University of Colorado Anschutz Medical Campus Aurora, CO, United States
Taylor A. Karl, MD, Blair Fennimore, MD, Frank I. Scott, MD, MSCE, Mark Gerich, MD University of Colorado Anschutz Medical Campus, Aurora, CO
Introduction: Crohn’s disease (CD) has many associated skin disorders. Metastatic Crohn’s disease (MCD) is one such disorder, defined by non-suppurative sarcoidal granulomas that are noncontiguous with the gastrointestinal tract. Owing to the rarity of MCD, there is no clinical trial data or consensus to guide treatment. Ustekinumab (UST) is a novel potential treatment for MCD with few reports to support its use. Here we present a patient with biopsy-proven MCD that improved after UST treatment.
Case Description/Methods: The patient is a 37-year-old woman with a history of perianal- and internal-penetrating ileocolonic CD. She had secondary loss of response to infliximab and primary non-response to adalimumab and certolizumab pegol. After several years of management with steroids and azathioprine she presented with worsening perineal, gluteal, and bilateral inframammary ulcerations. Biopsies of the ulcer borders showed granulomatous inflammation. After further workup, she was diagnosed with MCD and treated with steroids and a loading dose of UST. She was lost to follow-up but returned to our institution 5 months later with worsening MCD after tapering off prednisone and failing to continue UST maintenance therapy. Over the next month her MCD did not improve with systemic steroids or topical tacrolimus. She was given intravenous cyclosporine (CsA) which required dose reductions due to side effects. After roughly one month of CsA, she transitioned to oral tacrolimus. Although her lesions showed some improvement, they had not healed. Tacrolimus was discontinued shortly due to side effects. She was started on weekly methotrexate injections and a loading dose of UST. Approximately one month after receiving UST her wounds had nearly healed. She was discharged one month later at which point her MCD remained in near remission (Figure 1).
Discussion: MCD is a rare manifestation of CD with few validated treatment options. Based on evidence from case reports, some authors have proposed an approach that escalates from topical therapies to systemic steroids, metronidazole, and then immunomodulators or TNF inhibitors; however, no treatment has shown consistent efficacy. A few case reports have shown UST to be a novel therapy for refractory MCD. We believe our case provides further evidence supporting UST as a treatment of MCD. Future prospective studies are necessary to evaluate the effectiveness of UST in treating MCD.
Figure: Figure 1. Ustekinumab successfully treats Metastatic Crohn’s disease ulcerating inflammatory lesions. (A) Gluteal cleft lesion and (B) perineal lesion upon readmission. (C) Gluteal cleft lesion and (D) perineal lesion prior to UST infusion. (E) Gluteal cleft lesion and (F) perineal lesion 2 months after UST induction infusion.
Disclosures:
Taylor Karl indicated no relevant financial relationships.
Blair Fennimore indicated no relevant financial relationships.
Frank Scott: Janssen Pharmaceuticals – Grant/Research Support. Janssen Pharmaceuticals – Other Financial or Material Support, personal fees. Merck Pharmaceuticals – Other Financial or Material Support, personal fees. NIH – Grant/Research Support. PRIME Incorporated – Other Financial or Material Support, personal fees. Takeda Pharmaceuticals – Other Financial or Material Support, personal fees. Takeda Pharmaceuticals USA – Grant/Research Support. the Crohn’s and Colitis Foundation – Grant/Research Support.
Mark Gerich: Arena Pharmaceuticals – Other Financial or Material Support, personal fees. Bristol-Myers Squibb – Other Financial or Material Support, personal fees. Gilead – Other Financial or Material Support, personal fees. Janssen Pharmaceuticals – Other Financial or Material Support, personal fees. PRIME Incorporated – Other Financial or Material Support, personal fees.
Taylor A. Karl, MD, Blair Fennimore, MD, Frank I. Scott, MD, MSCE, Mark Gerich, MD. P1691 - Let’s Get You Comfortable in Your Own Skin: Response of Metastatic Crohn’s Disease to Ustekinumab, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
