P039 Anogenital granulomatosis presenting as painful progressive ulceration preceding gastrointestinal symptoms: a clinicopathological case

Abstract

Anogenital granulomatosis (AGG) is a rare inflammatory condition characterized by histologically proven granulomatous inflammation without evidence of luminal or perianal Crohn disease. Extraintestinal Crohn disease is regarded as the most frequent underlying cause, with the condition referred to as anogenital cutaneous Crohn disease. AGG may precede intestinal involvement and occur in the absence of gastrointestinal symptoms, resulting in diagnostic and treatment delays. We report the case of a 65-year-old woman with severe progressive multiple sclerosis, type 2 diabetes mellitus, inactive hidradenitis suppurativa, suprapubic catheterization and a defunctioning colostomy for multiple sclerosis-related slow transit. She presented with a 4-year history of progressively painful cutaneous ulceration. Initial symptoms consisted of superficial ‘paper-cut’ erosions in the left gluteal fold, which were attributed to pressure and moisture-associated skin damage in the context of reduced mobility. Conservative wound management was undertaken in the community. The erosions evolved into deep bilateral gluteal, groin, inframammary and axillary ulcers. Her course was complicated by sacral osteomyelitis arising from a sinus tract in the anal cleft, resulting in further functional decline and necessitating multiple prolonged courses of antibiotics. Dermatological reassessment identified well-demarcated, extremely tender ulcers. Skin biopsies from gluteal and inframammary sites demonstrated ulceration with numerous well-formed granulomas, multinucleated giant cells and eosinophils. They were not explained by comprehensive infectious investigations, including bacterial, mycobacterial, fungal and viral studies. Computed tomography imaging revealed stump proctocolitis. Colonoscopic biopsies showed granulomas within the rectum and rectal stump, with differential diagnoses of diversion colitis vs. luminal Crohn disease after ­gastrointestinal pathology review. Following stabilization of the infection, she commenced a tapering course of oral prednisolone, leading to marked improvement in ulcer healing, pain and functional status. This case illustrates AGG presenting without classical gastrointestinal manifestations and complicated by immobility and chronic infection. It emphasizes the need for clinicopathological correlation and early multidisciplinary involvement to reduce diagnostic delay and long-term morbidity.