Refractory Crohn's disease of the vulva treated with infliximab: a case report

Cutaneous Crohn's disease after proctocolectomy for medically refractory colonic Crohn's disease: a case series and review of the literature

Background

Cutaneous Crohn's disease (CCD), also known as metastatic Crohn's disease (CD), is one of the rarest and most challenging cutaneous manifestations of CD. It is characterized by non-caseating granulomatous inflammation of the skin at sites that are non-contiguous with the gastrointestinal (GI) tract. Diagnosis of CCD needs a high clinical suspicion since morphological presentation varies widely and lacks an apparent correlation to the activity of the luminal CD. The onset of CCD in patients without active GI CD is a particularly understudied phenomenon.

Methods

We present a case series of a unique patient group who developed CCD while in remission from a luminal CD perspective, mainly after a proctocolectomy for Crohn's colitis. We also provide a literature review and summary of case reports of CCD after proctocolectomy.

Results

Our 4 adult patients diagnosed with CCD after proctocolectomy presented herein, were successfully treated with high-dose corticosteroids, followed by biologic therapy. Furthermore, a comprehensive review of CCD is provided regarding its pathogenesis, clinical presentation, differential diagnosis, and the evidence behind the available treatments.

Conclusions

CCD should be considered in any CD patient presenting with skin lesions regardless of their disease activity status and history of proctocolectomy. The treatment remains challenging; biologics remain the cornerstone and a multidisciplinary approach is recommended. Larger randomized clinical trials are essential to determine the optimal treatment protocol and to improve outcomes.

Management of Pelvic Pain in Patients with Crohn's Disease-Current Overview

Crohn's disease (CD) is a subtype of chronic inflammatory bowel diseases (IBD) with characteristic skip lesions and transmural inflammation that may affect the entire gastrointestinal tract from the mouth to the anus. Persistent pain is one of the main symptoms of CD. This pain has multifactorial pathogenesis, but most often arises from intestinal inflammation itself, as well as from gut distention or partial intestinal obstruction. Some current evidence also suggests sensitization of sensory pathways, as well as modulation of those signals by the central nervous system, which highlights the impact of biopsychosocial factors. To date, most studies have focused only on the pain located in the abdomen, while pelvic pain has rarely been explored, despite it being a common symptom. The aim of this study is to provide an abbreviated summary of the current state of knowledge on the origins and treatment of pelvic pain in CD.

A successful management algorithm for vulvar abscess: A tertiary hospital experience

AIM

To develop a treatment and management algorithm for vulvar abscess.

METHODS

We evaluated the clinical findings and treatment modalities of patients hospitalized with vulvar abscess via a comprehensive literature review and a clinical study. Patients with a diagnosis of vulvar abscess (n = 28) between 2015 and 2019 in the gynecology clinic of our hospital were included in the clinical study. Each patient's age, obstetric history, body mass index, presence of concomitant diseases, abscess culture and size, mean length of hospital stay, treatment modalities, and recurrence rate were recorded.

RESULTS

The mean age and body mass index of the patients were 47.7 ± 11.5 years and 30.3 ± 2.7 kg/m² , respectively. Diabetes mellitus was the most common concomitant disease (60.7%, n = 17). The abscesses of 22 (78.5%) patients drained spontaneously. The abscess cavities of the remaining six (21.4%) patients were treated via incisional drainage. Gentamicin + clindamycin or levofloxacin + metronidazole were used as the primary antibiotic treatment. Hemovac drains were placed in four (14.2%) patients with abscess sites greater than 5 cm. By applying our treatment methods, 26 (92.8%) of our patients were discharged with full recovery, and two patients (7.2%) were referred due to uncontrolled diabetes mellitus. The recurrence rate of vulvar abscess was 0%.

CONCLUSIONS

This is the first study in the literature to present a successful algorithm for the treatment and management of vulvar abscess. Our treatment methods shed light on the treatment and management of vulvar abscess.

Vulval Crohn disease: A case series of 26 patients

Vulval Crohn disease is rare and likely under-reported, leading to difficulty in diagnosis and delay in treatment. In this case series, we report the clinical features and discuss therapy in 26 consecutive patients with vulval Crohn disease, with or without documented gastrointestinal disease, presenting between January 2016 and July 2018. We highlight the need for treatment that is in some cases more aggressive than the requirement to manage the patient's gastrointestinal involvement.

Delayed Diagnosis of Vulvar Crohn's Disease in a Patient with No Gastrointestinal Symptoms

Though Crohn's disease primarily affects the gastrointestinal tract, cutaneous Crohn's disease of the vulva can occur in the absence of gastrointestinal symptoms, complicating the diagnosis. Once clinicians suspect cutaneous Crohn's disease, antibiotics and traditional immunosuppressants comprise initial treatment. Unfortunately, sometimes these therapies are not effective, or they provide only short-lived symptomatic improvement. A few case reports have found tumor necrosis factor-α inhibitors to be helpful in such refractory cases. We describe a patient with long-standing, painful vulvar Crohn's lesions with no gastrointestinal manifestations of the disease. Her diagnosis was delayed for years, and initial therapy with antibiotics and steroids was unsuccessful. Finally, the patient experienced effective and long-lasting symptom improvement with infliximab (Remicade^TM).

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.

Metastatic Vulvar Crohn's Disease-A Rare Case Report and Short Review of Literature

Metastatic Crohn's disease (CD), a type of extraintestinal CD may present with gynecological manifestation which causes diagnostic dilemma and needs multidisciplinary approach. Vulvar lesions occur in very small number of cases with CD of which asymmetrical labial swelling and edema is the most common presentation. We report a case of hypertrophic exophytic variety of vulvar CD because of its rarity.

Crohn Disease of the Vulva without Gastrointestinal Manifestations in a 16-Year-Old Girl

BACKGROUND

Crohn disease of the vulva is a rare disease that is difficult to diagnose. There are limited reports describing treatment of this condition.

OBJECTIVE

To describe the diagnosis and treatment of a 16-year-old girl with Crohn disease of the vulva, without onset of intestinal symptoms.

METHODS

Crohn disease was diagnosed by histopathology. The patient was treated with corticosteroids and followed for 1 year.

RESULTS

After the final diagnosis, cutaneous lesions responded rapidly to corticosteroid treatment, which was gradually stopped after 6 months. The disease was well controlled at the 1-year follow-up.

CONCLUSION

Crohn disease of the vulva can develop alone without the onset of intestinal symptoms. Diagnosis relies on special pathologic findings. Corticosteroid treatment is effective for this condition.

Crohn's disease of the vulva

Crohn's disease (CD) of the vulva is a rare, yet under recognized condition. Fistulae arising from the digestive tract account for the greater part of genital lesions in CD. However, cutaneous so-called metastatic lesions of the vulva have been reported in the literature. They are clinically challenging for gastroenterologists as well as for gynecologists, with numerous differential diagnoses, especially among venereal diseases, and require a multidisciplinary approach. The most frequently observed features of the disease are labial swelling, vulvar ulcers, and hypertrophic lesions. Biopsy samples for histological study are mandatory, in order to establish the diagnosis of vulvar CD. Treatment options include oral prolonged courses of metronidazole and systemic immunosuppressive therapy such as corticosteroids and azathioprine, with promising data published on the efficacy of infliximab. Surgery remains restricted to medical treatment failures or resection of unsightly lesions. Prospective studies or case series with long follow-up data are still missing to guide the treatment of this condition.

Management of cutaneous disorders related to inflammatory bowel disease

Almost one-third of patients with inflammatory bowel disease (IBD) develop skin lesions. Cutaneous disorders associated with IBD may be divided into 5 groups based on the nature of the association: specific manifestations (orofacial and metastatic IBD), reactive disorders (erythema nodosum, pyoderma gangrenosum, pyodermatitis-pyostomatitis vegetans, Sweet's syndrome and cutaneous polyarteritis nodosa), miscellaneous (epidermolysis bullosa acquisita, bullous pemphigoid, linear IgA bullous disease, squamous cell carcinoma-Bowen's disease, hidradenitis suppurativa, secondary amyloidosis and psoriasis), manifestations secondary to malnutrition and malabsorption (zinc, vitamins and iron deficiency), and manifestations secondary to drug therapy (salicylates, immunosupressors, biological agents, antibiotics and steroids). Treatment should be individualized and directed to treating the underlying IBD as well as the specific dermatologic condition. The aim of this review includes the description of clinical manifestations, course, work-up and, most importantly, management of these disorders, providing an assessment of the literature on the topic.

Acquired vulvar lymphangioma circumscriptum: a comparison of 12 cases with Crohn's associated lesions or radiation therapy induced tumors

BACKGROUND

Lymphangioma circumscriptum (LC) is a benign lesion of lymphatic origin. Vulvar involvement occurs in various clinical settings.

METHODS

We present 12 cases, and compare lesions in patients with Crohn's disease and those associated with pelvic radiation.

RESULTS

The average age at presentation was 49 years. Thirty-three percent of the patients had Crohn's disease, 58% had radiation therapy and 9% had no significant medical history. Sixty-seven percent of the patients had multifocal lesions in anatomically distinct regions. Patients presented on average 16 years after onset of predisposing factors. Presenting complaints were pruritus, wetness and vulvar edema. Lesions were clinically heterogeneous, often found on the labia majora. Lesions consisted of dilated lymphatic channels at the junction of the reticular and papillary dermis. The cells lining these spaces lacked cytologic atypicality or mitotic activity. All lesions so examined were immunoreactive for D240. Patients were most often treated with surgical excision followed by laser ablation. Four of twelve patients, all with radiation-associated lesions, experienced disease progression necessitating additional surgery.

CONCLUSIONS

Patients with LC secondary to radiation, when compared to those with Crohn's disease, were 10 years younger, more likely to have associated co-morbidities, and frequently experienced disease progression needing additional surgeries. Acquired vulvar LC has multiple causes with differing prognosis.