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Background
Ulcerative colitis (UC) is characterised by recurring episodes of inflammation limited to the mucosal layer of the colon and rectum. Approximately 42% of patients with UC have extraintestinal complications, 1 the skin being one of the most frequently affected organs. The two most common skin disorders associated with UC, erythema nodosum and pyoderma gangrenosum , appear to be reactive response that are not specific to inflammatory bowel disease. 2 Although rare, urticarial vasculitis (UV) should be considered as one of the skin manifestations of UC and in some cases it actually preceded the intestinal symptoms.
Case presentation
A 75-year-old man with ulcerative colitis, on mesalazine 2400 mg daily and diet-controlled diabetes mellitus (non-insulin-dependent diabetes mellitus), presented with a 3-week history of rash ( figure 1 ) on both lower limbs associated with bilateral knee swelling. The rash started as mildly itchy, sore, raised red plaques on his lower limbs and then started to ascend gradually up his body, covering the trunk and arms.
One week after the appearance of the rash, he had a flare up of his UC with diarrhoea, more than 10 times per day, abdominal pain and rectal bleeding.
Investigations
Routine blood tests at presentation showed normal white cell count (WCC) including neutrophils, haemoglobin (Hb) 122 g/L, C reactive protein 85 mg/L, liver function test normal but with a slightly low albumin level 32 g/L (range 35-50 g/L), and normal renal function. Serology was remarkable for high antiproteinase 3 (anti-PR3 ANCA=11.3), positive antinuclear antibodies (1/320) and negative anti-double stranded DNA antibodies. Serum electrophoresis showed a faintly positive paraprotein band ([GAMMA] region). Stool culture was negative. Urine analysis showed proteinuria (urine protein 0.24 g/L).
A skin biopsy was performed demonstrating normal epidermis with a patchy inflammatory infiltrate focused on upper to mid-dermis predominately associated with vessels and also seen around the skin appendages ( figure2 A, B).
There was no evidence of dysplasia...