A granulomatous dermatitis associated with idiopathic ulcerative colitis

A 22-year-old white woman with a past medical history significant for left-sided ulcerative colitis since June 1996 was in good control until July 1998 when she developed bloody diarrhea treated with oral steroids. In September 1998, she was admitted to Mount Sinai Hospital because of worsening symptoms. Colonoscopic biopsy revealed recurrent ulcerative colitis. During the admission, she developed a painful erythematous plaque with central healing of 3 weeks' duration on the left side of the chest. A 3-mm punch biopsy was performed from the edge of the plaque. The patient underwent subtotal colectomy and ileostomy because of failure to respond to the medical treatment. Although no change of the skin lesion was observed after the biopsy, the lesion started to become less painful and flat, followed by complete resolution several days to a week after subtotal colectomy. The skin biopsy showed a mild epidermal hyperplasia, papillary dermal edema, and a superficial and deep dermal non-necrotizing granulomatous inflammation with numerous neutrophils (Fig. 1). The granulomata were seen in perivascular and interstitial areas, with occasional foci at the dermal subcutaneous junction (Fig. 2). The granulomatous infiltrates stained positively with KP-1 (CD68), confirming the histiocytic nature of the lesion (Fig. 3). As there was a neutrophilic infiltrate associated with the granulomata, an infectious etiology was suspected; however, special stains for acid-fast bacillus, fungus or bacteria failed to reveal microorganisms. The colonic resection showed universal mucosal colonic involvement without granulomata consistent with fulminant active ulcerative colitis.