S3469 An Atypical Presentation of Crohn's Disease in a Young Woman: Case Report

Abstract

INTRODUCTION: Crohn’s disease (CD) is an inflammatory bowel disease (IBD) that may involve any part of the gastrointestinal (GI) tract that may present with varied extra intestinal manifestations. CASE DESCRIPTION/METHODS: A 21-year-old woman presented to the ED with a two-week history of subjective fevers and progressively worsening asymmetric ankle pain and swelling that caused difficulty with ambulation. She also noted several tender, raised, red papules on her shins concerning for erythema nodosum. On review of systems, she endorsed intermittent semi-solid stools the week prior that she attributed to a recent antibiotic course initiated by her physician for presumed cellulitis. In the ED she was febrile and tachycardic with a normal chest radiograph and laboratory studies notable for a leukocytosis of 25.6 × 109 /L with left shift, C-reactive protein of 28 mg/L and mildly elevated serum transaminases. The initial differential diagnosis included infection, autoimmune disease, and malignancy. On admission she met sepsis criteria and was empirically started on broad-spectrum antibiotics; however, throughout her stay all cultures and tissue biopsies failed to reveal a causative infectious etiology. Fecal calprotectin collected upon admission was found to be significantly elevated. A computed tomography scan of the abdomen demonstrated intracolonic polypoid lesions and mesenteric lymphadenopathy concerning for potential malignancy, although subsequent positron emission tomography scan was inconsistent with this diagnosis. Colonoscopy demonstrated diffuse patchy colonic inflammation, relative ileal sparing, and scattered ulcerations involving the proximal sigmoid colon to cecum. Biopsy of the lesions revealed surface ulceration, crypt abscesses, and mild architectural distortion all consistent with moderate to severe CD. Antibiotics were withdrawn and the patient was started on Infliximab induction with a rapid improvement of both intestinal and extraintestinal symptoms. DISCUSSION: Crohn’s disease may prove to be an elusive diagnosis as varying extraintestinal manifestations make for a rare “classic” phenotype. Retrospective interview with this patient yielded details of intermittent oligoarthritis and years of recurrent loose stools that were likely symptoms of a smoldering diagnosis of CD that went overlooked. This case demonstrates the importance of vigilance when an otherwise healthy patient presents with atypical symptoms and a chief compliant that is not primarily related to GI manifestations.Figure 1.: Erythema Nodosum and asymmetric ankle pain, swelling and erythema on presentation to the emergency room.Figure 2.: Asymmetric ankle pain, swelling and erythema on presentation to the emergency room.Figure 3.: Colonoscopy demonstrating diffuse patchy colonic inflammation and scattered ulcerations.