Association Between Perianal Crohn`s Disease and Suppurative Hydradenitis, Diagnostic Challenge: Case Report

INTRODUCTION: Crohn's disease (CD) is an Inflammatory Bowel Disease (IBD) may present systemic manifestations in up to 50% of patients, such manifestations are called Extraintestinal Manifestations (EIM). Suppurative Hydradenitis (SH) is a chronic, recurrent and debilitating dermatological disease that causes inflammatory process of the follicular epithelium, which becomes susceptible to secondary bacterial infections. The association of CD and SH is known, but the isolated manifestation of CD in the perianal region associated with manifestation of SH is rare and makes diagnosis and therapy challenging. METHODS: To describe the clinical case of adolescent with SH and perianal CD by reviewing medical records. CLINICAL REPORT: AFSJ, 15 years old, male, obese, admitted to the Pediatric ward due to suppurative and painful buttock injuries, started two years ago, coinciding with the onset of puberty, with periods of improvement and worsening. Patient reported occasional diarrhea with 4 bowel movements a day, without mentioning blood or mucus. There was no growth of germs in the cultures performed and the antibiotic therapy employed did not improve the condition. The patient underwent biopsy of the lesions, which showed granuloma sketches (no necrosis, no foreign body granuloma characteristics), suggesting a cutaneous manifestation of Crohn's disease. Computed tomography (CT) with enterotomography visualization pattern without evidence of lesions. Colonoscopy showed no alterations and serial biopsies did not indicate acute inflammatory symptoms. Anorectal ultrasonography showed complex fistulas in the upper, middle and lower anal canal, suggesting perineal aggression secondary to CD. In a joint decision between gastroenterologists, pediatricians, dermatologists and coloproctologists, it was decided to introduce Adalimumab, but with slight improvement. Symptoms became more exuberant after two months, with extensive involvement of the perineum and buttocks, with apparent secondary bacterial infection. Proceeding with new hospitalization, antibiotic therapy (ciprofloxacin and clindamycin) and new biopsies, which this time also showed foreign body granulomas, suggestive of SH. Patient had significant improvement of symptoms with antibiotic therapy for 3 months, associated with corticotherapy. Adalimumab was prescribed after antimicrobial therapy to reduce infectious risk. DISCUSSION: The differential diagnosis between perianal CD and SH is a challenge, often delaying treatment. Although SH is admittedly an EIM of CD, association in this disease phenotype is rare, as demonstrated by the study by Kamal N. (2016), where the association of CD and SH was investigated over a 10-year period, and only found 15 patients where 73% had perianal CD. Biological anti-TNF therapy may be effective, although many cases still require surgical intervention. In the case of undiagnosed SH, immunosuppressive therapies may aggravate a subclinical infectious process exposing the patient to a poor clinical outcome, as in the case presented. Multidisciplinary assessment is critical and patient reevaluations should be early, especially in pediatric patients where the disease may cause functional and psychological impairment.