Dr. Akshay Kishore , Dr.C.Jayakumar , Dr.Praveena Bhaskaran , Dr Bhanu Vikraman Pillai. (PaedGastro)
Eleven year old female child presented with vulval discharge for the last 3 months. This was associated with on and off fever and of weight loss of3kg over the last 3 months. Pus culture from outside hospital grew ECOLI and was on treatment for that. As symptoms persisted Child was referred
History is negative for Kochs or immunodeficiency
History of recurrent oral ulcers was present.
Birth history with normal development.
Child was pale but with no lymphadenopathy /oral ulcers.
Right vulval swelling and erythema was present.
Differential diagnosis considered at this point were
1. Persistent abscess due to primary immunodeficiency
2. HIV
3. Tuberculosis
4. Inflammatory bowel disease
Labs HB- 10.8 , TC – 13.37 , N-67% , L-18% , PLT – 550000 , CRP – 35.16 , ESR-89mm/hour ,
RFT /LFT- normal
URE – 15-20 pus cells with leukocytes 2 +.
Immunoglobulin levels normal for age.
Peripheral smear showed microcytic hypochromic anemia with neutrophilic leukocytosis and thrombocytosis.
Pre op serology was negative.
She was admitted and started on cefepime and metrogyl.
USG abdomen showed – small labial collection with deeper extension to subcutaneous plane of right labial fold.
MRI pelvis- linear tract on the left perineum with external opening at the left labia. Linear tract on the right perineum with external opening at the right labia tracking posteriorly with a branch crossing in midline to the contra lateral side.
MR enterography showed multiple short segments of active small bowel inflammation noted in mid ileal loops.
Fecal calprotectin was elevated (800mcg/gm).
OGDscopy was normal.
Colonoscopy was done which was grossly normal except for the opening of fistula is tract with purulent discharge seen near the anal verge.
Diagnosis of crohns disease was made. Child was started on azathioprine and is under follow up.
Discussion : Crohns disease is associated with extraintestinal manifestation such as arthritis , erythema nodosum and uveitis. But vulval abscess is a rare finding of crohns disease. Fewer than 200 cases of vulvar crohns have been reported and may occur due to contiguous spread of Crohn’s disease. Other differential diagnosis such as infected bartholin abscess, necrotising fasciitis and STD has to be considered. Majority of patients are treated with metronidazole and combination of mesalamine or topical steroids or monoclonal antibody therapy.
Take home message : a patient presenting with vulval abscess , IBD should be ruled out.