A 39 year old woman with a history of an uncomplicated pregnancy 3 months prior presented to the Emergency Department with recurrent crampy abdominal pain, poor appetite, and alternating constipation and diarrhea with tenesmus, lasting for 2 weeks. She was recently diagnosed with complicated mastitis due to persistent breast ulcers, and more recently developed genital ulcers. The breast and genital lesions were red, non-tender, and without drainage.
She was febrile, tachycardic, and hypotensive upon admission. Abdominal exam was notable for bilateral lower quadrant pain without rebound. Breast exam revealed a non-purulent, non-tender, erythematous ulcer sparing the areola. Genital exam showed a similar ulcer on the medial thigh. Initial labs revealed a WBC count of 8,800/uL, Hgb 9.4 g/dl, Na 127 mg/dl, creatinine 0.83 mg/dl, ESR of 73, CRP of 23. She was admitted for sepsis from cellulitis.
Antibiotics and IV fluids were started and infectious disease, gastroenterology, and dermatology were consulted; the latter performing a skin biopsy. On hospital day 2, the patient developed further hypotension that was nonresponsive to fluids. She was transferred to the ICU and had an abdominal CT scan showing pancolitis. Blood cultures became positive for Bacteroides and her lactate was acutely elevated at 7mmol/L. General surgery was consulted and performed an emergent exploratory laparotomy. Gross appearance was consistent with toxic megacolon requiring a total colectomy. Pathology read of her skin biopsy was consistent with pyoderma gangrenosum (PG), and colon consistent with ulcerative colitis (UC). The patient had slow clinical improvement postoperatively, and was discharged home 12 days after surgery.
UC is an autoimmune disease that commonly presents in early adulthood, often exacerbated by pregnancy including the post-partum period. PG occurs in 1-2% of patients with inflammatory bowel disease (IBD), and is rarely the initial presentation. In this patient, both the breast and genital lesions were thought to be PG while most cases present in the lower extremities. Attention to atypical presentations, timing of symptom onset and progression, along with early diagnosis was crucial as extensive colonic involvement portends a poor prognosis. This case demonstrates the importance of keeping a broad differential for presumed “cellulitis”, especially in patients who fail to respond to empiric management.
PG is an under-recognized cause of skin lesions in otherwise healthy young patients. Diagnosis can be difficult, but autoimmune conditions must be considered when multiple organ systems appear to be affected. Timely identification and treatment of IBD will lead to disease control and avoidance of potentially life-threatening complications, like toxic megacolon. Early involvement of subspecialty services should be considered in these cases.
To cite this abstract:Schildhouse RJ, Ho K. Cutaneous Manifestations As the Initial Presentation of Ulcerative Colitis in the Post-Partum Period. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 781. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/cutaneous-manifestations-as-the-initial-presentation-of-ulcerative-colitis-in-the-post-partum-period/. Accessed May 22, 2019.