Interactive Quiz: Rash on a Teenager
Welcome to Gastroenterology Consultant’s latest interactive diagnostic quiz. Over the next few pages, we’ll present a case and ask you to make the diagnosis and treat the patient. Along the way, we’ll provide details about the case, and at the end, we'll share the patient’s outcome.
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First, let’s meet the patient…
A 13-year-old girl with a history of constipation and anemia presented with abdominal pain and a new rash. She and her mother reported that the girl had had daily, intermittent episodes of epigastric and lower abdominal cramping that had often been followed by watery, nonbloody, nonmucoid diarrhea over the past 2 months.
Her rash was painless, nonpruritic, and limited to her upper and lower extremities. Additionally, her mother noted that the girl had experienced fatigue and a 3.6-kg weight loss during this same 2-month period.
The examination findings were notable for several tender, nonblanching, red, slightly raised and palpable discrete lesions on the lateral and extensor surface of her upper arms and on the anterolateral aspect of her lower legs bilaterally (Figures 1 and 2). These lesions turned purplish brown over the next several days. She also had an anal skin tag and bilateral brachymetatarsia.
Are you correct? >>
Answer: Vasculitis
This mild, nonblanching, palpable, purpuric rash was clinically consistent with vasculitis. Although there was no biopsy of the lesions, the skin findings likely represent a leukocytoclastic vasculitis.
Initial examination revealed an afebrile, sallow, but pleasant girl not in distress. Her vital signs were normal for her age. Her height was 157 cm (55th percentile) and her weight was 55 kg (87th percentile), corresponding to a body mass index of 22.3 kg/m2 (87th percentile).
She had no alopecia or oral lesions except for a geographic tongue. There was no conjunctival injection or drainage. There was no cervical mass or lymphadenopathy. Cardiac and lung examination findings were unremarkable. Her abdomen was soft and not tender or distended; no organomegaly or mass was appreciated. The remainder of physical examination findings were unremarkable.
Her stool tested positive for occult bleeding, but infectious study results were nondiagnostic. Her hemoglobin level was low at 8.5 g/dL (reference range, 11.3-13.4 g/dL) with a mean corpuscular volume of 77.8 µm3 (reference range, 79.5-85.2 µm3), and her C-reactive protein level was elevated at 6.8 mg/dL (reference range, <1.0 mg/dL). Her stool calprotectin level was significantly elevated at more than 2000 µg/g (reference range, ≤50 µg/g). The remainder of the findings of a complete blood cell count, a basic metabolic panel, and liver function tests were within normal limits.
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Answer: Computed tomography
An abdominal computed tomography scan revealed thickening from the distal ascending to transverse colon and terminal ileum.
She had previously received a diagnosis of iron-deficiency anemia, presumed to be secondary to menstrual blood loss, and she had been taking oral iron supplementation. She took no other medications. She noted that her fatigue had continued despite the iron supplementation. Her father had a history of irritable bowel syndrome. She reported no surgical procedures or hospitalizations, and she had no known allergies.
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Answer: Inflammatory bowel disease
The result of the abdominal computed tomography scan was suggestive of inflammatory bowel disease (IBD). A colonoscopy revealed patchy areas of chronic colitis with multiple noncaseating granulomas on a biopsy specimen, a finding consistent with Crohn colitis.
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Answer: Prescribe metronidazole, mesalamine, and infliximab
The patient was started on metronidazole, mesalamine, and infliximab. Her rash began to fade by the time of discharge.
The skin manifestations that have been described with IBD are erythema nodosum (most common), pyoderma gangrenosum, neutrophilic dermatoses, cutaneous vasculitis, and epidermolysis bullosa acquisita. However, the occurrence of skin manifestations prior to the development of IBD is rare.
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Answer: 10%
Extraintestinal conditions associated with IBD (including nonspecific symptoms such as arthralgias) are identified in approximately 10% of patients at presentation and up to 30% of patients within the first few years after IBD diagnosis. The conditions do not consistently correlate with the degree of intestinal inflammation.
To read the full case report, see:
Alookaran J, Sarandria JJ, Zayas J. Inflammatory bowel disease presenting as a rash [published online October 25, 2017]. Consultant for Pediatricians. https://www.consultant360.com/exclusives/inflammatory-bowel-disease-presenting-rash.