S4917 Ptosis: An Uncommon Manifestation of Crohn’s Disease

Introduction: Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract with multifactorial etiology involving genetic, immune, and environmental factors. Up to 30% of CD cases exhibit extraintestinal manifestations, with ocular involvement in approximately 10%. These manifestations may precede gastrointestinal symptoms, complicating diagnosis. Ptosis as an initial symptom is rare and largely undocumented. This case highlights ptosis as a neurological manifestation of CD. Case Description/Methods: A 54-year-old woman presented with left upper quadrant abdominal pain, intermittent fevers to 103°F, chronic diarrhea and progressive left-sided ptosis for 4 years, preceding onset of her gastrointestinal symptoms. Prior evaluations included a colonoscopy in 2023 with acute ileitis and a capsule endoscopy with jejunal ulcers. Myasthenia gravis antibodies were negative, but the patient was treated with oral steroids in the outpatient setting. Physical examination was largely benign. Labs including gastrointestinal pathogen panel, C. difficile, Quantiferon®, cytomegalovirus, and antineutrophil cytoplasmic antibodies were negative. Computed tomography abdomen showed distal and terminal ileitis. Neurologic and ophthalmologic work-up was unremarkable. Differential diagnoses included CD, infectious ileitis, neoplasia, and vasculitis. Colonoscopy demonstrated ileitis with ulceration and erythema. Pathology showed active ileitis with ulceration and cryptitis with negative acid-fast bacillus/cytomegalovirus staining, consistent with CD. Discussion: Atypical features included ptosis and recurrent high-grade fevers as a presentation of CD. The pathophysiology of ptosis in CD is not well-defined but may involve autoimmune-mediated mononeuritis or inflammatory microvascular damage. Neurologic manifestations of Crohn’s disease are rare, occurring in 0.25% to 35.7% of cases. Ocular manifestations such as episcleritis and uveitis are more common, though isolated ptosis is exceptionally rare. Immune dysregulation and pro-inflammatory cytokines may contribute to neural involvement. This case underscores the heterogeneity of CD, consideration of CD in the differential for fever of unknown origin, and the importance of recognizing atypical presentations. Ptosis as a presenting symptom highlights the need for comprehensive evaluation of systemic and extraintestinal manifestations in suspected CD. Early identification and targeted therapy can improve outcomes and prevent morbidity associated with delayed diagnosis. Further research is needed to understand the mechanisms linking CD and neurological involvement.