17803823 Visualization

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