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.