P016 A case of metastatic Crohn disease successfully treated with upadacitinib

Abstract

Metastatic Crohn disease (MCD) is a rare condition with histopathological features in keeping with Crohn disease within the skin, external to the gastrointestinal tract. A 61-year-old male patient presented with a 9-month history of an itchy, painful fissuring rash on the buttocks and genital and perianal regions. A few months prior, he was diagnosed with Crohn colitis. Superadded skin infection at the time of presentation was treated but this did not lead to improvement. Histopathology from biopsy of an area of skin noncontiguous with the gastrointestinal tract highlighted a hyperplastic, acanthotic epidermis, with lymphocyte exocytosis and non-necrotizing granulomata, surrounded by a mantle of lymphocytes and plasma cells. Given the pathological and clinical features, MCD was diagnosed. Treatment was commenced with an adalimumab biosimilar, mesalazine and prednisolone, with only modest improvement. Subsequent erythematous crusty plaques on the left lower leg developed and were biopsied, also reported as MCD. After 10 months of biosimilar treatment, both skin and bowel symptoms continued. In liaison with gastroenterology, the patient was switched to upadacitinib. Within days, there was rapid and significant clearance of skin lesions and subsequent improvement in bowel symptoms. There are fewer than 100 cases of MCD in the literature and the initial therapeutic approach is often unsatisfactory as there is no consensus for standardized treatment. There are only three reported cases of upadacitinib as a successful treatment modality for MCD. Our case adds to the emerging evidence base that upadacitinib can be an effective management option for patients with MCD. The observations may contribute to the development of standardized guidelines, to aid earlier resolution of these often debilitating skin changes.