Vulvar inflammation as the only clinical manifestation of Crohn disease in an 8-year-old girl

Perianal Imaging in Crohn Disease: Current Status With a Focus on MRI, From the AJR Special Series on Imaging of Inflammation

Fistulizing perianal disease is a frequent, chronic, and often debilitating manifestation of Crohn disease (CD) in adults and children, which in the past was relatively refractory to treatment. The advent of biologic agents such as anti-tumor necrosis factor-α and cellular therapies, used in conjunction with a range of surgical interventions, has greatly improved disease outcomes, although complete remission can still be elusive. This review considers current perianal imaging options, specifically pelvic MRI and endoanal and transperineal ultrasound, and their roles in diagnosis, management, and assessment of treatment response. Pelvic MRI is the first line technique for imaging of perianal CD given the complexity of fistulas encountered in CD. MRI technical acquisition parameters for adults and children and an approach to MRI interpretation and reporting are provided. Anatomic classification systems for fistulising perianal disease are presented. We also explore the history, current landscape, and future developments of MRI features of perianal disease as imaging biomarkers to quantify activity and severity, and consider CD MRI-based inflammatory activity scores. We discuss the reliability and validation of a number of indices (including PEMPAC, MAGNIFI-CD, mVAI, and Van Assche Index), their potential to quantify treatment response, and possible prognostic capabilities.

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.

A Diagnostic Approach to Conditions that Mimic Sexual Abuse

Primary care providers are often the first point of contact when there are concerns of child sexual abuse. The history is the key factor in making the diagnosis as most children who have experienced child sexual abuse do not have an abnormal anogenital examination. When anogenital symptoms precipitate concerns for sexual abuse, especially in the absence of a history of sexual abuse, it is important to be aware of conditions that mimic sexual abuse. Being familiar with such conditions allows the provider to determine appropriate management, differentiate an anatomical variant or medical condition from abuse, and provide reassurance to the patient and family. Unnecessarily reporting these cases can have detrimental effects on the patient and family. If any doubt arises, patients can be referred for further evaluation by an expert in child abuse. This article presents many common medical conditions that can mimic sexual abuse, with a focus on history, examination findings, and management. [Pediatr Ann. 2020;49(8):e334-e340.].

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.

Vulvar swelling as the first presentation of Crohn's disease in children-A report of three cases

Vulvar swelling is a rare manifestation of metastatic Crohn's disease in children. It often predates gastrointestinal symptoms and can be the first presentation of pediatric Crohn's disease. We report three cases of pediatric Crohn's disease presenting with vulvar swelling. We discuss this rare presentation and its treatment and highlight the importance of recognizing it so that prompt investigation and appropriate management can be initiated.

Vulvar involvement in pediatric Crohn's disease: a systematic review

PURPOSE

The aim of the study is to report a systematic review (from 2000 to 2017) of all pediatric cases of vulvar Crohn's disease (VCD) and to highlight the key-points for a correct diagnosis and management of this rare condition.

METHODS

An electronic search using the Pubmed/Medline, Scopus, EMBASE, Cochrane database and Google Scholar database was performed according to PRISMA guidelines.

RESULTS

Twenty pediatric studies and 22 cases of VCD were included for analysis. All the articles reported a single case, except two articles where two cases, respectively, are described. Clinical vulvar examination showed the following main manifestations: vulvar erythema (9/22 cases, 40.9%), vulvar swelling (8/22 cases, 36.4%), vulvar edema (8/22 cases, 36.4%), vulvar ulcers (4/22 cases, 18.2%). Perianal and/or anal involvement (fissures, vegetations, skin tags, erythema, papules, nodules) were recorded in ten cases (45.4%). Steroids per os and/or topical administration were the most prescribed treatment, achieving clinical remission in 11 cases (50%), used alone or in combination with metronidazole or 5-aminosalicylic acid, azathioprine or sulphasalazine/mesalazine.

CONCLUSIONS

This review shows that pediatric VCD is an uncommon disease, difficult to be diagnosed as either symptoms or clinical lesions are not specific. A multidisciplinary approach is advised to reach a correct diagnosis and plan clinical treatment.

Penile and Scrotal Swelling: An Underrecognized Presentation of Crohn's Disease

BACKGROUND

Penile and scrotal swelling can occur as an extraintestinal manifestation of Crohn's disease (CD) and is thought to be an uncommon form of metastatic CD (MCD). Because of the rarity of this manifestation, much is unknown concerning the presentation, treatment, and response to therapy in children with genital MCD.

METHODS

Boys ages 1 to 17 years presenting with genital edema and a confirmed diagnosis or strong suspicion of CD who were evaluated at the Mayo Clinic between 1996 and 2014 were included for review. We sought to characterize the clinical and pathologic features of genital MCD and response to treatment in our cohort of patients.

RESULTS

Eight patients with genital MCD were identified from our institution (mean age 11.4 yrs, range 7-16 yrs). Seven (88%) patients experienced cutaneous symptoms before a formal diagnosis of CD was made, and two of the seven had no adverse gastrointestinal symptoms at that time. Patients were prescribed an average of 3.4 medications (topical and systemic) for management of their gastrointestinal CD and MCD.

CONCLUSIONS

Penile and scrotal swelling can occur as an extraintestinal manifestation of CD and is thought to be an uncommon form of MCD. In boys, genital swelling typically precedes intestinal CD. Treatment of the underlying CD with systemic medications was most helpful in this series. An evaluation for CD is necessary in all patients presenting with unexplained genital swelling.

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.

Magnetic resonance imaging of perianal and perineal crohn disease in children and adolescents

Noninvasive, nonionizing, multiparametric magnetic resonance (MR) imaging of the pelvis using a field strength of 3 T now provides a comprehensive assessment of perineal involvement in pediatric Crohn disease. MR imaging accurately evaluates inflammatory disease activity, and allows determination of the number and course of fistula tracts as well as their relationships to vital perianal structures, including the external anal sphincter, helping to guide surgical management and improve outcomes. This article provides an up-to-date review of perineal MR imaging findings of Crohn disease in the pediatric population, including fistulous disease, abscesses, and skin manifestations. Imaging technique is also discussed.

Lesions of the clitoris: a review

The clitoris may become involved by vulvar lesions. There are also lesions arising from the clitoris. A familiarity with these lesions is necessary for the high index of suspicion needed for their diagnosis.

MRI of vulvar Crohn disease

Crohn disease is a chronic granulomatous inflammatory disorder that most commonly affects the gastrointestinal tract, particularly the distal small bowel and colon. While certain extraintestinal manifestations of Crohn disease are relatively common and well-known, others, such as metastatic cutaneous involvement, are quite rare and may be difficult to recognize, particularly in the pediatric population. This case report illustrates the magnetic resonance imaging (MRI) appearance of vulvar region cutaneous Crohn disease in an 11-year-old girl.