S4922 Cutaneous Ulcers as the First Manifestation of Inflammatory Bowel Disease in a Young Man: An Interdisciplinary Diagnostic Challenge

Introduction: Cutaneous manifestations of inflammatory bowel disease, such as pyoderma gangrenosum (PG), can precede gastrointestinal symptoms, and mimic infection or vasculitis, delaying diagnosis. We present a case of a young man whose painful skin ulcers, initially thought to be infectious or autoimmune in origin, led to a new diagnosis of Crohn’s disease. Case Description/Methods: A 27-year-old uninsured Mexican man presented to the emergency department with painful ulcers on his thighs, groin, and right arm, along with fever, chills, and diarrhea. The ulcers began 1.5 weeks prior as small pustules that rapidly expanded. He denied recent travel, new medications, or known medical conditions; but, admitted chronic diarrhea, recurrent aphthous ulcers, and similar skin lesions 3 years earlier. His mother and sister have lupus. On admission, he was febrile and tachycardic. Skin exam revealed well-circumscribed, tender ulcers with erythematous borders in different stages. Tests showed leukocytosis, normocytic anemia, hypoalbuminemia, hyponatremia, and transaminitis. Broad-spectrum antibiotics were initiated for presumed sepsis secondary to cellulitis. Dermatology, infectious diseases, and rheumatology were consulted. Blood cultures, ANA, HIV, viral hepatitis panels, AFB culture, and stool studies were negative. C-reactive protein and erythrocyte sedimentation rate were elevated. Skin biopsy showed superficial and mid-dermal perivascular and periadnexal dermatitis with microabscesses. The wound culture grew Pseudomonas aeruginosa, supporting an initial infectious etiology. Patient was prescribed cefepime with mild improvement. However, infectious diseases remained concerned for a non-infectious primary etiology and gastroenterology was consulted. Colonoscopy revealed severely erythematous and ulcerated mucosa consistent with Crohn's disease. Dermatology then suspected PG as the cause of the skin lesions. Systemic and topical corticosteroids resulted in rapid improvement of both gastrointestinal and cutaneous symptoms. Discussion: This case underscores the importance of an interdisciplinary approach to a syndromic diagnosis for complex cutaneous ulcers. PG can mimic other conditions delaying diagnosis and treatment of underlying inflammatory bowel disease. This patient’s limited access to healthcare as an uninsured Hispanic man emphasizes the impact of health disparities. Collaboration among specialties led to a correct diagnosis and favorable outcome. Disclosure: AI assistance used in writing portions of this summary.