--- a
+++ b/processing/MACCROBAT/17803823.txt
@@ -0,0 +1,22 @@
+A 23 year old white male with a 4 year history of Crohn's disease presented with an acute two day history of malaise, fever, abdominal pain, vomiting and stomal diarrhoea.
+He complained of joint pains affecting the shoulders, elbows, wrists, metacarpophalangeals, knees and ankles.
+There was also a rash on the elbows, ankles and feet, which began as erythematous macules and evolved to vesico-pustular lesions followed by crusting.
+There was no history of sexual exposure or any intercurrent infection.
+He was on no regular medication, but had discontinued Pentasa 4 months earlier.
+One month earlier he had undergone a laparotomy to excise a complex ileo-cutaneous fistula with blind tracts, and two weeks earlier a defunctioning ileostomy had been created in view of persistent abdominal pain.
+The cutaneous fistula had been present for a year, but was associated with a terminal ileal stricture and ileo-rectal fistula of at least 2 years duration.
+His bowel disease had been resistant to immunosuppressive drugs including azathioprine, corticosteroiods and three infusions of Infliximab a year earlier.
+There had been no extra-intestinal manifestations.
+On admission to the hospital, he was thin, afebrile with a resting tachycardia of 125/minute.
+The rest of the cardio-respiratory examination was normal.
+The abdomen was minimally tender around the ileostomy without guarding or rebound tenderness.
+Examination of the skin revealed some pustules and crusts around the elbows, ankles and feet (Fig 1 and  2).
+The buttocks were spared.
+There were clinical signs of synovitis of the wrists, proximal interphalangeal and metacarpophalangeal joints, and also both ankles.
+Results of the laboratory tests showed a haemoglobin of 13.1 gm/dl, white blood count 15.8 × 109/L, platelets 585 × 109/L, C- reactive protein 37.7 mg/L and erythrocyte sedimentation rate 69 mm/hr.
+Urea and electrolytes, complement, urine analysis and microscopy were normal.
+Rheumatoid factor, antinuclear and antineutrophil cytoplasmic antibodies, cryoglobulins and Hepatitis B and C serology were negative.
+Transthoracic echocardiogram showed no signs of endocarditis, and multiple blood cultures were sterile.
+A skin biopsy from the ankle revealed a perivascular lymphohistiocytic infiltrate with prominent neutrophils and associated fibrinoid necrosis of vessels consistent with 'leukocytoclastic' vasculitis.
+He was commenced on 60 mg prednisolone per day leading to prompt and complete resolution of all features.
+The dose of prednisolone was rapidly tapered over the course of one month by the patient, faster than advised but without any recurrence over the following 3 years.