A 56-year-old male with a history of duodenal ulcer at 18 years of age, COPD (non-smoker for three years, previously two packs of cigarettes/day).
Intervened anal papilla in 2007 with perianal fistula and recurrence.
She was admitted for diarrhea of 8-10 daily, soft-liquid stools, some with blood, diurnal and nocturnal of two months duration, which partially resolved after oral ciprofloxacin treatment.
On the days prior to admission, there was clinical worsening with bloody mucus (6-8 stools/day), hypogastric pain and severe pain.
In the last month, the patient complained of increasing asthenia and fever peaks up to 38.5oC, predominantly in the evening during the last week.
There were no active perianal fistulas or suppuration.
Since admission, it shows the sudden appearance of erythematous inflammatory lesions with a pustulous appearance on plaques, on the arms and back of both hands, with a moisturized, painful center of asymmetric distribution.
A rectal examination revealed the presence of perianal disease complicated by two fistulous orifices, mucorrales and acute fissure in the posterior midline.
Analytically, microcytic anemia without leukocytosis and normal coagulation was observed, highlighting GGT of 203 mU/ml, CRP: 248 mg/l and VSG: 120 mm/h.
Hemocultive and coprocultive were negative.
Abdominal ultrasound describes thickening of the rectosigmoid walls, confirmed by abdominal CT, which also reveals thickening of the transverse and blind colon, with multiple lymph nodes in the free territory of the iliac vessels.
At the junction of the rectal mucosa, edematous and erythematous forms appear with pseudopolypoid formations that extend throughout most of the colon, intercalating areas with preserved mucosa.
The ileum is macroscopically normal.
Colonic biopsies confirm the presence of ulceration and chronic inflammation, with no evidence of granulomas.
The patient is evaluated by pathology.
A skin biopsy of the hypothesized hand eminence demonstrates the presence of neutrophilic infiltrate with dermal edema without evidence of vasculitis, confirming the diagnosis of neutrophilic dermatosis (ND).
Therefore, the patient is diagnosed with: a) colonic Crohn's disease with moderate activity sprout with CDAI: 345 (debut of disease) and perianal disease (EPA), accepted Montreal Syndrome: A3we criteria
Treatment was initiated with fluid therapy, methylprednisolone (60 mg/i.v./24 h), antibiotics (ciprofloxacin 400 mg/i.v./12 h and metronidazole 1500 mg/24 h/good enteral response).
The fever disappeared within 48 h, improving abdominal discomfort and diarrhea in a few days.
Topical beclomethasone was added as treatment of skin lesions.
These became smaller, decreasing local discomfort after 3 days of treatment.
The patient was discharged with descending doses of oral prednisone and the papules disappeared after 6 weeks without scarring or cutaneous sequelae.
