cystic cavities. The diagnostic biopsies in both cases showed sarcoidal granulomas with an associated superficial and deep perivascular mixed infiltrate including eosinophils. On endoscopy, both patients showed lesions of active Crohn disease in the colon. Because changes that would suggest cutaneous Crohn disease may not be present on the initial biopsy, unusual presentations and negative cultures may warrant a second biopsy. A high index of suspicion and open communication with the clinician are essential to diagnose this disease.

Genital ulcers. Evaluation and treatment

Ulcerations may appear on the genitalia in a variety of both infectious and noninfectious conditions. The vast diversity of etiologies, coupled with the often overlapping morphological features, make the diagnosis of genital ulcerations a challenging endeavor. This article highlights the most important clinical manifestations and laboratory findings which aid in the proper diagnosis of genital ulcerations.

Metastatic Crohn's disease involving the penis

Metastatic Crohn's disease is a rare complication in Crohn's disease and there have been only several cases of metastatic Crohn's disease involving the penis. We report one such case. A 22-year-old male student developed anal pain and alternative constipation and diarrhea in December, 1985, followed by diarrhea and lower abdominal pain in January, 1986. He was diagnosed as having Crohn's disease of ileocolitis type. He was admitted to our hospital in July, 1987 because of exacerbation of Crohn's disease. He had anal tags. Soon after admission, two red swollen lesions with central ulcer and erosions were demonstrated at the eversion of the foreskin adjacent to coronal sulcus. Histology of the lesions revealed granulomas with epithelioid cells and giant cells. The lesion responded to a topical steroid. Eight cases of metastatic Crohn's disease involving the penis are briefly reviewed.

Cutaneous Crohn's disease in children

BACKGROUND

Although cutaneous Crohn's disease is well recognized in adults, in children it is extremely rare.

OBJECTIVE

Our purpose was to describe five children with cutaneous Crohn's disease and to review the literature.

METHODS

The medical records of five children with cutaneous Crohn's disease were retrospectively reviewed for clinical features and laboratory data. An extensive review of the literature was conducted.

RESULTS

Five children, one boy and four girls, 6 to 12 years of age at onset, had cutaneous manifestations of Crohn's disease. Three had genital swelling, and the other 2 had buttock abscesses. Most were seen before the diagnosis of gastrointestinal Crohn's disease was made. There have been 80 cases of cutaneous Crohn's disease described, including our series. Only 14 were in children. Two thirds of children with cutaneous Crohn's disease had genital involvement compared with about half of the adult cases. Sixteen of the 80 patients had cutaneous lesions without preceding gastrointestinal Crohn's disease. Of these, approximately 70% had genital lesions.

CONCLUSION

Although Crohn's disease is common in children, cutaneous manifestations are rarely a presenting sign. However, when cutaneous Crohn's disease is present in children, it commonly precedes the gastrointestinal disease.

A clinicopathologic approach to granulomatous dermatoses

Reaching a diagnosis or formulating a differential diagnosis in dermatopathology involves combining information from clinical and pathological sources. Traditionally, this process is presented as a chronologic progression from the patient's complaint, through the evaluation of findings, terminating in the microscopic examination of the biopsy specimen. However, dermatopathologists often find the sequence reversed. They must first form an impression of the diagnosis from the slide and then supplement it with clinical information. The purpose of this article is to present the spectrum of granulomatous dermatoses from a pathologic perspective. The dermatoses are categorized into five groups on the basis of histologic patterns.

Metastatic Crohn's disease of the umbilicus

We report a case of metastatic Crohn's disease of the umbilicus which responded to topical corticosteroid treatment. Crohn's disease is a granulomatous disease of the bowel which may affect other organs. The skin is commonly involved, and the cutaneous manifestations may be non-specific, e.g. pyoderma gangrenosum or erythema nodosum, or specific with epithelioid granulomas and multinucleated giant cells in the skin. Specific skin lesions may be contiguous with the bowel at sites including the perineum, mouth and adjacent to fistulae, or separated from it by normal skin from the bowel, a rare condition which has been termed 'metastatic' Crohn's disease.

Vulval Crohn's disease: difficulties in diagnosis

Four patients with chronic vulval inflammation are described. The histological features of non-caseating granulomata and multinucleated giant cells are compatible with Crohn's disease, but only two patients had proven gastrointestinal involvement. The clinical and histological characteristics of Crohn's disease and other granulomatous inflammations of the vulva are discussed and the literature is reviewed.

Surgical management of perineal and metastatic cutaneous Crohn's disease

Skin lesions are the commonest extraintestinal manifestation of Crohn's disease. Lesions that develop at sites remote from the gastrointestinal tract and have granulomas on histological examination are termed metastatic cutaneous Crohn's disease. Management is difficult as medical treatment is often ineffective. This report describes the use of surgical debridement of areas of perineal metastatic cutaneous Crohn's disease in five patients, all of whom had failed to improve after a variety of medical treatments. One patient had a poor result with continuing mild perineal discharge and four had a good outcome with complete resolution of symptoms and satisfactory cosmetic results.

Disseminated metastatic cutaneous Crohn's disease

Metastatic cutaneous Crohn's disease, in which noncaseating granulomatous infiltration of the skin occurs at sites separated from the gastrointestinal tract by normal tissue, is the least common dermatological manifestation of Crohn's disease. We report the case of an 18-year-old man who developed very widespread metastatic cutaneous Crohn's disease 2 years after he had first developed mild oral and anal lesions. His gastrointestinal symptoms had been satisfactorily controlled for 18 months with sulphasalazine alone prior to his developing skin lesions. The cutaneous lesions responded rapidly to oral prednisolone which was tailed off over 5 months and then withdrawn. He relapsed 6 months later and now requires a low dose of oral prednisolone to control the skin lesions. The only complication of this therapy has been exacerbation of mild acne vulgaris.