Mahmoud Isseh, MD1, Mouhanna Abu Ghanimeh, MD2, Sandra Naffouj, MD1, Nicholas Horton, MD1, Nazih Isseh, MD3, Nirmal Kaur, MD1
1Henry Ford Health System, Detroit, MI; 2Henry Ford Hospital, Detroit, MI; 3University of Tennessee Health Science Center, Memphis, TN
Introduction: Oral manifestations (OM) have been reported in crohn’s disease (CD). The prevalence of these manifestations ranges between 0.5%-50% in adults and 10%-80% in pediatrics. OM of CD may coincide with the intestinal manifestations, or less commonly precede them. Aphthous ulcers, angular cheilitis, swelling of the lips and gingiva, cobblestoning of the mucosa, deep linear ulcers and periodontal disease have been reported in the literature.
Case Description/Methods: An 18-year-old female with no significant history presented to her PCP with recurrent lip swelling and dryness. She was diagnosed initially with angioedema without urticaria. History of an environmental exposure was inconsistent and testing for hereditary angioedema, including C1 esterase and C4 levels were unremarkable. She was referred to a dermatologist who diagnosed her with peri-oral dermatitis. Treatment with antihistamines, topical steroids, antifungals, antibiotics and petroleum jelly were unsuccessful. She was treated with PO prednisone for a presumed pemphigus vulgaris with symptomatic improvement, but with relapse two weeks after weaning steroids. Due to chronicity of symptoms, a lip biopsy was done and showed a psoriasiform dermatitis with a granulomatous inflammation. Direct immunofluorescent testing was unremarkable. Results were concerning for CD versus cheilitis granulomatosa. She denied GI symptoms, weight loss or family history of IBD. Further testing revealed a normal ferritin, vitamin B12, folate, ANCA, and QuantiFERON-TB. She was referred to GI for further evaluation. An EGD showed a normal esophagus, stomach and examined duodenum. Biopsies from stomach and duodenum were unremarkable. A colonoscopy showed a normal perianal area, colon and terminal ileum. Biopsies from the left colon showed a focal active colitis, foci of neutrophilic cryptitis and focal epithelioid granuloma without dysplasia. Stains for acid fast bacilli and fungi were negative. Biopsies from the right colon and terminal ileum were unremarkable. MRE showed no evidence of active small bowel CD. Given the early onset and widespread distribution, the decision was to start adalimumab. Her OM improved significantly. A repeat colonoscopy with biopsies was unremarkable.
Discussion: The recognition of OM can play an important clue in diagnosis and management of CD, especially that an isolated oral disease is uncommon as a first presentation. Infections, nutritional deficiencies and medication side effects are important to consider as differential diagnosis.
Citation: Mahmoud Isseh, MD; Mouhanna Abu Ghanimeh, MD; Sandra Naffouj, MD; Nicholas Horton, MD; Nazih Isseh, MD; Nirmal Kaur, MD. P1078 - CHRONIC PERI-ORAL DERMATITIS AS THE FIRST MANIFESTATIONS OF CROHN'S DISEASE. Program No. P1078. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.