AN UNUSUAL MANIFESTATION OF METASTATIC CROHN’S DISEASE: A CASE REPORT

Abstract

Abstract INTRODUCTION Crohn’s Disease (CD) is a chronic granulomatous inflammatory disease involving any section of the gastrointestinal (GI) tract. Metastatic Crohn’s Disease (MCD) is a rare extraintestinal manifestation of CD defined as cutaneous granulomatous lesions non-adjacent to the GI tract. We present a case of suppurative lymphadenitis as a presentation of MCD. This has not yet been reported in the literature. CASE REPORT A 22-year-old female with a history of iron deficiency anemia and left calf abscess, secondary to Methicillin-Resistant Staphylococcus Aureus (MRSA) infection, was diagnosed with ileocolonic CD at 18. Her CD was complicated by strictures and abdominal and left tubo-ovarian abscesses with a fistula to the sigmoid. She underwent Ileocolonic resection, sigmoid colectomy and left salpingo-oophorectomy. Histology of the ovarian abscesses unveiled granulation tissue with pseudocysts. Azathioprine and Infliximab were started. At 20, the patient reported acute onset of swelling and pain on the left side of her neck. She denied any constitutional symptoms, sick person or animal contacts, travel, use of recreational drugs and sexual activities. Physical exam was remarkable for a tender, rubbery, 2-centimetre left cervical lymph node. The neck Ultrasound showed cervical lymphadenitis. Antibiotic was started and later extended to target resistant infections. Despite this, she reported worsening symptoms. Computed Tomography of the neck noted a collection suggestive of suppurative lymphadenitis. Incision and Drainage (I & D) of the abscess was done; MRSA was detected. Histology exposed necrotizing granulomata encircled by palisading histocytes and giant cells. There was no evidence of dysplasia, fungal, acid-fast bacilli or spirochetes. Further, Human Immunodeficiency Virus serology, Interferon-Gamma Release Assay and chest radiograph were unremarkable. Later, she underwent surgical excision revealing a fistula to the lower mandible. A drain was placed and then removed upon recovery. Meantime, her CD stayed stable; Infliximab was held till the completion of antibiotics. A year later, she reported a tender, swollen lump on the left side of her groin with an ultrasound confirming inguinal suppurative lymphadenitis. Antibiotics were started, and I &D was done for lasting symptoms. The culture and histology were similar to the previous. Considering the history of CD and histology findings, MCD was concluded as the etiology of this patient’s recurrent MRSA abscesses. CONCLUSION Patients on biologic therapy are immunocompromised and presumed high risk for super-infections. In a setting of a persistent infection, despite antibiotics, the possibility of MCD as the cause of lymphadenitis should be raised to cue the clinician to alter therapy and address the MCD within a multidisciplinary setting.