Metastatic Crohn Disease with Groin Localization in an Adult Patient

Introduction

Metastatic Crohn disease (MCD) is a rare skin manifestation of Crohn disease (CD). MCD can develop on any cutaneous surface, but has a predilection for the genital region, especially in children [1]. Herein, we present an adult case of MCD with groin localization, so as to highlight the fact that this localization can easily be overlooked if patients do not present with any gastrointestinal symptoms.

Case Presentation

A 58-year-old male presented with a painful ulcer that had appeared on his right groin 10 days earlier. He did not report having any systemic diseases or systemic symptoms involving the gastrointestinal system. Upon dermatological examination there was a linear, 1.3 cm × 5 cm tender ulcer on his right groin. The ulcer was rather deep and extended to the subcutaneous tissue, forming a fistulous tract. A swab culture of the discharge showed Enterococcus faecalis, Enterococcus faecium, Escherichia coli, and Klebsiella pneumoniae growth; therefore, parenteral sulbactam-ampicillin therapy was initiated. Despite the lack of high-risk sexual behavior, doxycycline was empirically added to the patient antibiotic regimen for lymphogranuloma venereum infection, but the ulcer did not improve. A skin punch biopsy sample was obtained from the edge of the ulcer and histopathological analysis showed suppurative granulomatous inflammation. Histological stains were negative for bacterial and fungal microorganisms. Following histopathological examination, cutaneous tuberculosis, deep fungal infection, tularemia, and syphilis, which can lead to granuloma formation, were ruled out via additional detailed tests, including skin culture, PCR, and serological tests.

To assess the connection of the ulcer, fistulography was performed, which showed distribution of the radiocontrast agent in several tracts between soft tissues. Abdominal computed tomography scan showed terminal ileitis and a fistula extending to the skin, although the patient did not report any gastrointestinal symptoms relating to the diagnosis of CD. Colonoscopy and colonoscopic biopsy were performed, and the findings were consistent with active colitis. Based on the clinical, radiological, colonoscopic, and histopathologic findings, the patient was diagnosed with MCD. After starting oral mesalazine, azathioprine, and prednisolone, the fistulous discharge decreased, but the ulcer did not heal completely (Figure 1); consequently, fistulectomy and right hemicolectomy were performed.

Figure 1.

Ulcer with incompletely healed fistula opening.

Discussion

MCD is the least common dermatologic manifestation of CD. In 70% of adult patients MCD lesions appear after the initial diagnosis of CD; therefore, its diagnosis can be challenging in adults without active gastrointestinal symptoms at presentation [2]. The presented patient did not have any gastrointestinal symptoms, which delayed the diagnosis of MCD. Another challenging aspect of diagnosis is ulcer localization. Although the most common presentation of MCD in children is the genital region, the most common presentation in adults is the extremities. Genital localization is of particular importance in sexually active adult patients, as it can mimic sexually transmitted diseases.

Conclusions

MCD is a rare cause of genital ulcers in adult patients and can present without gastrointestinal symptoms. Genital ulcers with granuloma formation in adults should suggest MCD, even in patients that do not report any gastrointestinal symptoms.