Recalcitrant plantar warts during azathioprine therapy for Crohn’s disease
We present a case of a 29-year-old man with ileo-cecal Crohn’s disease (CD), diagnosed 15 years ago. Initially, the patient received prednisone for induction therapy and was maintained on clinical remission with azathioprine 200 mg and budesonide 9 mg q.d. for the last 8 years. At the time of the patient’s first visit to our department he presented with persistent abdominal pain with alternating loose, non-bloody stools and constipation. Physical examination revealed mild left lower abdominal pain. Laboratory investigation showed no signs of inflammation. Imaging with magnetic resonance enteroclysis did not reveal any abnormalities. An ileocolonoscopy with biopsies did not show any active signs of CD activity. He was discharged on osmotic laxatives resulting in relief of his abdominal complaints.\nDuring our evaluation, the patient also reported severe warts at the soles of his feet. A few small warts were already present at the time of diagnosis of his CD, but they progressed after introduction of azathioprine. Physical examination showed hyperkeratotic plaques of coalescing warts, covering major parts of the weight-baring areas of his feet (). In addition to their unsightly cosmetic effect, the warts have started to impede his walking. He had been thoroughly evaluated by dermatology for alternative causes of plantar lesions. His warts had failed to respond to conventional therapies including liquid nitrogen (20-25 times), salicylic acid, and coagulation therapy. Eventually, azathioprine therapy was withdrawn, after considering the risks of reactivating his quiescent CD. However, withdrawal of azathioprine did not result in resolution of his warts. Currently, the patient is scheduled for laser surgery of his recalcitrant plantar warts.