Vulvoperineal Crohn's disease responsive to metronidazole
A 47-year-old woman presented for evaluation of multiple persistent painful\nvulvoperineal lesions that had appeared in the last 5 years. She went on several\nantibiotic courses without any improvement. She denied bowel complaints or weight loss.\nHer past medical history was only remarkable for hypertension. On physical examination,\nan exuberant inflammation of the vulva with aftoid ulcers of the labia minor and majora,\nand linear ulcerations in the inguinocrural folds were observed. A deep linear fissure\nabove the clitoris and a "knife-cut" ulcer with sharp margins on the buttocks fold were\nalso present (). A skin biopsy revealed an\nulcerated epidermis with a fistulous tract and aspects of chronic inflammation with\nlymphocytes, hystiocytes and multinucleated giant cells in a non- caseating\ngranulomatous pattern on the dermis ().\nFungal and mycobacterial elements were not detected by histology or in tissue culture.\nLaboratory investigations were normal except for C-reactive protein of 41 mg/dl (<5).\nSyphilis, HIV serologies and Mantoux test were negative. PCR testing for herpes simplex\nvirus was negative. Chest X-ray showed no abnormalities. Based on the clinical and\nhistological findings a vulvoperineal cutaneous Crohn's disease (CD) diagnosis was made.\nThe patient was referred to gastroenterology for evaluation of bowel involvement.\nEndoscopic studies of the digestive tract and biopsies from the ileum, colon and rectum\nshowed no abnormalities, so that a diagnosis of vulvoperineal cutaneous CD without\ndigestive involvement was assumed. The patient went on daily metronidazole (1000 mg) and\nciprofloxacin (1000 mg) with a striking improvement. Antibiotherapy was discontinued at\n3 months and azathioprine (50 mg daily) was introduced. However, the condition worsened\nand metronidazole (1000 mg daily) was added to azathioprine and marked improvement was\nobserved after 12 days. At 2 months of combined therapy (metronidazole 1000 mg plus\nazathioprine 150 mg daily) sustained clinical improvement was observed ().