Abstract

Dermatologic lesions are well-known sequelae of inflammatory bowel disease. Crohn disease, in particular, is frequently associated with lesions representing direct extension from the affected bowel to the skin of the perianal or peristomal regions. Less commonly, characteristic granulomatous skin lesions can be found both distant and discontinuous from the gastrointestinal tract – an entity known as metastatic Crohn disease. In children and young adults, metastatic Crohn disease most commonly affects the genital skin with fewer reports of involvement of intertriginous regions. It can be a challenging diagnosis, both clinically and pathologically, with a broad differential diagnosis. We present a 22-year-old female with spastic quadriplegic cerebral palsy and congenital hydrocephalus status-post ventriculoperitoneal shunt. She was diagnosed with Crohn disease approximately one year prior and had undergone right hemicolectomy and ileostomy with gastrostomy tube. She was receiving infliximab infusions but continued to have chronic perineal and perianal ulcers. Dermatology was consulted for a three-week history of an enlarging and increasingly painful ulceration in her right axilla. The differential diagnosis included cutaneous Crohn disease, pyoderma gangrenosum, hidradenitis suppurativa, and infection. Punch biopsy demonstrated epidermal ulceration with loose, non-caseating granulomas and a lymphoplasmacytic infiltrate. Histochemical stains for infectious organisms were negative. The patient’s infliximab treatment was increased, but management was complicated by the patient’s continued refusal of care, and she ultimately passed away. This case illustrates an unusual and challenging clinical presentation of metastatic Crohn disease complicated by complex medical and social factors, highlighting the importance of dermatology consultation in conjunction with histopathologic examination.