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

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 (Figures 2 and 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.

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 ( Figures  2 and 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.

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 Received: 24 April 2020 Accepted: 12 June 2020 Published: 14 July 2020   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.

Keywords: Abdominal pain, Crohn's disease, IBD
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.

Author Contributions
Christopher Kim -Conception of the work, Design of the work, Acquisition of data, Analysis of data, Interpretation of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved Paul Guzik -Conception of the work, Design of the work, Interpretation of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved F Parker Hudson -Conception of the work, Analysis of data, Interpretation of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved Kavitha Kumbum -Conception of the work, Acquisition of data, Analysis of data, Interpretation of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved

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The corresponding author is the guarantor of submission.

Source of Support
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Consent Statement
Written informed consent was obtained from the patient for publication of this article.