SUBCUTANEOUS STERNAL ABSCESS AS AN EXTRAINTESTINAL MANIFESTATION OF ULCERATIVE COLITIS

Abstract

Background: Cutaneous lesions are one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD), seen in approximately 10% of the cases. Subcutaneous abscesses are known to rarely affect patients with IBD and occur in parallel to the activity of primary disease. We report a 17 year-old male with ulcerative colitis (UC) who presented with a sternal abscess Case: A 17 year-old male diagnosed at an outside hospital with UC 2 years ago presented with a mass in the anterior chest, fever and facial lesions. His home medications were mesalamine, docusate, hyocyamine, ferrous sulfate, isotretinoin, loperamide and a prednisone taper. Repeated tapering courses of prednisone were used for a long period of time because of recurrent skin lesions on his trunk, extremities and face. His review of systems was positive for abdominal pain and bloody diarrhea. His examination showed a 6 × 6 cm tender, fluctuant mass in the anterior chest, facial vesiculopustular lesions and ulcerated skin lesions on the face, leg and back. Pertinent investigations were: elevated WBC of 27.1 X10E+09/L (72% neutrophils, 9% bands), platelets 1102 X10E+09/L, ESR 59 mm/h, decreased albumin of 2.5 gms/dl and hemoglobin of 7.4 gms/dl. Blood and abscess cavity cultures for bacteria, fungi and acid fast bacillus were negative. The abscess fluid consisted of a predominantly neutrophilic infiltrate. A CT scan of the chest showed sternal osteomyelitis surrounded by an abscess. Initial treatment included surgical drainage and antibiotics. An upper endoscopy and colonoscopy with biopsies showed active pan colitis and a normal terminal ileum. As the skin lesions and symptoms of colitis improved significantly in response to systemic steroids, the patient was placed on 6-mercaptopurine for maintenance of remission and isotretinoin was discontinued. Conclusion: Aseptic skin abscesses result from a deep localization of neutrophilic disease and are related to disease activity in IBD. Therefore, appropriate treatment of the underlying disease and for possible infection is necessary