What's Your Diagnosis?
What Are These Bullous Lesions on the Extremities of a Young Woman With Crohn Disease?
Hunter T. Holloway, DO • Stephen C. Brawley, MD, PhD • Pamela C. Scott, MD
Eastern Virginia Medical School Portsmouth Family Medicine, Portsmouth, Virginia
Holloway HT, Brawley SC, Scott PC. What are these bullous lesions on the extremities of a young woman with Crohn disease? Consultant. 2021;61(10):e14-e17. doi:10.25270/con.2021.04.00009
Received November 18, 2020. Accepted January 19, 2021. Published online April 19, 2021.
The authors report no relevant financial relationships.
Hunter T. Holloway, DO, Eastern Virginia Medical School Portsmouth Family Medicine, 3640 High Street #3b, Portsmouth, VA 23707 (email@example.com)
A 35-year-old woman presented to our clinic with chronic bilateral lower extremity ulcerations that had worsened over the past 2 weeks. The lesions had started as small, tender nodules that subsequently formed superficial bullae that broke down to ulcerations, which released serosanguinous fluid. At the time of presentation, her lesions were at different stages of evolution. She reported pain with dressing changes and weakness ambulating with a rolling walker. She also denied fever.
History. Her medical history was significant for Crohn disease status post-proctocolectomy, type 2 diabetes, morbid obesity, and hidradenitis suppurativa. She was not taking any immunemodulating medications or biologic agents for Crohn disease.
Approximately 1 month prior to presentation, the patient was referred by her primary care provider to a vascular surgeon for the lower extremity ulcers. The surgeon then prescribed an Unna boot (zinc oxide compression bandages).
The only prior diagnostic studies the patient had were lower extremity arterial and venous ultrasonography scans, results of which were unremarkable. The results of a biopsy of a lower extremity ulcer showed underlying neutrophilic and granulomatous dermatosis and fibrosis.
Physical examination. Numerous ulcerations of varying size were sharply demarcated on the patient’s bilateral lower extremities, and remnants of the Unna boot therapy were noted (Figures 1 and 2). In addition, crops of erythematous nodules were noted on the patient’s bilateral lower and upper extremities (Figure 3).
Figure 1. Bullous and ulcerative lesions on the patient’s right leg. Note the varying stages of lesion evolution.
Figure 2. Ulcerative lesion on the dorsal surface of the patient’s left foot. Note the surrounding areas of violaceous induration.
Figure 3. Crops of erythema nodosum were noted on the patient’s left upper thigh. Similar lesions were found on patient’s upper extremities.
The results of initial hematology, chemistry, and rheumatologic tests are listed in the Table (click to enlarge).
Answer and discussion on next page.