Pyoderma Gangrenosum among Patients with Inflammatory Bowel Disease: A Descriptive Cohort Study

Hidden in Plain Sight: A Case Series of Inflammatory Bowel Disease With Dermatologic Lesions As Initial or Concurrent Manifestations

Pyoderma gangrenosum (PG) and erythema nodosum (EN) are rare skin conditions associated with inflammatory bowel disease (IBD), with increasing incidence as the disease progresses. We describe three cases of newly diagnosed IBD with cutaneous extraintestinal manifestations (EIMs) at the time of diagnosis. Three previously healthy patients presented with bloody diarrhea and concomitant nodular and ulcerating skin lesions at the onset of diarrhea. Dermatopathology showed PG and EN with endoscopic confirmation of ulcerative colitis. Clinical improvement was achieved with steroids and biological agents. These cases display the importance of a proper review of symptoms and a detailed workup of dermatological lesions prior to assuming infectious etiology.

A novel murine model of pyoderma gangrenosum reveals that inflammatory skin-gut crosstalk is mediated by IL-1β-primed neutrophils

Pyoderma gangrenosum (PG) is a debilitating skin condition often accompanied by inflammatory bowel disease (IBD). Strikingly, ~40% of patients that present with PG have underlying IBD, suggesting shared but unknown mechanisms of pathogenesis. Impeding the development of effective treatments for PG is the absence of an animal model that exhibits features of both skin and gut manifestations. This study describes the development of the first experimental drug-induced mouse model of PG with concomitant intestinal inflammation. Topical application of pyrimidine synthesis inhibitors on wounded mouse skin generates skin ulcers enriched in neutrophil extracellular traps (NETs) as well as pro-inflammatory cellular and soluble mediators mimicking human PG. The mice also develop spontaneous intestinal inflammation demonstrated by histologic damage. Further investigations revealed increased circulating low density IL-1β primed neutrophils that undergo enhanced NETosis at inflamed tissue sites supported by an increase in circulatory citrullinated histone 3, a marker of aberrant NET formation. Granulocyte depletion dampens the intestinal inflammation in this model, further supporting the notion that granulocytes contribute to the skin-gut crosstalk in PG mice. We anticipate that this novel murine PG model will enable researchers to probe common disease mechanisms and identify more effective targets for treatment for PG patients with IBD.

Inflammatory Bowel Diseases Affect the Phenotype and Disease Course of Coexisting Immune-Mediated Inflammatory Diseases: A Systematic Review With Meta-Analysis

BACKGROUND

It is unclear whether inflammatory bowel diseases (IBDs) affect the phenotype and severity of co-occurring immune-mediated inflammatory diseases (IMIDs). We aimed to investigate the characteristics of IMIDs in relation to co-occurring IBD.

METHODS

We conducted a systematic review of Medline and EMBASE databases from inception to September 2020. We identified studies reporting the phenotype, severity, or disease course of IMIDs among patients with or without co-occurring IBD. A meta-analysis was conducted using random effects models.

RESULTS

The electronic search yielded 13 220 studies that we narrowed down to 73 eligible studies for full-text review, including 42 on primary sclerosing cholangitis, 12 on axial spondyloarthropathies, and 8 studies on psoriasis. In primary sclerosing cholangitis, IBD was associated with less frequent involvement of extrahepatic bile ducts (risk ratio [RR], 0.50; 95% confidence interval [CI], 0.33-0.75), longer liver transplantation-free survival (hazard ratio, 0.70; 95% CI, 0.60-0.82), and no increased risk of cholangiocarcinoma (RR, 0.88; 95% CI, 0.59-1.31). Patients with axial spondyloarthropathies and co-occurring IBD were characterized by an increased risk of dactylitis (RR, 2.06; 95% CI, 1.24-3.42), a lower Bath Ankylosing Spondylitis Radiology Index (mean difference [MD] = -2.28; 95% CI, -3.26 to -1.30), and better Schober's test results (MD = 1.07; 95% CI, 0.64-1.49). Psoriasis and co-occurring IBD was associated with reduced disease severity (RR, 1.41; 95% CI, 1.02-1.96) and less frequent presentation in nails (RR, 0.14; 95% CI, 0.05-0.42), with no apparent impact on psoriatic arthritis (RR, 0.94; 95% CI, 0.27-3.31).

CONCLUSIONS

This systematic review with meta-analysis found IBD is associated with a distinct disease phenotype among the IMIDs investigated. Our findings emphasize the importance of multidisciplinary approaches to patients with co-occurring IMIDs and IBD.

PYODERMA GANGRENOSUM AS THE ONLY MANIFESTATION OF ASYMPTOMATIC NEWLY DIAGNOSED NONSPECIFIC ULCERATIVE COLITIS. CLINICAL CASE

OBJECTIVE

The aim: To study the clinical case data for the feasibility of the obligatory inclusion of endoscopic methods of the gastrointestinal tract examination in patients with pyoderma gangrenosum of an unknown etiology.

PATIENTS AND METHODS

Clinical case: A patient under our supervision was with a not previously treated pyoderma gangrenosum of the shin skin. In the process of differential diagnostics by colonoscopic examination, nonspecific ulcerative colitis was diagnosed without clinical intestinal manifestation. A prescribed pathogenetic treatment of nonspecific ulcerative colitis led to the healing of the ulcer on the leg and induction of colitis remission. Thus, the first manifestation of asymptomatic colitis was pyoderma gangrenosum.

CONCLUSION

Conclusions: Patients with pyoderma gangrenosum should be aware of the possibility of NUC, even in the absence of gastrointestinal symptoms, to get an early diagnosis and adequate treatment, to avoid disease manifestation and further complications. The inclusion of obligatory endoscopic examination of the gastrointestinal tract will increase the diagnosis of the etiology of severe skin lesions and increase the detection of asymptomatic nonspecific ulcerative colitis.

Risk Factors for Developing Hidradenitis Suppurativa in Patients With Inflammatory Bowel Disease: A Retrospective Case-Control Study

Background

Hidradenitis suppurativa (HS) is associated with inflammatory bowel disease (IBD), though risk factors remain to be determined.

Aim

To characterize HS among a cohort of IBD patients and identify risk factors for its development.

Methods

This was a retrospective case–control study at the ambulatory IBD centre at Mount Sinai Hospital from inception to May 2019. Patients with IBD who developed HS were included. Cases were matched 5:1 by age, gender (male versus female) and IBD type (ulcerative colitis [UC] or Crohn’s disease [CD]) to controls who had IBD without HS. Conditional logistic regression was used to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs).

Results

Twenty-nine cases of HS (19 CD and 10 UC) and 145 controls were included. Of the 29 patients with HS, 11 (37.9%) were male and 18 (62.1%) were female. The severity of HS was mild in 10 (34.5%), moderate in 16 (55.2%) and severe in 3 (10.3%) patients. Patients with HS and IBD were more likely to be active (OR 10.3, 95% CI 2.0 to 54.0, P = 0.006) or past (OR 8.4, 95% CI 2.7 to 25.8, P < 0.005) smokers. Patients with HS and IBD were also more likely to have active endoscopic disease (OR 3.8, 95% CI 1.2 to 12.2, P = 0.022). Furthermore, those with HS and CD were more likely to have active perianal disease (OR 21.1, 95% CI 6.2 to 71.9, P < 0.005).

Conclusions

Active IBD, perianal disease and smoking may be associated with HS in IBD. Larger studies are needed to better characterize this morbid condition.

Quantification of the relationship between pyoderma gangrenosum and Crohn's disease: a population-based case-control study

BACKGROUND

Although Crohn's disease (CD) is an established underlying disease in pyoderma gangrenosum (PG), studies comparing patients with PG and controls with respect to the presence of CD are lacking. Consequently, the relative risk imposed by CD for the development of PG is yet to be elucidated.

OBJECTIVE

The study aims to quantify the magnitude of the association between CD and subsequent development of PG, thus enabling to evaluate the risk of PG with CD.

METHODS

A matched case-control study was conducted in Israel comparing PG patients (N = 302) with age-, sex- and ethnicity-matched control subjects (N = 1497) regarding the presence of CD. Logistic regression model was used for multivariate analysis.

RESULTS

The prevalence of CD was higher in patients with PG than in control subjects (7.0% vs. 0.3%, respectively; p < .001). There was a 28-fold increase in the odds of PG with CD (OR, 28.08; 95% CI, 9.56-82.41). This association was robust to a sensitivity analysis excluding CD cases diagnosed up to 3 years prior to PG (OR, 30.30; 95% CI, 8.82-104.09), and to a multivariate analysis adjusting for confounding factors (OR, 21.57; 95% CI, 7.20-64.58). The median latency between the diagnosis of CD and the development of PG was 8.08 years. Patients with both PG and CD were younger and had a higher prevalence of smoking when compared to other patients with PG.

CONCLUSIONS

CD increases the odds of having PG by 28-folds. Patients with CD should be advised to avoid additional precipitating factors of PG like pathergy and smoking.

Common and critical inflammatory dermatoses every pathologist should know

Inflammatory dermatopathology remains a challenging area for surgical pathologists. Yet every surgical pathologist encounters inflammatory dermatoses as part of routine practice. This review will focus on selected diagnoses that are either commonly encountered in the routine practice of surgical pathology or are critically important. The following entities will be covered: spongiotic dermatoses, lichen simplex chronicus, and early lichen sclerosus in the setting of vulvar biopsies, as well as graft versus host disease, Stevens-Johnson syndrome/toxic epidermal necrolysis, granuloma anulare, pyoderma gangrenosum, and calciphylaxis. Practical points and key histologic features will be emphasized.

The Skin in Celiac Disease Patients: The Other Side of the Coin

Celiac disease (CD) is an autoimmune enteropathy that primarily affects the small intestine and is characterized by atrophy of intestinal villi. The manifestations of the disease improve following a gluten-free diet (GFD). CD is associated with various extra-intestinal diseases. Several skin manifestations are described in CD patients. The present paper reviews all CD-associated skin diseases reported in the literature and tries to analyze the pathogenic mechanisms possibly involved in these associations. Different hypotheses have been proposed to explain the possible mechanisms involved in every association between CD and cutaneous manifestations. An abnormal small intestinal permeability seems to be implicated in various dermatological manifestations. However, most of the associations between CD and cutaneous diseases is based on case reports and case series and a few controlled studies. To better assess the real involvement of the cutaneous district in CD patients, large multicentric controlled clinical trials are required.

Diagnosis and treatment of dermatologic diseases in inflammatory bowel disease

PURPOSE OF REVIEW

Dermatologic manifestations in patients with inflammatory bowel disease (IBD) are increasingly recognized as related disorders, secondary to specific therapies used to treat IBD, or complications of IBD itself. These dermatologic manifestations can be difficult to manage.

RECENT FINDINGS

We summarize three categories of dermatologic manifestations in this review: extraintestinal cutaneous disorders, paradoxical manifestations to biologic therapies, and other drug-induced cutaneous manifestations. In particular, we provide current data surrounding clinical characteristics, epidemiology, and treatment modalities for individual cutaneous manifestations.

SUMMARY

Many extraintestinal cutaneous manifestations can be managed by optimized treatment of IBD itself, as shared treatment pathways exist. Paradoxical reactions to biologic agents may be driven by the individual biologic therapy. In these instances, if topical therapies or immunomodulators are not effective in treating the paradoxical cutaneous reaction, a change of class may be required. Nonmelanoma and melanoma skin cancers have been linked to specific therapies for IBD (including thiopurines and antitumor necrosis factor alpha agents, respectively). Therefore, optimizing preventive efforts towards skin cancer is warranted. Recognition of these cutaneous disorders by the practicing gastroenterologist is important, as is collaboration with dermatology for management of many cutaneous disorders.

Pyoderma Gangrenosum: An Update on Pathophysiology, Diagnosis and Treatment

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic disorder with prototypical clinical presentations. Its pathophysiology is complex and not fully explained. Recent information regarding the genetic basis of PG and the role of auto-inflammation provides a better understanding of the disease and new therapeutic targets. PG equally affects patients of both sexes and of any age. Uncontrolled cutaneous neutrophilic inflammation is the cornerstone in a genetically predisposed individual. Multimodality management is often required to reduce inflammation, optimize wound healing, and treat underlying disease. A gold standard for the management of PG does not exist and high-level evidence is limited. Multiple factors must be taken into account when deciding on the optimum treatment for individual patients: location, number and size of lesion/ulceration(s), extracutaneous involvement, presence of associated disease, cost, and side effects of treatment, as well as patient comorbidities and preferences. Refractory and rapidly progressive cases require early initiation of systemic therapy. Newer targeted therapies represent a promising pathway for the management of PG, and the main focus of this review is the management and evidence supporting the role of new targeted therapies in PG.

Extraintestinal manifestations of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a systemic disease, and it not only affects the gastrointestinal tract, but also may show a variety of extraintestinal manifestations (EIMs). EIMs can involve multiple systems. This paper reviews the EIMs of IBD for a more comprehensive understanding of IBD to guide its clinical diagnosis and treatment.

Pyoderma gangrenosum: An important dermatologic condition occasionally associated with rheumatic diseases

Pyoderma gangrenosum (PG) presents with refractory, sterile, deep ulcers most often on the lower legs. Clinically, PG exhibits four types, i.e., ulcerative, bullous, pustular, and vegetative types. PG may be triggered by surgical operation or even by minor iatrogenic procedures such as needle prick or catheter insertion, which is well-known as pathergy. PG is sometimes seen in association with several systemic diseases including rheumatoid arthritis (RA), inflammatory bowel disease, hematologic malignancy, and Takayasu’s arteritis. In particular, various cutaneous manifestations are induced in association with RA by virtue of the activation of inflammatory cells (neutrophils, lymphocytes, macrophages), vasculopathy, vasculitis, drugs, and so on. Clinical appearances of ulcerative PG mimic rheumatoid vasculitis or leg ulcers due to impaired circulation in patients with RA. In addition, patients with PG sometimes develop joint manifestations as well. Therefore, it is necessary for not only dermatologists but also rheumatologists to understand PG.