Ulcerative colitis presenting as pyrexia of unknown origin (PUO) without bowel symptoms

Graham Johnston

doi:10.7861/clinmedicine.13-1-112a

Editor – I read with interest the case report by Khan et al of ulcerative colitis presenting as a pyrexia of unknown origin (PUO) (Clin Med August 2012 pp 389–90). In their clinical search for a cause of PUO they briefly mention a lesion of the lower leg which is described as a shallow leg ulcer with no clinical evidence of infection, but which grew methicillin-resistant Staphylococcus aureus and was treated with teicoplanin. No further details or sequelae are reported.

Ulcerative colitis is associated with the uncommon ulcerating skin condition pyoderma gangrenosum (PG). PG may affect any part of the skin, although the classical scenario describes a lesion of the lower leg in a female patient over 50 years of age, as reported by Khan in their case. While PG can be painful and debilitating, early or vegetative lesions can present simply as low grade leg ulcers in otherwise healthy patients. Skin biopsy shows a non-specific neutrophilic infiltrate but is only useful in excluding other differential diagnoses for painful ulcers such as vasculitis. Diagnosis is a clinical one based on the characteristic appearance of a rapidly enlarging, painful ulcer with a purple and undermined edge and a cribriform (colander-like) base.

The clinical diagnosis of PG should trigger a search to identify the 50–70% of patients who have associated disorders, including inflammatory bowel disease, arthritis and haematological malignancy. Treatment with high dose oral steroids and/or ciclopsorin can be effective and response can be rapid. Indeed a response to oral steroids is one of the minor diagnostic criteria used in this condition. Therapeutic trials of these agents in suspected multi-system inflammatory disorders can, therefore, inadvertently eradicate a useful cutaneous physical sign.

Fellows are reminded to consider atypical skin lesions when assessing and considering therapeutic trials in patients with suspected occult inflammatory or neoplastic disorders.

Footnotes

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References

1. Cox NH
Jorizzo JL Bourke JF Savage COS. Vasculitis, Neutrophilic Dermatoses and Related Disorders. In: Burns DA Breathnach S Cox NH, Griffithes (eds), Rook's Textbook of Dermatology. London: Wiley-Blackwell, 2010.