Female patient, 34 years old, smoker of 10 cigarettes/day, victimized.
Previous admission to Internal Medicine due to weight loss, general malaise and fever, normocytic anemia, elevation of unknown acute phase, alkaline phosphatase and hypoalbuminemia were detected.
Previously asymptomatic, she was admitted to the hospital in April 2009 with abdominal pain of one month duration with 4-6 semi-liquid daily stools, without blood or mucus, occasionally nocturnal.
Loss of appetite lost 6 kg weight in that month and fever up to 39 °C with general malaise.
In the 10 days prior to admission, erythematous, pruritic lesions of up to 2 cm in diameter appear, evolving to umbilicated pustules in upper limbs and trunk.
There are no articular or ocular manifestations.
Laboratory tests showed normocytic normochromic anemia, leukocytosis with neutrophilia and elevated ESR (84 mm/h) and CRP (168 mg/l).
Coprocultive and parasitological stools were negative.
Cholestasis revealed patchy erythematous areas from 35 cm from the anal margin to the right colon with mucous bridges and serpiginous ulcers with healthy mucosa between them.
Abdominal CT confirmed inflammation of the colon wall and a circumferential thickening of the terminal ileum with reactive adenopathies.
Histopathology showed intense chronic inflammatory activity without granulomas.
Skin biopsies showed intense edema of the papillary dermis, spongiotic changes in the epidermis and a dense inflammatory infiltrate in the reticular dermis with predominance of leukocytes, all compatible with neutrophilic dermatosis.
Therefore, the patient was diagnosed with ileocolic Crohn's disease with inflammatory pattern ( Montreal classification: A2L3B1), moderate activity (CDAI:310) and Sweet's syndrome.
After the introduction of corticoids (methylprednisolone 60 mg/i.v./24 h), antibiotic therapy (ciprofloxacin 400 mg/i.v./24 h and metronidazole daily improved the symptoms.
During follow-up at the outpatient clinic, their disappearance was observed two months after treatment with corticosteroids in descending doses, leaving the patient in complete clinical remission.
After 6 weeks without symptoms, progressive worsening of the general condition was observed again, with high fever, abdominal pain, asthenia, weight loss of 5 kg and diarrhea without pathological products.
The patient presented a new skin lesion of similar characteristics, with papules raised on well-defined plaques, erythematous, painful, asymmetrical distribution, in the neck, chest and left arm, highlighting a small spell 2 cm
She complained of widespread arthromyalgia in the last week, with redness, swelling, increased local heat and functional impotence in the right elbow.
Evaluated by Rheumatology, monoarthritis of elbow was confirmed, indicating local measures and symptomatic treatment.
Normocytic anemia (Hb: 10.3 g/dl), leukocytosis with left shift and thrombocytosis, ESR of 40 mm/h and CRP of 194 mg/l, with negative rheumatoid factor were evidenced.
Abdominal ultrasound confirmed an increase in colonic parietal thickness, predominantly in the right and blind colon, and a significant increase in vascularization.
Coprocultives and Clostridium difficile toxin were negative and skin biopsy showed an important leukocyte infiltrate with dermal edema, compatible with neutrophilic dermatosis.
i. suspected Crohn's disease sprout, monoarthritis and a new episode of Sweet's syndrome started with symptomatic parenteral corticosteroid therapy (methylprednisolone 60 mg/i.v. 24 h).
The articular manifestations and the cutaneous lesions improved progressively, although the total disappearance of the cutaneous lesions was observed at 4 weeks, only a slight scaly redness persisted in the posterior base with completely disappearance of the lesion.
