Kosin Med J.  2022 Dec;37(4):361-366. 10.7180/kmj.22.027.

Multiple extraintestinal manifestations in a patient with acute severe ulcerative colitis: a case report

Affiliations
  • 1Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
  • 2Division of Gastroenterology, Department of Internal Medicine, Dong-Eui Medical Center, Busan, Korea
  • 3Biomedical Research Institute, Pusan National University Hospital, Busan, Korea

Abstract

Patients with inflammatory bowel disease (IBD) are at risk for extraintestinal manifestations (EIM) over the course of their disease. As EIMs can involve nearly every organ, and strongly influence the quality of life, early recognition and adequate treatment are necessary to prevent severe morbidity and mortality in affected patients. Pyoderma gangrenosum is a highly severe and debilitating skin condition that occurs in 1% to 10% of ulcerative colitis (UC) patients. Thromboembolic events are also serious EIMs and usually present as deep vein thromboses in the legs or as pulmonary embolisms. A 19-year-old woman presented with bloody diarrhea lasting for 3 months and deep ulceration on the right foot. She was diagnosed with UC. The patient's skin lesions did not improve with intravenous corticosteroids and oral mesalazine. After she was started on infliximab, we observed rapid resolution of the skin lesions. She continued to complain of mild dyspnea while in the hospital. Computed tomography performed using the thromboembolism protocol revealed pulmonary thromboembolism and deep venous thrombosis. The patient underwent anticoagulant therapy with low-molecular-weight heparin, and her dyspnea gradually improved. Anticoagulation was continued with warfarin. It is rare for IBD patients to have multiple EIMs; however, this case demonstrates that multiple EIMs are a possible presentation in UC and underscores the importance of a meticulous clinical examination and adequate evaluation in the management of IBD patients presenting with EIMs.

Keyword

Case reports; Extraintestinal manifestations; Inflammatory bowel disease; Pyoderma gangrenosum; Thromboembolism

Figure

  • Fig. 1. Pyoderma gangrenosum and thromboembolism in a patient with acute severe ulcerative colitis before treatment with infliximab. (A) A large skin ulceration with a purulent base and an irregular edge was located on the dorsal side of the patient’s right foot. (B) Colonoscopy revealed diffuse, hyperemic, edematous, colonic mucosa with friability and deep ulcerations. (C) A histopathologic examination of the colonic mucosa showed focal cryptitis and crypt distortion (arrows) with inflammatory cell infiltration (H&E, ×40). (D) Computed tomography revealed pulmonary thromboembolism at the segmental and subsegmental branches of the left lower lobar pulmonary artery and deep vein thrombosis in the left superficial femoral vein.

  • Fig. 2. Resolution of pyoderma gangrenosum and thromboembolism and endoscopic mucosal healing after treatment with infliximab. (A) The large skin ulceration of the right foot had completely healed at a 6-month follow-up visit. Only a scar remained. (B) Colonoscopy performed 6 months after discharge revealed completely healed colonic mucosa with small inflammatory polyps. (C) Pulmonary thromboembolism and deep venous thrombosis were not detected on a 6-month follow-up computed tomography scan.


Reference

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