Weiser Jessica A, Markowitz David M, Husain Sameera, Grossman Marc E
Department of Dermatology, Columbia Presbyterian Medical Center, New York, NY, USA.
Skinmed. 2011 May-Jun;9(3):196-8.
A 61-year-old man with a 12-year history of quiescent Crohn's disease on mesalamine presented to his gastroenterologist in April 2009, complaining of abdominal cramping, diarrhea, and a 25-lb weight loss over 6 weeks. He did not respond to prednisone 50 mg and 6-mercaptopurine 100 mg daily. Abdominal computed tomography findings revealed diffuse submucosal edema consistent with extensive colitis. Colonoscopy demonstrated diffuse inflammation with erythema, friability, and shallow ulcerations in the rectum and colon. Biopsies were consistent with Crohn's colitis. He was admitted for infliximab infusion for his unremitting diarrhea. Five days before admission, the patient noted mild swelling and redness of the left lower eyelid, which progressed to involve the right lower eyelid with frank pus draining from both eyes. He had no visual impairment or eye pain. Two days before admission, an ophthalmologist prescribed a steroid eyedrop with no relief. He also complained of seropurulent painful skin lesions on his face and scalp, which spread to involve his upper trunk and proximal arms. On admission to the hospital, dermatology, ophthalmology, and infectious disease consultations were obtained to rule out disseminated infection before initiation of infliximab therapy. The patient was afebrile and hemodynamically stable. His oral mucosa was normal. He had prominent bilateral lower eyelid edema, erythema, and superficial erosions with hemorrhagic crusting and frank green purulent drainage from both eyes, with crusting along the lower lash line and bilateral sclera injection (Figure 1). On his scalp, face, trunk, and proximal extremities, he had 25 to 30 erythematous, 4- to 8-mm papulopustules with narrow red halos, some with central necrosis and crusting (Figure 2). Cultures from the purulent ocular drainage and pustules on the trunk and arms were all negative for bacteria, virus, and fungi. Gram stain from the eye drainage showed polymorphonuclear leukocytes without organisms. Tissue cultures were negative for bacterial, fungal, and mycobacterial infection. Skin biopsy taken from the central upper back demonstrated subcorneal pustules with areas of eroded epidermis and collections of neutrophils in the superficial dermis (Figure 3). Special stains were negative for organisms. He received infliximab infusion 5 mg/kg for a total dose of 420 mg over 2 hours. Within 48 hours of infusion, there was notable decrease in size of lesions, in addition to reduction of purulent drainage from both eyes. The patient was discharged home following infliximab infusion. His skin lesions resolved during a period of 2 weeks, leaving small pink atrophic scars. He received his second infusion of infliximab 2 weeks after discharge with continued improvement in his gastrointestinal symptoms.
一名61岁男性，有12年静止期克罗恩病病史，一直在服用美沙拉嗪，2009年4月前往胃肠病专家处就诊，主诉腹部绞痛、腹泻，6周内体重减轻25磅。他对每日50毫克泼尼松和100毫克6-巯基嘌呤治疗无反应。腹部计算机断层扫描结果显示弥漫性黏膜下水肿，符合广泛性结肠炎表现。结肠镜检查显示直肠和结肠弥漫性炎症，伴有红斑、易脆和浅溃疡。活检结果符合克罗恩结肠炎。因腹泻不止，他入院接受英夫利昔单抗输注治疗。入院前5天，患者注意到左下眼睑轻度肿胀和发红，随后发展至右下眼睑，双眼有明显脓性分泌物。他没有视力障碍或眼痛。入院前两天，眼科医生开了一种类固醇眼药水，但症状未缓解。他还主诉面部和头皮出现浆液脓性疼痛性皮肤病变，病变蔓延至上躯干和近端手臂。入院时，在开始英夫利昔单抗治疗前，咨询了皮肤科、眼科和传染病科以排除播散性感染。患者无发热，血流动力学稳定。他的口腔黏膜正常。他双侧下眼睑明显水肿、红斑，有浅表糜烂，伴有出血结痂，双眼有明显绿色脓性分泌物，下睑缘有结痂，双侧巩膜充血（图1）。在他的头皮、面部、躯干和近端肢体上，有25至30个4至8毫米的红斑性丘疹脓疱，周围有狭窄的红色晕圈，有些有中央坏死和结痂（图2）。来自脓性眼部分泌物以及躯干和手臂脓疱的培养物，细菌、病毒和真菌检测均为阴性。眼部引流液革兰氏染色显示多形核白细胞，未见微生物。组织培养细菌、真菌和分枝杆菌感染均为阴性。取自上背部中央的皮肤活检显示角质层下脓疱，表皮有糜烂区域，浅表真皮有中性粒细胞聚集（图3）。特殊染色未见微生物。他接受了英夫利昔单抗输注，剂量为5毫克/千克，2小时内总剂量达420毫克。输注后48小时内，病变大小明显减小，双眼脓性分泌物也减少。英夫利昔单抗输注后患者出院。他的皮肤病变在2周内消退，留下小的粉红色萎缩性瘢痕。出院2周后，他接受了第二次英夫利昔单抗输注，胃肠道症状持续改善。
