--- 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.