Jamil O. Alexis, MD, He Qiu, MD, MBA, Janice G. Shen, MD, Keith Sultan, MD
Northwell Health System, Manhasset, NY
Introduction: Ulcerative colitis (UC) is characterized by chronic mucosal inflammation limited to the colon. The most common manifestation of UC is progressively worsening hematochezia that may be accompanied by extraintestinal manifestations including, peripheral arthritis, uveitis, primary sclerosing cholangitis, fatty liver, venous/arterial thromboembolism, and pulmonary disease. Erythema nodosum (EN) and pyoderma gangrenosum (PG) are the most common dermatologic manifestations. Uncommonly, UC may present with unpredictable urticaria and angioedema that may be life threatening. We present a rare care of acute UC flare with migratory urticaria as the initial presenting symptom.
Case Description/Methods: A 25-year-old woman with UC presented with 1 week of abdominal pain, bloody stools, bilateral ankle and knee pain with non-blanching rash over her right shoulder, left armpit, and left groin. GI PCR and C. difficile assay were negative. Rheumatoid factor, double stranded DNA, anti-cyclic citrullinated peptide antibodies, anti-Smith antibody, anti-ribonuclear protein, and C1 esterase inhibitor were negative. The patient was started on cetirizine with resolution of the arthralgia. However, new rashes were noted under right axilla and left antecubital fossa over a two day period.Patient subsequently developed dysphagia and left sided mandibular swelling. Indirect laryngoscopy was unremarkable. She was immediately treated with IV methylprednisolone and transitioned to a slow oral steroid taper over 3 months with improvement of gastrointestinal and dermatologic symptoms. Skin biopsies revealed superficial and mid-dermal perivascular lymphocytic infiltrate consistent with urticaria.
Discussion: This patient presented with unpredictable migratory skin lesions involving multiple mucosal surfaces that brought concerns of possible airway involvement. The etiology was initially unclear as limited infectious and rheumatologic work up was negative, as well as negative allergen and medication exposure.Cutaneous vasculitis was considered, however biopsy showed urticaria. Patient’s symptoms significantly improved after the initiation of oral steroids. Migratory urticaria with associated angioedema can be a manifestation of an acute flare of UC that warrants evaluation by otolaryngologist and prompt initiation of steroids. Glucocorticoids may address symptoms of a pro-inflammatory state while allowing for more time to rule out other etiologies of extraintestinal manifestations of a patient’s presentations.
Citation: Jamil O. Alexis, MD, He Qiu, MD, MBA, Janice G. Shen, MD, Keith Sultan, MD. P1446 - A RARE CASE OF MIGRATORY URTICARIA CAUSING DYSPHAGIA DURING AN ACUTE FLARE OF ULCERATIVE COLITIS. Program No. P1446. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.