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Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn’s disease mimicking cellulitis: a case report

BACKGROUND: Leukocytoclastic vasculitis (LCV) is an immune-complex mediated vasculitis characterized by neutrophilic inflammation and nuclear debris in post capillary venules. LCV is a rare dermatologic manifestation of Crohn’s disease (CD) and may occur with the onset of the disease or any time aft...

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Autores principales: Buck, Meredith, Dumic, Igor, McDermott, Wendy, Nordstrom, Charles, Dawan, Samarth, Virata, Andrew, Martin, Scott, Hudson, Ann, Milovanovic, Tamara, Nordin, Terri
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7389435/
https://www.ncbi.nlm.nih.gov/pubmed/32727390
http://dx.doi.org/10.1186/s12876-020-01371-3
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author Buck, Meredith
Dumic, Igor
McDermott, Wendy
Nordstrom, Charles
Dawan, Samarth
Virata, Andrew
Martin, Scott
Hudson, Ann
Milovanovic, Tamara
Nordin, Terri
author_facet Buck, Meredith
Dumic, Igor
McDermott, Wendy
Nordstrom, Charles
Dawan, Samarth
Virata, Andrew
Martin, Scott
Hudson, Ann
Milovanovic, Tamara
Nordin, Terri
author_sort Buck, Meredith
collection PubMed
description BACKGROUND: Leukocytoclastic vasculitis (LCV) is an immune-complex mediated vasculitis characterized by neutrophilic inflammation and nuclear debris in post capillary venules. LCV is a rare dermatologic manifestation of Crohn’s disease (CD) and may occur with the onset of the disease or any time after the diagnosis including the period of exacerbation. CASE PRESENTATION: We present a 70 year old woman with history of psoriasis and treatment refractory CD requiring monoclonal antibody therapy with ustekinumab. One month prior to the current admission, she developed abdominal pain, worsening diarrhea and was diagnosed with CD exacerbation for which she was given ustekinumab. While her abdominal symptoms mildly improved with ustekinumab, she developed new bilateral lower extremity rash initially treated with levofloxacin for presumed cellulitis. The rash consisted of mild erythematous, non-scaling patches with scattered non-palpable petechiae on the lower extremities with subsequent involvement of abdomen, lower back and buttocks. Abdominal exam showed diffuse tenderness without mass, guarding or rebound while reminder of physical exam was unremarkable. Following the failure of antimicrobial therapy, she was diagnosed with LCV by skin biopsy. Complete work up was negative for infectious, malignant and inflammatory etiologies of LCV. Patient improved with increased dose of budesonide and subsequently continued to tolerate ustekinumab without recurrence of LCV. DISCUSSION AND CONCLUSION: LCV is a rare form of vasculitis and one of the rarest dermatologic manifestations of CD, appearing at any stage of the disease. LCV has been associated with autoimmune diseases, infections, specific drugs (levofloxacin, ustekinumab), and malignancy. Clinical presentation of LCV is variable and frequently mistaken for cellulitis. LCV should be considered in differential diagnosis of bilateral lower extremity rash in patients with CD after infectious, malignant and auto-immune/inflammatory etiologies are excluded. Unlike erythema nodosum (EN) and pyoderma gangrenosum (PG), LCV requires biopsy for diagnosis. Most patients respond well to steroids without scarring.
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spelling pubmed-73894352020-07-31 Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn’s disease mimicking cellulitis: a case report Buck, Meredith Dumic, Igor McDermott, Wendy Nordstrom, Charles Dawan, Samarth Virata, Andrew Martin, Scott Hudson, Ann Milovanovic, Tamara Nordin, Terri BMC Gastroenterol Case Report BACKGROUND: Leukocytoclastic vasculitis (LCV) is an immune-complex mediated vasculitis characterized by neutrophilic inflammation and nuclear debris in post capillary venules. LCV is a rare dermatologic manifestation of Crohn’s disease (CD) and may occur with the onset of the disease or any time after the diagnosis including the period of exacerbation. CASE PRESENTATION: We present a 70 year old woman with history of psoriasis and treatment refractory CD requiring monoclonal antibody therapy with ustekinumab. One month prior to the current admission, she developed abdominal pain, worsening diarrhea and was diagnosed with CD exacerbation for which she was given ustekinumab. While her abdominal symptoms mildly improved with ustekinumab, she developed new bilateral lower extremity rash initially treated with levofloxacin for presumed cellulitis. The rash consisted of mild erythematous, non-scaling patches with scattered non-palpable petechiae on the lower extremities with subsequent involvement of abdomen, lower back and buttocks. Abdominal exam showed diffuse tenderness without mass, guarding or rebound while reminder of physical exam was unremarkable. Following the failure of antimicrobial therapy, she was diagnosed with LCV by skin biopsy. Complete work up was negative for infectious, malignant and inflammatory etiologies of LCV. Patient improved with increased dose of budesonide and subsequently continued to tolerate ustekinumab without recurrence of LCV. DISCUSSION AND CONCLUSION: LCV is a rare form of vasculitis and one of the rarest dermatologic manifestations of CD, appearing at any stage of the disease. LCV has been associated with autoimmune diseases, infections, specific drugs (levofloxacin, ustekinumab), and malignancy. Clinical presentation of LCV is variable and frequently mistaken for cellulitis. LCV should be considered in differential diagnosis of bilateral lower extremity rash in patients with CD after infectious, malignant and auto-immune/inflammatory etiologies are excluded. Unlike erythema nodosum (EN) and pyoderma gangrenosum (PG), LCV requires biopsy for diagnosis. Most patients respond well to steroids without scarring. BioMed Central 2020-07-29 /pmc/articles/PMC7389435/ /pubmed/32727390 http://dx.doi.org/10.1186/s12876-020-01371-3 Text en © The Author(s) 2020 Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Case Report
Buck, Meredith
Dumic, Igor
McDermott, Wendy
Nordstrom, Charles
Dawan, Samarth
Virata, Andrew
Martin, Scott
Hudson, Ann
Milovanovic, Tamara
Nordin, Terri
Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn’s disease mimicking cellulitis: a case report
title Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn’s disease mimicking cellulitis: a case report
title_full Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn’s disease mimicking cellulitis: a case report
title_fullStr Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn’s disease mimicking cellulitis: a case report
title_full_unstemmed Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn’s disease mimicking cellulitis: a case report
title_short Leukocytoclastic vasculitis as a rare dermatologic manifestation of Crohn’s disease mimicking cellulitis: a case report
title_sort leukocytoclastic vasculitis as a rare dermatologic manifestation of crohn’s disease mimicking cellulitis: a case report
topic Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7389435/
https://www.ncbi.nlm.nih.gov/pubmed/32727390
http://dx.doi.org/10.1186/s12876-020-01371-3
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