Aseptic abscesses: a study of 30 patients with or without inflammatory bowel disease and review of the literature

Insights into the Pathogenesis of Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis of unclear etiology. Numerous theories of its underlying pathogenesis have been proposed, including external triggers, neutrophilic dysfunction, complement activation, and autoimmunity, as well as a possible component of underlying genetic susceptibility. This review seeks to synthesize current understanding of the pathogenesis of PG and integrate interactions between the multitude of implicated host immune pathways to guide and inform future directions into the treatment of PG.

Aseptic abscess syndrome: a case report of a patient achieving remission with both infliximab originator and biosimilar administered at varied intervals

Aseptic abscesses syndrome is a rare but increasingly recognized disease that falls within the spectrum of autoinflammatory disorders. Here, we describe the case of a patient who presented with abdominal pain and fever, along with multiple abdominal and extra-abdominal abscesses, in the absence of underlying hematologic, autoimmune, infectious, or neoplastic conditions. Initially, the patient responded to glucocorticoids, but experienced several flares upon discontinuation, leading to the initiation of treatment with a TNFα inhibitor. After 5 years, an attempt to discontinue treatment resulted in a new flare of the disease. Remission was eventually achieved with a biosimilar TNFα inhibitor, albeit requiring shortened infusion intervals.

Aseptic abscess associated with SAPHO syndrome: a case report

Aseptic abscess (AA) is a rare autoinflammatory disorder, characterized by the formation of sterile abscesses in various organs, and is accompanied by inflammatory bowel disease. Antibiotic treatment is ineffective, but steroid therapy shows a good response. AA can be difficult to differentiate from infection because abscesses appear similar both radiologically and histopathologically. Herein, we present the case of a 56-year-old woman with AA in the anterior chest wall and synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome.

Aseptic Splenic Abscesses With Concomitant Sweet Syndrome as Extraintestinal Manifestations of New-Onset Crohn's Disease

Splenic abscesses are typically infectious in nature but have rarely been reported as an extraintestinal manifestation of inflammatory bowel disease, particularly of Crohn's disease. In the United States, reported cases are even more scarce. We present a case of aseptic splenic abscess with concomitant Sweet syndrome in a middle-aged woman with newly diagnosed Crohn's disease. Extensive workup was required to reach final diagnosis, and she rapidly improved with corticosteroid therapy and has been maintained on risankizumab. We aim to contribute to limited data and heighten clinician awareness of these atypical extraintestinal manifestations.

Lung and Cutaneous Abscesses in a Patient with Ulcerative Colitis: A Case Report and Literature Review

Aseptic abscess (AA) syndrome is a rare inflammatory disorder often associated with inflammatory bowel disease (IBD). Cases of IBD-associated AA have been reported in Japan, India, and Canada, but rarely in China. Herein, we present the case of a Chinese patient with IBD-associated AAs and review the literature on AA with underlying IBD. We report the case of a 48-year-old male patient with multiple AAs on his left hand and lungs who was successfully treated with prednisone. He had undergone cutaneous abscess incision and drainage twice in the previous 2 years. The patient presented to our hospital with ulcerative colitis and pain in the dorsum of the left hand. Pus from his hand and blood cultures revealed sterile cutaneous abscesses. Chest computed tomography examination during hospitalization revealed a lung abscess. The AA was unresponsive to cefotiam or cefoperazone-sulbactam. The patient's left hand and lung conditions did not improve until prednisone was administered. The patient was followed up as an outpatient for 3 months and recovered without any clinical symptoms. We retrieved 17 cases of IBD-associated AA from the literature. None of the patients showed evidence of infection and failed antibiotic treatment, and all improved with corticosteroid use. AA may be an extra-intestinal manifestation of IBD. Effective medications include corticosteroids and immunosuppressive agents. This case may increase the awareness of AA and aid in early identification.

Approach to the Atypical Wound

The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.

Characterization and Management of Amicrobial Pustulosis of the Folds, Aseptic Abscess Syndrome, Behçet Disease, Neutrophilic Eccrine Hidradenitis, and Pyostomatitis Vegetans-Pyodermatitis Vegetans

Neutrophilic dermatoses are a broadly heterogeneous group of inflammatory skin disorders. This article reviews 5 conditions: amicrobial pustulosis of the folds, aseptic abscess syndrome, Behçet disease, neutrophilic eccrine hidradenitis, and pyostomatitis vegetans-pyodermatitis vegetans.The authors include up-to-date information about their epidemiology, pathogenesis, clinicopathologic features, diagnosis, and management.

Symptoms and Management of Aseptic Liver Abscesses

Aseptic liver abscesses occur very rarely. Clinical guidelines on the management of the disease do not exist, and the diagnosis is challenging.We screen MEDLINE and PUBMED databases for relevant case reports from inception to November 2022. Information on patient age, sex, initial symptoms, the extent of abscess formation, further diagnoses, treatment, and course of the disease is analyzed.Thirty cases with sterile hepatic abscess formation are identified. In most patients (n=18), the spleen is affected as well. Patients typically present with fever, abdominal pain, and increased inflammatory values. Comorbidity with inflammatory bowel disease is very common (n=18) and is associated with a significantly younger age at the time of hepatic abscess development. In addition, many patients show autoimmune-mediated cutaneous, ocular, or arthritic rheumatoid manifestations. Histological examination of abscess material reveals neutrophilic infiltration. The majority of patients initially receive corticosteroid therapy. Furthermore, response to azathioprine, anti-TNF-α antibodies, and other immunomodulatory drugs is reported. Ten out of fourteen patients with a long-term follow-up (≥ 36 months) have at least one relapse of hepatic abscess formation.Aseptic hepatic abscesses should be considered in the case of sterile punctures and non-response to antibiotics. Patients with aseptic liver abscesses have a high risk of recurrence warranting immunomodulatory maintenance therapy.

Hepatic Abscess in Inflammatory Bowel Disease: A Systematic Scoping Review of an Overlooked Entity

Background

Liver abscess is one of the hepatobiliary manifestations of inflammatory bowel disease (IBD) that has been scarcely described in the literature.

Objectives

To conduct a scoping review to provide a detailed description of the occurrence of hepatic abscess in patients with IBD and summarize the observed clinical features.

Methodology

Searches were carried out using relevant keywords in Medline (via PubMed) and Web of Science from inception until June 13, 2022. Only articles that reported the occurrence of hepatic abscess in patients with IBD were included.

Results

Forty-eight publications (40 case reports and 8 case series) were included, representing 73 patients with IBD who were radiologically or intraoperatively diagnosed with hepatic abscess. Patients with Crohn's disease were more predisposed to developing hepatic abscess than patients with ulcerative colitis (79.5% vs. 20.5%, respectively). Furthermore, pyogenic liver abscess was found to be more prevalent (57.9%) compared with aseptic (38.7%) and amebic (3.2%) abscesses. No clear relation was found between death or prolonged hospital stay in terms of the clinical presentation or management plan, as mortality was reported in different age groups with different managements.

Conclusion

To date, there is no consensus regarding the appropriate management of hepatic abscess as an extraintestinal manifestation of IBD. However, the condition shares several features with liver abscess diagnosed among the general population.

Clinical guidance of pyoderma gangrenosum 2022

Pyoderma gangrenosum (PG) is a rare, neutrophilic skin disease. For the purpose of accurate diagnosis and proper treatment of PG, the Japanese clinical practice guidance for PG developed by the Japanese Dermatological Association was published in 2022. In this guidance, clinical aspects, pathogenesis, current therapies, and clinical questions on PG are described from the viewpoints of current knowledge and evidence-based medicine. Here, the English version of the Japanese clinical practice guidelines for PG is presented and is intended to be widely referred to in the clinical examination and treatment of PG.

Host-microbiota relationship in the pathophysiology of aseptic abscess syndrome: protocol for a multicentre case-control study (ABSCESSBIOT)

INTRODUCTION

Aseptic abscess (AA) syndrome is a rare disease whose pathophysiology is unknown. It is often associated with inflammatory bowel disease and characterised by sterile inflammation with collections of neutrophils affecting several organs, especially the spleen. Microbiota are known to influence local and systemic immune responses, and both gut and oral microbiota perturbations have been reported in diseases associated with AA syndrome. However, interactions between these factors have never been studied in AA syndrome. The purpose of this translational case-control study (ABSCESSBIOT) is to investigate gut and/or oral microbiota in patients with AA syndrome compared with healthy controls. Moreover, microbiota associated metabolites quantification and Treg/Th17 balance characterisation will give a mechanistic insight on how microbiota may be involved in the pathophysiology of AA syndrome.

METHODS AND ANALYSIS

This French multicentre case-control study including 30 French centres (University hospital or regional hospital) aims to prospectively enrol 30 patients with AA syndrome with 30 matched controls and to analyse microbiota profiling (in stools and saliva), microbial metabolites quantification in stools and circulating CD4+ T cell populations.

ETHICS AND DISSEMINATION

This study protocol was reviewed and approved by an independent French regional review board (n° 2017-A03499-44, Comité de Protection des Personnes Ile de France 1) on 10 October 2022, and declared to the competent French authority (Agence Nationale de Sécurité du Médicament et des produits de santé, France). Oral and written informed consent will be obtained from each included patient and the control participant. Study results will be reported to the scientific community at conferences and in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

Clinical Trials web-based platform (NCT05537909).

Case report: Aseptic splenic abscesses in childhood-onset systemic lupus erythematosus

Background

Systemic lupus erythematosus (SLE) can involve any organ system and cause a wide range of manifestations. Noninfectious inflammatory lesions termed aseptic abscesses have been reported in some autoimmune and autoinflammatory conditions but not in childhood-onset SLE. In this report, we highlight the unusual finding of occult splenic abscesses in two children diagnosed with SLE who had no evidence of concomitant infection.

Case presentation

An 8-year-old and an 11-year-old were admitted separately to the hospital with fever for 7 and 14 days, respectively. In the younger child, a generalized rash preceded the fever. Both had been well, with no significant past medical history prior to the onset of the illness. In both girls, abdominal ultrasonography showed multiple small hypoechoic lesions suggestive of abscesses scattered throughout the spleen. Their C-reactive protein and blood cultures were negative, and symptoms persisted despite intravenous antibiotics. Fulfilling the clinical and immunologic criteria for diagnosis, both were ultimately diagnosed with childhood-onset SLE. Rapid recovery of symptoms and complete resolution of the abscesses ensued with corticosteroids and immunosuppressive therapy.

Conclusions

These two cases suggest that aseptic splenic abscesses may occur in childhood-onset SLE. Autoimmune conditions such as SLE should be included in the differential diagnosis of children with occult splenic abscesses.

Aseptic Abscess of the Spleen as an Antecedent Manifestation of Behçet's Disease

Behçet's disease (BD) is a multisystem autoimmune vasculitis that manifests as oral and genital ulcers with varying degrees of dermatological and ocular involvement. Aseptic splenic abscesses are a rare entity commonly occurring in autoinflammatory diseases and are rarely associated with BD. Here, we present the case of a 16-year-old male with BD who presented with prolonged fever and constitutional symptoms and was found to have an aseptic splenic abscess. Rapid resolution of the symptoms along with radiological evidence of abscess shrinkage was achieved with corticosteroid therapy.

Multiple ulcerative colitis-associated aseptic abscesses successfully treated with infliximab: a case report

Aseptic abscesses are rare extraintestinal manifestations of inflammatory bowel disease. Herein, we present the case of a 69-year-old female patient with ulcerative colitis in whom multiple aseptic abscesses were successfully treated with infliximab. Aseptic abscesses associated with ulcerative colitis are difficult to differentiate from infectious abscesses. In the present case, we reached a diagnosis of aseptic abscesses associated with ulcerative colitis as antibiotics were ineffective and repeated Gram stains and cultures of blood and abscess were negative. Aseptic abscesses are commonly found in the spleen, lymph nodes, liver, and skin; however, in the present case, the periosteum was the major site. Prednisolone is often effective for aseptic abscesses; however, the present patient was initially treated with a combination of 40 mg/day of prednisolone and granulocyte and monocyte adsorption apheresis, with inadequate effect. Infliximab was administered as the patient was steroid-resistant, with strong effect. Subsequently, infliximab treatment has been continued, with no recurrence after 2 years. However, as there have been reports of cases of recurrence even after remission with treatment, careful follow-up in the future is therefore necessary.

Successful treatment of Crohn's disease, aseptic liver abscess and psoriasis with ustekinumab

Crohn's disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract that is commonly known to affect the ileum and colon. Aseptic abscess (AA) has been pathologically described as sterile abscess with a predominance of polymorphonuclear leucocyte infiltrates, and is considered a rare extraintestinal manifestation of CD. AA presents a great challenge to physicians in determining if it is an extraintestinal manifestation of CD or an actual infection with pathogenic microorganisms. There is a strong association between CD and psoriasis. But the coexistence of AA and psoriasis in CD was unusual. Ustekinumab, as an IL 12/23 inhibitor, is the only treatment with a similar mechanism currently available for both CD and psoriasis. We report a case of successful use of ustekinumab to treat a CD patient with hepatic AA and psoriasis.

Hypersplenism and thrombocytopenia after exposure to ustekinumab in a patient with Crohn's disease

Crohn's disease can be characterized as a chronic inflammatory state causing various clinical presentations and long-term risks that should be considered when determining the optimal therapeutic strategy. To date, while a few case reports have been available regarding ustekinumab-induced thrombocytopenia, none are available regarding hypersplenism. We describe a 33-year-old woman who developed only Ileocolonic Crohn's disease on ustekinumab due to failure of anti-TNF with septic shock and thrombocytopenia. Abdominal computed tomography revealed hepatosplenomegaly, parasacral collection, and fistulization. The patient was transferred to the intensive care unit and managed accordingly. Various treatment modalities were attempted, but none of them improved her platelet count. Our case report demonstrates that ustekinumab may induce hypersplenism and subsequently thrombocytopenia and should be considered a potential cause of low platelet count.

Relapsing Polychondritis in a Patient With Auricular Chondritis and Inflammatory Bowel Disease: A Case Report With Literature Review

Relapsing polychondritis (RP) most commonly presents as inflammation and degeneration of cartilaginous tissue in the auricles, nasal septum, and lungs (in severe instances). RP is a rare autoimmune condition associated with other autoimmune diseases in 30% of cases. The prevalence of gastrointestinal involvement with RP is tenuous; however, there is a growing collection of case studies associating auricular chondritis with concomitant inflammatory bowel disease (IBD), including both ulcerative colitis and Crohn's disease. We report the case of a 35-year-old patient presenting with autoimmune pancreatitis, with a past medical history of Crohn's disease, primary sclerosing cholangitis (PSC), and suspected RP. Although RP is rare, the disease's multiple clinical presentations and recurrent episodic nature can cause significant diagnostic delays and are often overlooked by physicians. Thus, low disease prevalence may be due to under-recognition and under-reporting of disease symptoms. As RP is a clinical diagnosis, increased awareness of the disease presentation and clinical characteristics may increase disease recognition and improve treatment outcomes.

Aseptic Abscess Syndrome in Rheumatoid Arthritis Patient

Aseptic abscess syndrome (AAS) is a rare, potentially life-threatening disorder, with numerous features of neutrophilic dermatoses. The main symptoms include aseptic abscess-like collections in internal organs (spleen, liver, lungs), lack of microbes (bacteria, viruses, or parasites) after an exhaustive search, ineffectiveness of antibiotics, and high sensitivity to corticosteroid therapy. AAS is characterized by the development of deep, inflammatory abscesses and systemic symptoms (weight loss, abdominal pain, fever, and leukocytosis). They may be associated with inflammatory bowel disease (IBD) and autoimmune diseases. The patient in this study is a 67-year-old man, suffering from rheumatoid arthritis (RA), with numerous purulent abscesses in the mediastinum, within the subcutaneous tissue above the extension surfaces of the joints, and on the dorsum of the hands. The lesions are accompanied by bone destruction. The patient was treated with prednisone 40 mg and adalimumab, which resulted in a quick reduction of inflammatory markers and clinical improvement, as well as the healing and absorption of abscesses. Despite COVID-19 infection, treatment with remdesivir, prednisone, and adalimumab was continued, with the complete resolution of the lesions. AAS is difficult to recognize, so practitioners have to be aware of this condition, especially in patients with RA.

Aseptic nasal septal abscess in patients with ulcerative colitis: two case reports. Case report

Ulcerative colitis (UC) may be associated with different extra-intestinal manifestations (EIM), which are often difficult to diagnose and treat, and may complicate the course of the disease. EIM are a multidisciplinary problem encountered by doctors of various specializations. However, many incidences of EIM in patients with UC remain unknown. The coexistence of UC and aseptic nasal abscess (ANA) is uncommon. Here, we describe two cases of ANA in young female patients with UC. ANA run in parallel with intestinal disease activity and led to necrosis of the septal cartilage. Moreover, pyoderma gangrenosum was described in one of them. Aseptic abscess syndrome should be kept in mind when a microbial factor is not identified, the diagnosis is not clear or a patient is not improving on appropriate antibacterial therapy. ANA can present as a rare complication of UC.

Divergent Adaptations in Autonomic Nerve Activity and Neuroimmune Signaling Associated With the Severity of Inflammation in Chronic Colitis

BACKGROUND

The autonomic nervous system (ANS) is thought to play a critical role in the anti-inflammatory reflex pathway in acute colitis via its interaction with the spleen and colon. Inflammation in the intestine is associated with a blunting of vagal signaling and increased sympathetic activity. As a corollary, methods to restore sympatho-vagal balance are being investigated as therapeutic strategies for the treatment of intestinal inflammation. Nevertheless, it is indefinite whether these autonomic signaling adaptations in colitis are detrimental or beneficial to controlling intestinal inflammation. In this study, models of moderate and severe chronic colitis are utilized to resolve the correlations between sympatho-vagal signaling and the severity of intestinal inflammation.

METHODS

Spleens and colons were collected from Winnie (moderate colitis), Winnie-Prolapse (severe colitis), and control C57BL/6 mice. Changes to the size and histomorphology of spleens were evaluated. Flow cytometry was used to determine the expression of adrenergic and cholinergic signaling proteins in splenic B and T lymphocytes. The inflammatory profile of the spleen and colon was determined using a RT-PCR gene array. Blood pressure, heart rate, splanchnic sympathetic nerve and vagus nerve activity were recorded.

RESULTS

Spleens and colons from Winnie and Winnie-Prolapse mice exhibited gross abnormalities by histopathology. Genes associated with a pro-inflammatory response were upregulated in the colons from Winnie and further augmented in colons from Winnie-Prolapse mice. Conversely, many pro-inflammatory markers were downregulated in the spleens from Winnie-Prolapse mice. Heightened activity of the splanchnic nerve was observed in Winnie but not Winnie-Prolapse mice. Conversely, vagal nerve activity was greater in Winnie-Prolapse mice compared with Winnie mice. Splenic lymphocytes expressing α1 and β2 adrenoreceptors were reduced, but those expressing α7 nAChR and producing acetylcholine were increased in Winnie and Winnie-Prolapse mice.

CONCLUSIONS

Sympathetic activity may correlate with an adaptive mechanism to reduce the severity of chronic colitis. The Winnie and Winnie-Prolapse mouse models of moderate and severe chronic colitis are well suited to examine the pathophysiology of progressive chronic intestinal inflammation.

Aseptic Abscess Syndrome: Clinical Characteristics, Associated Diseases, and up to 30 Years’ Evolution Data on a 71-Patient Series

Aseptic abscess (AA) syndrome is a rare type of inflammatory disorder involving polymorphonuclear neutrophils (PMNs), often associated with inflammatory bowel disease (IBD). This study sought to describe the clinical characteristics and evolution of this syndrome in a large cohort. We included all patients included in the French AA syndrome register from 1999 to 2020. All patients fulfilled the criteria outlined by André et al. in 2007. Seventy-one patients were included, 37 of which were men (52.1%), of a mean age of 34.5 ± 17 years. The abscesses were located in the spleen (71.8%), lymph nodes (50.7%), skin (29.5%), liver (28.1%), lung (22.5), and rarer locations (brain, genitals, kidneys, ENT, muscles, or breasts). Of all the patients, 59% presented with an associated disease, primarily IBD (42%). They were treated with colchicine (28.1%), corticosteroids (85.9%), immunosuppressants (61.9%), and biologics (32.3%). A relapse was observed in 62% of cases, mostly in the same organ. Upon multivariate analysis, factors associated with the risk of relapse were: prescription of colchicine (HR 0.52; 95% CI [0.28–0.97]; p = 0.042), associated IBD (HR 0.57; 95% CI [0.32–0.99]; p = 0.047), and hepatic or skin abscesses at diagnosis (HR 2.14; 95% CI [1.35–3.40]; p = 0.001 and HR 1.78; 95% CI [1.07–2.93]; p = 0.024, respectively). No deaths occurred related to this disease. This large retrospective cohort study with long follow up showed that AA syndrome is a relapsing systemic disease that can evolve on its own or be the precursor of an underlying disease, such as IBD. Of all the available treatments, colchicine appeared to be protective against relapse.

Aseptic Cavernosal Abscess: An Unrecognized Feature of Neutrophilic Dermatosis

A 50-year-old man developed a sterile cavernosal abscess followed by prominent features of necrotizing neutrophilic dermatosis. We conducted a literature review, which revealed that aseptic abscesses in the corpus cavernosum occur in association with neutrophilic dermatosis. Patients with this condition frequently receive unnecessary antibiotic treatment and surgical interventions. Although this condition responds to systemic corticosteroids, the functional prognosis of the penis is poor. Abscess formation may be the initial presentation of neutrophilic dermatoses, and underlying conditions may even be absent. Clinicians need to be aware of this condition to distinguish it from bacterial infection and initiate early disease-specific treatments.

Aseptic abscess in the abdominal wall accompanied by monoclonal gammopathy simulating the local recurrence of rectal cancer: A case report

BACKGROUND

Infectious abscesses in the abdominal wall can be secondary to retained foreign bodies (e.g., stones, use of artificial mesh, use of silk yarn in surgical suture), inflammatory diseases (e.g., acute appendicitis), and perforated malignancies of the digestive tract (particularly the colon). Aseptic abscesses (AAs) are relatively rare. To the best of our knowledge, this is the first report of an AA in the abdominal wall accompanied by monoclonal gammopathy of undetermined significance (MGUS) at 5 years after laparoscopic proctectomy.

CASE SUMMARY

A 72-year-old female patient presented with an enlarged painless mass in the lower abdomen for 1 year. She had a history of obesity, diabetes, and MGUS. Her surgical history was laparoscopic resection for rectal cancer 6 years prior, followed by chemotherapy. She was afebrile. Abdominal examination revealed a smooth abdomen with a clinically palpable solid mass under a laparotomy scar in the left lower quadrant. No obvious tenderness or skin redness was spotted. Laboratory data were not remarkable. Computed tomography scan revealed a low-density mass of 4.8 cm in diameter in the lower abdominal wall, which showed high uptake on positron emission tomography. The preoperative diagnosis was an abscess or tumor, and surgical resection was recommended. The mass was confirmed to be an AA by microbiological and pathological examinations. The patient recovered well after surgery. There was no evidence of recurrence 2 years later.

CONCLUSION

It is important to consider underlying conditions (diabetes, chemotherapy, MGUS) which may contribute to AA formation in the surgical wound.

Recurrent aseptic liver abscesses in a patient with Crohn's disease: True infection or a Crohn's flare?

A liver abscess is identified as a rare extraintestinal manifestation of Crohn's disease, with an incidence of approximately 150 in 100,000 patients with this condition. In many of these patients, infectious causes are identified, and the patient's condition is often noted to improve with antibiotics. An aseptic abscess (AA) is an increasingly recognized entity, especially in patients with inflammatory bowel disease, where repetitive evaluations to identify the infectious cause are futile. The average age of diagnosis for an AA is 29 years. The most common site is the spleen, followed by the lymph nodes and then the liver. In this study, we present a unique case of extensive aseptic liver abscesses extending into the pleural cavity in a young patient with Crohn's disease.

Sterile subconjunctival abscess in an HLA-B51-positive patient with ulcerative colitis

Purpose

To report a rare case of aseptic abscess presenting as a subconjunctival abscess in an HLA-B51-positive patient with ulcerative colitis.

Observations

A 25-year-old, male, Japanese patient with ulcerative colitis presented with an unilateral subconjunctival abscess. Infective endocarditis with endophthalmitis was suspected of being the cause, and systemic antimicrobial therapy was begun. The patient became critically ill and experienced the complication of heart failure with mitral valve perforation but improved dramatically with high-dose corticosteroids and intravenous infliximab following mitral valvuloplasty. His HLA typing was positive for HLA-B51.

Conclusions and importance

Both infectious and non-infectious etiologies should be considered in a patient with a subconjunctival abscess with systemic inflammation. An aseptic abscess can present as a subconjunctival abscess, and HLA-B51 may play a role in the pathogenesis of this rare condition.

Rapidly Progressing Aseptic Abscesses in a Patient with Ulcerative Colitis

Aseptic abscesses (AAs) are extraintestinal manifestations of inflammatory bowel disease (IBD). IBD-associated AAs are rare in Japan. We treated a 45-year-old man with ulcerative colitis (UC)-associated AAs. During remission, multiple progressive abscesses were detected in the spleen; he underwent splenectomy because an infectious disease was suspected. Although his condition improved temporarily after splenectomy, a large liver abscess was noted, and a diagnosis of UC-associated AAs was made. Granulocytapheresis (GCAP) and infliximab (IFX) administration resolved the abscess. This is the first reported case of UC-associated AAs in a Japanese patient treated by splenectomy, GCAP, and IFX.

Aseptic abscess syndrome

A 43-year-old woman with Crohn's disease was admitted to the hospital with weight loss and 1 week of fever, abdominal pain and diarrhoea. At presentation, the patient was not on steroids or other immunosuppressive agents. Cross-sectional imaging of the abdomen revealed active colitis and multiple splenic and hepatic abscesses. All culture data were negative, including aspiration of purulent material from the spleen. Despite weeks of intravenous antibiotics, daily fever and abdominal pain persisted, the intra-abdominal abscesses grew, and she developed pleuritic chest pain and consolidations of the right lung. The patient was ultimately diagnosed with aseptic abscess syndrome, a rare sequelae of inflammatory bowel disease. All antimicrobials were discontinued and she was treated with high-dose intravenous steroids, resulting in rapid clinical improvement. She was transitioned to infliximab and azathioprine as an outpatient and repeat imaging demonstrated complete resolution of the deep abscesses that had involved her spleen, liver and lungs.

Phenotypes and Pathophysiology of Syndromic Hidradenitis Suppurativa: Different Faces of the Same Disease? A Systematic Review

BACKGROUND

There is growing evidence that (certain) hidradenitis suppurativa (HS) comorbidities comprise syndromes including HS as a key cutaneous manifestation. These apparently autoinflammatory syndromes and their diagnostic delay might have detrimental effects on affected patients.

METHODS

A systematic review was performed on the databases MEDLINE, EMBASE, and CENTRAL utilizing a standardized extraction form according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Sixty-four eligible articles on syndromic HS were retrieved. The identified syndromes included already described ones (pyoderma gangrenosum-acne-suppurative hidradenitis, pyogenic arthritis-pyoderma gangrenosum-acne-suppurative hidradenitis, psoriatic arthritis-pyoderma gangrenosum-acne-suppurative hidradenitis, pyoderma gangrenosum-acne vulgaris-hidradenitis suppurativa-ankylosing spondylitis, synovitis-acne-pustulosis-hyperostosis-osteitis) and further novel symptom constellations. Cutaneous signs, including HS lesions, usually precede signs from other organs. The cutaneous signs of a considerable proportion of patients appear refractory to conventional treatment, and monotherapy with biologics does not suffice to sustain remission.

CONCLUSION

The results are subsequently discussed with focus on the pathophysiology and treatment of the detected syndromes. The dermatologist's role in the precise diagnosis and early treatment administration of HS is pivotal. The purpose of the treatment should be the effective prevention or delay of the autoinflammatory march and its irreversible consequences.

Atypical Clinical Presentation of Hidradenitis Suppurativa in a Patient with Severe Mannose-Binding Lectin Deficiency

Mannose-binding lectin (MBL) deficiency is associated with recurrent infections, autoimmune and inflammatory skin disease, and vascular complications. MBL deficiency is not a recognized comorbidity in hidradenitis suppurativa (HS); the latter is associated with the group of autoinflammatory disorders. A 32-year-old woman presented with a history of recurrent painful, deep-seated abscesses and pustular lesions since the age of 13 years. Lesions were noted predominantly in HS distribution, i.e., submammary, inguinal, and perianal areas were affected. However, unusual locations (jawlines, neck) were also affected. The patient fulfilled the clinical criteria for HS but the presentation was atypical because lesions were noted in unusual locations, most lesions were in Hurley stage 1 (sparsity of sinus tracts and scarring), and most cultures from abscesses and pustular lesions were negative. The excruciating pain caused by constantly developing abscesses had a profound impact on the patient's quality of life. Laboratory workup showed an exceptionally low serum MBL level. Treatment was challenging with only a temporary, mild response to oral antibiotic therapy and no response to immunosuppressive and hormonal therapies. This atypical HS presentation may reflect an enhancement of proinflammatory mechanisms. Health care providers should be aware of this clinicopathologic presentation so that the establishment of HS diagnosis is not delayed and the patient receives appropriate counseling.

Complete aortic replacement in aortitis due to aseptic abscess syndrome

A 36-year-old man was admitted for a tender inflammatory type IV thoracoabdominal aortic aneurysm with multiple aortic dilations. After open repair, he remained frail, but results of all infectious and inflammatory investigations were negative. Hypermetabolic intrasplenic collections were discovered on postoperative computed tomography, and aortitis with aseptic abscess syndrome was strongly suggested. Immunosuppressive therapy was undertaken, and his health improved dramatically. After 7 years of treatment, however, the initial aortic dilations had developed in size, necessitating multiple surgical procedures leading to complete aortic replacement. The postoperative course was uneventful with a satisfactory final computed tomography scan. Subsequent to immunotherapy, no new aneurysm developed.

Splenic abscesses as a first manifestation of Crohn's disease: a case report

Background

Splenic nodules are uncommon entities that occur rarely in the general population. Although an infectious etiology (primarily bacteria, followed by mycobacteria) is usually found, noninfectious diseases, including malignancies and autoimmune disorders, can also be involved. For instance, in course of inflammatory bowel diseases (IBDs), in particular Crohn’s Disease, aseptic splenic abscesses have been reported in patients with a long history of illness, or in those unresponsive to medical treatments, while are only anecdotally reported in the early phase of the disease. Hence, we presented the case of aseptic splenic nodules as a first manifestation of Crohn’s Disease.

Case presentation

A 21-year-old woman with a silent medical history was admitted to the Emergency Department of our hospital complaining of fever of 38–39 °C (mainly in the evening) for the past 10 days and left flank abdominal pain, accompanied by sweating and fatigue. An abdominal computed tomography showed multiple splenic nodules of unknown origin. Because of the absence of clinical improvement after several antibiotic therapiesand a positron emission tomography (PET) with hypercaptation strictly localized to spleen, she underwent splenectomy, in suspicion of lymphoma. For persistence of symptoms after splenectomy, she underwent many instrumental examination, including a colonoscopy with bowel and intestinal biopsies that poses diagnosis of Crohn’s disease. A second PET confirmed this diagnosis showing this time also the gastrointestinal involvement.

Conclusion

An unusual onset of Crohn’s disease with multiple splenic nodules is reported. This case suggests that in light of splenic nodules of unknown etiology attention should be paid to all possible diagnoses of aseptic abscesses, including IBDs (primarily Crohn’s Disease).