Metastatic Crohn's disease: a review and approach to therapy

Pediatric cutaneous Crohn disease: A case series of 89 patients and review

BACKGROUND

Cutaneous (or "Metastatic") Crohn disease (CCD) is a rare and underrecognized disease characterized by cutaneous granulomatous inflammation. We describe patient demographics, clinical characteristics, histology, and treatment of 89 pediatric cases of CCD, including 78 previously reported and 11 new cases seen at four academic institutions. We emphasize the efficacy of biologic mono- and dual therapy.

METHODS

PubMed identified cases using keywords including "metastatic Crohn disease" and "cutaneous Crohn disease". Patients were identified by retrospective review of the electronic health record including histopathologic diagnosis consistent with CCD. Chart review collected demographic, clinical, and histologic data.

RESULTS

Most pediatric patients with CCD are male 55% (49/89), present with edema (73/89, 82%) and erythema (47/89, 53%) of the genitals (33/49, 67%), and have intestinal Crohn disease (69/89, 78%). Oral corticosteroids (53/75, 71%) and metronidazole (29/75, 39%) are the most frequently prescribed medications. Of the 17 patients treated with tumor necrosis factor (TNF)-blockade, 94% (16/17) had partial or total clearance. Ustekinumab resulted in clearance of cutaneous disease in two patients (2/3, 67%) and partial clearance in one patient (1/3, 33%). Two cases achieved total clearance with the use of dual biologic therapy defined as the use of two biologic therapies with differing mechanisms of action or the use of a biologic therapy and small molecule inhibitor.

CONCLUSIONS

TNF blockade is an effective treatment for pediatric CCD, and interleukin-12/23 inhibitors may be similarly effective. Consideration of dual biologic therapy may be useful in pediatric patients requiring discordant therapies for their intestinal and cutaneous CD.

Fistulising skin metastases in Crohn's disease: a case report and review of the literature

BACKGROUND

Metastatic Crohn's disease is a rare disorder characterized by various granulomatous skin lesions that occur independently of gastrointestinal tract involvement. However, currently there is no standardized care or specific treatment. Therapeutic approaches include immunosuppressive agents, such as corticosteroids, azathioprine, and monoclonal antibodies targeting inflammatory cytokines like tumor necrosis factor (TNF).

CASE PRESENTATION

We present a case of a 29-year-old western European woman with significant blind ending abdominal subcutaneous fistulas and abscesses, who sought evaluation in the dermatology department. Histological examination revealed multiple epithelioid cell granulomas. There was no evidence of infectious or rheumatologic diseases such as sarcoidosis. The tentative diagnosis was metastatic Crohn's disease, which was not related to an intestinal manifestation of the disease. The patient responded to infliximab but had to discontinue it due to an allergic reaction. Subsequent adalimumab treatment failed to induce clinical remission; thus, therapy was switched to ustekinumab, resulting in a positive response. Written informed consent for publication of their clinical details and clinical images was obtained from the patient. For our study more than 1600 publications were screened for cases of metastatic Crohn's disease on PubMed database. 59 case reports with 171 patients were included in the analysis and evaluated for localization, diagnostic and therapeutic approaches, and complications and were summarized in this review.

CONCLUSION

The successful ustekinumab treatment of a patient with metastatic Crohn's disease underscores the potential of this minimally investigated therapeutic option, highlighting the need for future treatment guidelines given the increasing prevalence of such cases.

A Challenging Case of Metastatic Crohn's Disease Without Gastrointestinal Manifestations

Metastatic Crohn's disease (MCD) is a rare cutaneous manifestation of Crohn's Disease (CD), defined as non-caseating, granulomatous skin lesions non-contiguous with the gastrointestinal (GI) tract. Most patients with MCD either have concomitant classic manifestations of CD or develop them within a few months to years. We report a case of MCD without known involvement of the GI tract, after more than three years from diagnosis. After failure or intolerance to several conventional treatments, including oral corticosteroids and azathioprine, adalimumab was initiated with a good response.  Diagnosis of cutaneous CD is made by a combination of clinical and histopathological findings. Therapeutic options include topical, intralesional, and systemic corticosteroids as well as topical and systemic immunosuppressants and immunomodulators. Surgical excision may be considered for refractory cases.

Metastatic Crohn's Disease in External Genitalia With Good Outcome on Adalimumab: A Rare Case of a Saudi Female and a Short Review

Crohn's disease (CD), an inflammatory bowel disease that involves the gastrointestinal tract, is observed in daily hospital practice. On the other hand, metastatic Crohn's disease (MCD) is a rare entity in which cutaneous lesions are found in regions apart from the digestive system. This article describes a rare case of cutaneous CD in a Saudi female, which manifested initially as vulvar and perianal skin lesions. The diagnosis was proven by skin biopsy, and adalimumab offered effective treatment. Although cutaneous MCD is rare, it is an important cutaneous manifestation, as early detection creates the possibility of accessing effective management.

Managing metastatic Crohn's disease: a single center experience, review of the current evidence, and treatment algorithm

BACKGROUND

Crohn's disease (CD) is an inflammatory bowel disease (IBD) that, besides gastrointestinal symptoms, may encompass extra-intestinal symptoms, such as dermatological manifestations. Of those, metastatic CD (MCD) is a rare extra-intestinal manifestation for which the management is uncertain.

METHODS

We conducted a retrospective case series of patients with MCD seen at the University hospital Leuven, Belgium, combined with an overview of the recent literature. Electronic medical records were searched from January 2003 till April 2022. For the literature search, Medline, Embase, Trip Database, and The Cochrane Library were searched from inception to April 1, 2022.

RESULTS

A total of 11 patients with MCD were retrieved. In all cases noncaseating granulomatous inflammation was found on skin biopsies. Two adults and one child were diagnosed with MCD prior to their diagnosis of CD. Seven patients were treated with steroids (intralesional, topical or systemic). Six patients needed a biological therapy to treat MCD. Surgical excision was performed in three patients. All patients reported a successful outcome and most cases achieved remission. The literature search yielded 53 articles, including three reviews, three systematic reviews, 30 case reports and six case series. A treatment algorithm was generated based on literature and multidisciplinary discussion.

CONCLUSION

MCD remains a rare entity and diagnosis is often difficult. A multidisciplinary approach including skin biopsy is necessary to diagnose and treat MCD efficiently. Outcome is generally favorable, and lesions respond well to steroids and biologicals. We propose a treatment algorithm based on the available evidence and multidisciplinary discussion.

Nonhealing Genital Ulcers as Clue to a Multisystem Disease

A female patient in her late 40s presented with a 3-year history of nonhealing ulcers in her groin and axillae. What is your diagnosis?

[Granulomatous dermatoses]

The group of granulomatous dermatoses refers to a multitude of clinically different diseases, which are characterized by a histopathologically similar pattern of inflammation. The cause of granulomatous inflammatory reactions can be infections and also noninfectious stimuli, such as cell disintegration or foreign bodies. The aim of this immunological defence reaction is encapsulation in order to prevent further spread and delimitation from healthy tissue. This is histologically expressed as a granuloma in the sense of a circumscribed aggregation of histiocytes and multinucleated giant cells mostly in dermal connective tissue. The following can be histologically differentiated: sarcoid granuloma characterized by a sparse lymphocytic inflammatory infiltrate and tuberculous granuloma with central necrosis and denser lymphocytic inflammatory infiltrate. Neutrophilic granulocytes together with macrophages occur in suppurative granulomas and palisaded granulomas are characterized by peripherally arrayed macrophages.

Genital and Intertriginous Rashes Refractory to Antimicrobial Treatments: Have You Thought about Crohn's Disease?

Crohn's disease is an inflammatory bowel disease that can have multiple extraintestinal manifestations and can develop prior to, following, or simultaneously with gastrointestinal tract involvement (Aberumand et al. (2017), Georgious et al. (2006), Larsen et al. (2010), Levine and Burakoff (2011), Louis et al. (2018)). This report examines the case of a 16-year-old male with a rash of the genital, intergluteal, and inguinal regions refractory to antimicrobial treatments suspicious for an extraintestinal manifestation of Crohn's disease. The patient was diagnosed with inflammatory, nonfistulizing colonic Crohn's disease following presentation with gastrointestinal symptoms including abdominal pain and bloody stools 6 months after the onset of the rash. The genital lesions resolved after starting treatment for Crohn's disease with adalimumab.

Crohn's Disease with Cutaneous Polyarteritis Nodosa in a Child: A Case Report

A 10-year-old boy presented with a 1-day history of multiple painful erythematous skin lesions on his upper and lower extremities. He was admitted to the Department of Pediatrics with persistent right lower abdominal pain and diarrhea. Punch biopsy of a skin lesion on his lower leg showed necrotizing granulomatous vasculitis with septal panniculitis consistent with polyarteritis nodosa, and our differential diagnosis included cutaneous manifestations of Croh's disease. Abdominal ultrasonography revealed distended colonic loops suggestive of inflammatory bowel disease. Upper and lower gastrointestinal endoscopy revealed lesions involving the duodenum, cecum, colon, and rectum. He developed multiple perianal fistulas during hospitalization. Additional laboratory tests revealed positive results for anti-saccharomyces cerevisiae and antinuclear antibodies. Based on his clinical presentation and laboratory findings, he was diagnosed with Crohn's disease associated with cutaneous polyarteritis nodosa. We report a rare case of a child who presented with cutaneous polyarteritis nodosa as an extraintestinal manifestation of Crohn's disease.

Metastatic Crohn's disease: an underestimated entity

Cutaneous metastatic Crohn's disease (MCD) is a rare but challenging dermatologic manifestation of Crohn's disease. It is histologically defined as the presence of non-caseating granulomas at skin sites separated from and non-contiguous to the gastrointestinal tract. Cutaneous metastatic Crohn's disease should be distinguished from the much more frequent contiguous cutaneous manifestations of Crohn's disease that present at perianal or, less common, peristomal sites with direct extension from the intestine to the adjacent skin. Versatile clinical presentation and the fact that occurrence can predate the initial diagnosis of Crohn's disease may lead to misdiagnosis, delayed treatment and underreporting. As case numbers are small and randomized controlled studies on management are lacking, the therapeutic approach remains challenging and is often unsatisfactory. We here performed a systematic literature search identifying 264 published pediatric and adult cases of MCD and additionally report three of our own cases. Our review summarizes clinical characteristics, putative etiopathology, histologic findings, differential diagnoses and treatment options for MCD.

Metastatic Crohn Disease: A Clinicohistological Appraisal From a Tertiary Care Center in India

BACKGROUND

Granulomatous dermatitis due to noncontiguous involvement of Crohn disease (CD) of the gut has been described as metastatic CD (MCD). MCD is the rarest form of cutaneous manifestations of CD. This study aims to analyze the clinicohistological features of MCD in a tertiary care center of India.

MATERIALS AND METHODS

A retrospective review of patients diagnosed clinically and histologically with MCD over past 5 years was performed. Data on cutaneous features, histological findings, and response to treatment were collected.

RESULTS

Twelve patients (3 men and 9 women) with a mean age of 29 years were identified. All women had vulval involvement in the form of edema (80%), ulceration (60%), and fistula (20%). Among the 3 men, 2 had perineal and scrotal swelling and ulcer, whereas the third patient presented with leg ulcer. Intestinal CD was already diagnosed in 50% patients (5/10) at cutaneous presentation, whereas it was diagnosed subsequently in 30% (3/10) cases. Histological examination revealed nonnecrotizing granulomatous inflammation in the dermis in 11 patients (92%). Additional histological features included eosinophilic infiltrate (58%), panniculitis (33%), and vasculitis (33%). The patients were treated with various combinations of oral prednisolone, metronidazole, minocycline, azathioprine, and subcutaneous adalimumab with partial relief.

CONCLUSION

MCD shows a wide spectrum of clinical presentation, with anogenital involvement being the most common. Histology reveals nonnecrotizing granulomas in the dermis in majority of the cases. The diagnosis is extremely challenging in patients without gastrointestinal involvement at presentation, and thus, a high index of suspicion is imperative.

Vulvar swelling and the timely diagnosis of Crohn's disease: A case report

Children with vulvar swelling often present to multiple physicians and face a prolonged period of ambiguity and extraneous treatments. Here, we report a case of an 8-year-old girl who presented to the dermatology clinic with a 2-month history of vulvar swelling and was ultimately diagnosed with Crohn’s disease. Although extra-intestinal manifestations are common in inflammatory bowel diseases, they rarely present before an existing diagnosis. This report highlights this potential early manifestation and demonstrates how timely diagnosis leads to improved outcomes for patients, their families, and healthcare systems.

Vulvar Crohn disease: Diagnostic challenges and approach to therapy

Crohn disease (CD) may be complicated by contiguous, metastatic, or associated inflammatory cutaneous lesions. Vulvar CD is a rare phenomenon characterized by granulomatous genital inflammation that occurs independently from fistulizing CD. Left untreated, vulvar CD can result in debilitating lymphedema, disfiguring anatomic changes, secondary abscesses, cellulitis, and squamous cell carcinoma. We present a series of cases to highlight the clinical presentation of vulvar CD, the diagnostic testing required to distinguish complicating conditions, the asynchronous courses of skin and intestinal disease, and the complexities in the management of this disease and associated conditions. We review our multidisciplinary approach to care, aimed at reducing morbidity and improving patient quality of life.

Wound healing of metastatic perineal Crohn's disease using hyperbaric oxygen therapy: A case series

BACKGROUND

Metastatic Crohn's disease (CD) is a rare manifestation of CD. It involves inflammatory skin lesions with histopathological findings (granulomas) similar to CD, without connection to the gastrointestinal tract. Hyperbaric oxygen therapy (HBO) has been suggested as a possible treatment option.

OBJECTIVE

This study aimed to identify and treat a consecutive series of patients with biopsy-proven metastatic CD and monitor wound healing using prospectively acquired outcomes.

METHODS

Pathology results of all patients with ongoing perineal wound-healing problems after proctectomy between 2005 and 2018 at the Amsterdam University Medical Centre were assessed for metastatic CD. Patients with a biopsy-proven diagnosis of perineal metastatic CD were offered HBO (40 daily sessions of 100% oxygen at 2.4 atmosphere absolute). Wound healing was monitored using photographs and standardised questionnaires (the Inflammatory Bowel Disease Questionnaire, EuroQol Visual Analogue Scale and the Female Sexual Function Index) at baseline and 1 and 3 months after HBO.

RESULTS

Out of 13 patients in the cohort with persisting perineal wounds after proctectomy, six (46%) had biopsy results consistent with metastatic CD. Of these, three accepted treatment with HBO. All three patients were female. One patient had complete healing of her perineal wound; another patient showed initial improvement but had a flare of luminal and perineal disease at the 3-month follow-up. The third patient showed improvement solely in the questionnaires, with higher scores on all three questionnaires.

CONCLUSION

A high rate of metastatic CD was found in patients with ongoing wound-healing problems after proctectomy, implying that the disease might not be as rare in these selected patients as previously thought. HBO might be beneficial in the treatment of metastatic CD.

Rapid Resolution of Vulvar Crohn's Disease With Ustekinumab

In the evaluation of patients with inflammatory bowel disease, assessment of extraintestinal manifestations of disease is integral to clinical management. The patient described in this case is a 24-year-old woman with a history of inflammatory colonic Crohn's disease (CD) who presented to the hospital with one week of vaginal pain and swelling. Initial assessment focused on infectious etiologies, though final diagnosis of vulvar CD was made on biopsy. Clinical course and treatment of vulvar CD are poorly defined in existing literature. This case highlights the multidisciplinary management of inflammatory bowel disease patients and successful treatment of a rare extraintestinal manifestation with anti-interleukin 12/23 therapy.

A Rare Clinical Presentation of Metastatic Crohn's Disease

A 31-year-old female with a history of systemic lupus erythematous, IgA nephropathy, and psoriasis presented with a one-month history of a painful, pruritic rash under the bilateral breasts and in the genital region. Cutaneous examination revealed a large, tender ulcer under the left breast with a shiny erythematous base and peripheral hypertrophic changes. Small ulcers were present on the bilateral inguinal folds, and the labia majora were edematous with multiple erythematous papules. Histological examination of the left breast revealed ulceration with granulomatous dermatitis, consistent with a diagnosis of metastatic Crohn's disease. Metastatic Crohn's disease is a rare cutaneous manifestation of Crohn's disease characterized by non-caseating granulomas in regions non-contiguous with the gastrointestinal tract. At the time of diagnosis, our patient reported no gastrointestinal symptoms aside from occasional blood-streaked stools from hemorrhoids. This case demonstrates the importance of considering the disease when a patient presents with intertriginous or genital lesions, even in the absence of systemic manifestations.

Clinical, Imaging, and Pathologic Features of Conditions with Combined Esophageal and Cutaneous Manifestations

A variety of clinically significant conditions can affect both the esophagus and the skin. Esophageal and cutaneous manifestations may directly reflect the underlying disease process, as in infections such as herpes simplex virus, bullous diseases such as epidermolysis bullosa and mucous membrane pemphigoid, connective tissue diseases such as systemic sclerosis, and inflammatory diseases such as lichen planus. Alternatively, esophageal and cutaneous findings may result from conditions that are closely associated with and potentially pathognomonic for but distinct from the underlying disease process, as in genetic diseases such as Cowden syndrome or paraneoplastic syndromes such as acrokeratosis paraneoplastica. Other diseases such as Crohn disease may have cutaneous manifestations that directly reflect the same underlying inflammatory process that affects the gastrointestinal tract or cutaneous manifestations that represent reactive or associated conditions distinct from the underlying inflammatory process. The cutaneous manifestations of disease may precede, coincide with, or follow the esophageal manifestations of disease. The authors present the characteristic clinical features and imaging findings associated with common and uncommon conditions that have esophageal and cutaneous manifestations. Each condition is presented with a brief overview, discussion of salient clinical and cutaneous manifestations, and description of the typical esophageal imaging findings, with particular attention to implications for diagnosis, prognosis, and treatment. Recognition of potential associations between cutaneous lesions and esophageal imaging findings is important for establishing a specific diagnosis or generating a meaningful differential diagnosis.

Current clinical issue of skin lesions in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) is associated with a number of extraintestinal complications, including skin lesions. Most reports have shown that skin lesions are found in 10-15% of IBD cases, although this depends on the definition of skin lesions. The representative skin lesions in patients with IBD are erythema nodosum, pyoderma gangrenosum, Sweet's syndrome, and so on. These lesions are often associated with IBD progression, and intestinal lesions in particular require appropriate treatment. Recently, another clinical issue regarding skin lesions in patients with IBD, a so-called paradoxical reaction, during the treatment with anti-tumor necrosis factor (TNF)-α agents has emerged. These reactions are termed paradoxical reactions because the skin lesions sometimes resemble psoriasis, although the anti-TNF-α agents have been historically used to treat psoriasis. Paradoxical reactions are reportedly found in approximately 5-10% of patients using anti-TNF-α agents and are no longer rare. Now that the use of biologics is at its culmination, reports regarding paradoxical reactions are predicted to increase in number; thus, we must recognize skin lesions with IBD patients including this type of adverse events and manage them appropriately while consulting with dermatologists.

Cutaneous manifestations of metastatic Crohn's disease

Metastatic Crohn's disease is a rare cutaneous complication of primary Crohn's disease. It is a granulomatous inflammatory process, similar to the pathogenic mechanism of Crohn's disease, that occurs in sites discontiguous from the gastrointestinal tract. Metastatic Crohn's disease can precede the development of Crohn's disease by months to years, and children are more likely to present with metastatic Crohn's disease in the absence of gastrointestinal symptoms. Given that approximately 30% of individuals with Crohn's disease present in childhood, early recognition of extraintestinal manifestations of Crohn's disease such as metastatic Crohn's disease can aid in timely diagnosis and management of bowel disease. We present data from two pediatric cases of metastatic Crohn's disease recently seen at our institution in addition to the 61 reported cases of pediatric metastatic Crohn's disease in the literature. This review article will focus on the epidemiology, pathogenesis, clinical features, and histology of and treatment options for pediatric metastatic Crohn's disease.

Clinical experience and diagnostic algorithm of vulval Crohn's disease

BACKGROUND AND AIM

Vulval Crohn's disease (VCD) is a rare extraintestinal cutaneous manifestation of Crohn's disease. No consensus on the diagnostic workup and therapeutic management of this condition has been provided in the current literature.

PATIENTS AND METHODS

Retrospective, multicentre descriptive case series of female patients diagnosed and treated with VCD. By chart review, data on initial symptoms, clinical courses, histologic findings and therapeutic management were collected.

RESULTS

Fifteen female patients with a median age of 28 years (interquartile range: 28-44 years) suffering from Crohn's disease of the ileum (27%), colon (33%) and ileocolon (40%) were included. VCD manifested most frequently with vulval swelling (93%), pain (80%) and erythema (73%). Histologic analysis demonstrated granulomatous inflammation in 78% and a mixed inflammatory cell infiltrate in 67% of cases. In eight (53%) cases, topical therapy resulted in temporary reduction of vulval symptoms. Combotreatment with immunosuppressive agents and tumour necrosis factor α inhibitors was the most effective second-line therapy: five (33%) patients achieved sustained clinical remission with this therapeutic strategy.

CONCLUSION

The diagnostic workup of VCD is challenging and should be approached in a multidisciplinary manner. Histopathologic analysis of the vulva supports the diagnosis. Topical therapy and systemic treatment with immunosuppressive agents and tumour necrosis factor α inhibitors are advised to treat this condition.

Cutaneous Crohn's disease with superimposed psoriasis: A unique case with overlapping histology

Crohn's disease (CD) is an idiopathic, chronic inflammatory disorder of the gastrointestinal tract. We recently encountered a unique case in which a patient with longstanding CD presented with skin lesions with histopathologic features of both psoriasis and granulomatous inflammation suggestive of cutaneous CD. To our knowledge, this has not been described concomitantly in the same patient, in the same lesions. Review of the literature suggests that the intersection of these 2 histopathological reaction patterns may not be pure coincidence. Clinical-pathologic correlation of this case will be discussed, along with a review of the potential mechanisms of this unique disease presentation.

Granulomatous & histiocytic dermatitides

Granulomas of the skin may be classified in several ways. They are either infectious or non-infectious in character, and they contain areas of necrobiosis or necrosis, or not. Responsible infectious agents may be mycobacterial, fungal, treponemal, or parasitic organisms, and each case of granulomatous dermatitis should be assessed histochemically for those microbes. In the non-infectious group, examples of necrobiotic or necrotizing granulomas include granuloma annulare; necrobiosis lipoidica; rheumatoid nodule; and lupus miliaris disseminates faciei. Non-necrobiotic/necrotizing and non-infectious lesions are exemplified by sarcoidosis; foreign-body reactions; Melkersson-Rosenthal syndrome; Blau syndrome; elastolytic granuloma; lichenoid and granulomatous dermatitis; interstitial granulomatous dermatitis; cutaneous involvement by Crohn disease; granulomatous rosacea; and granulomatous pigmented purpura. Histiocytic dermatitides that do not feature granuloma formation are peculiar reactions to infection, such as cutaneous malakoplakia; leishmaniasis; histoplasmosis; lepromatous leprosy; rhinoscleroma; lymphogranuloma venereum; and granuloma inguinale.