A Rare and Unusual Case of Healing Pyoderma Gangrenosum in Uncontrolled Crohnsʼ Disease

Abstract

Pyoderma gangrenosum (PG) is a rare extraintestinal manifestation of inflammatory bowel disease (IBD). A literature review suggests that 6 to 40% of patients with IBD will experience extraintestinal manifestations. Respectively, Erythema nodosum and pyoderma gangrenosum are the first and second extraintestinal manifestations of IBD. PG is seen in an estimated 5% of Ulcerative Colitis patients and even less in Crohn's disease. PG is the more rare extraintestinal manifestation for Crohn's disease. Although PG is a neutrophilic dermatosis, the cause of PG remains not well understood due to its low incidence. The general axiom for these cutaneous manifestations is to control the inflammatory disease flare in order to obtain resolution of this extraintestinal manifestation. For our case report, we present a 39-year-old African American male inmate who presented with a year of intermittent uncontrolled Crohn's disease with healing Pyoderma gangrenosum. Prior to his incarceration the patient well controlled with a mesalamine regimen without any symptoms of abdominal pain or bloody diarrhea. After incarceration, he became noncompliant with therapy and developed intermittent flares. Patient's physical exam consisted of gross bloody diarrhea associated with a 30-40 pound weight loss over two years and intermittent abdominal pain, most severe in his epigastric region. Patient also presented with healing maculopapular lesions circumferentially extending from his knees to feet. Literature review suggests that pyoderma gangrenosum resolves when the underlying condition, in this case Crohn's disease, is managed. However, we present this rare and unique case due to the patient's pyoderma gangranosum presenting in a healing phase amidst uncontrolled Crohn's disease. There has only been one other reported case study where a patient presented with intractable PG amid controlled Crohn's disease activity. These two cases raise more questions about the molecular mechanism that drive the disease activity. Futhermore, it underscores potential weaknesses to the axiom that disease activity and extraintestinal manifestations run parallel to each other prompting further need for research to understand the molecular drivers of inflammatory bowel diseases.2060 Figure 1 No Caption available.