A Fatal Association between a Seizure and Drug-Induced Parkinsonism

Abstract

The most common site ofcutaneous involvement in Crohn's disease is the perineum5 with lesions occurring in 43-94% of patients. Internal fistulas such as recto-vaginal6, ileouterine and ileo-tubal7 have also been reported. Corticosteroids azathioprine and sulphasalazine have been the mainstay of medical treatment for vulval Crohn's. The results of various local treatments with steroids and/or antibacterial agents have been disappointing8. Systemic steroids and cytotoxic agents have also been shown to have no beneficial effect on the vulval lesion. Regular curettage of vulval ulcers with concomitant oral zinc sulphate administration have been used to good effect in some patients9. It has also been recommended that removal of the adjacent bowel is of benefit if it is involved in the disease process, as cutaneous ulceration is unlikely to heal when diseased intestine is still present. Surgical intervention is however, followed by unhealed wounds in up to one half of patients'0. Limited local excision will frequently result in recurrence and failure to control the lesion. Extensive radical excision of all the area involved has been proposed as the best chance of cure. The long-term use of metronidazole for perianal and vulval disease has recently been found to be of use'2. A standard regimen has been instituted in some units with regard to vulval ulceration. This includes local care in the form of iodine and a dextromononer absorptive dressing. This is combined with prednisolone orally and long term metronidazole therapy'3. Most patients tolerate metronidazole therapy well without significant side effects. Minor side effects include a metallic taste and darkening of the urine together with gastrointestinal upset. More severe side effects such as peripheral neuropathy may occur in long-term therapy.