(P073) SWEET AND SALTY : SWEET SYNDROME AS THE INITIAL PRESENTATION OF NEWLY DIAGNOSED ULCERATIVE COLITIS

Introduction

Sweet syndrome is a rare cutaneous disorder that arises secondary to various inciting factors, including certain medications, bacterial or viral infections, autoimmune or autoinflammatory conditions, and malignancies. It is classified into three subtypes, with classical Sweet syndrome being the most common.

Case Presentation

A 60-year-old male with no significant medical history presented with multiple painful erythematous and pustular skin lesions persisting for two weeks, following a trip to Aruba. His symptoms began with a painful lesion on his posterior scapular region attributed to an insect bite. He sought local care where the lesion was drained and packed. Upon returning home, his PCP initiated fluoroquinolone therapy. Subsequently, the patient developed daily fevers, experienced a 5-pound weight loss, began passing bloody stools, complained of bilateral shoulder pain, and noticed the appearance of additional similar lesions across his torso and groin.

CT scan revealed colitis, and the patient met SIRS criteria, prompting the initiation of IV antibiotics. Initially suspected to have a MRSA-related abscess, he was maintained on vancomycin, although uncertainty remained regarding a unifying diagnosis.

Flexible sigmoidoscopy was performed, revealing severe Mayo 3 colitis and deep ulcerations in the rectum with a continuous, circumferential pattern and no sparing areas. Inflammation worsened proximally, with narrowing of the lumen observed in the upper rectum. Skin lesion biopsy revealed intraepidermal neutrophils with associated spongiosis, a dense neutrophilic infiltrate in the dermis with apoptotic debris consistent with Sweet syndrome.

Given these biopsy results, antibiotics were discontinued, and the patient was started on steroids, leading to symptom improvement. The cold forceps biopsy from the colon showed severe active proctitis with ulceration, crypt disarray, and plasmacytosis, consistent with ulcerative colitis. The patient was transitioned to oral steroids and discharged with outpatient GI follow-up for the consideration of biologic therapy.

Discussion

Current literature reports SS predominantly in middle-aged white women with colonic involvement and other EIMs, though its association with either ulcerative colitis (UC) or Crohn's disease remains uncertain. While the temporal relationship between SS and IBD activity is not well established, it is most frequently seen during active phases of IBD. This case highlights SS as the initial presentation of IBD in an older male, manifesting prior to any gastrointestinal symptoms or other EIMs. 

Conclusion

Skin lesions, though rare, can be an early sign of IBD, making prompt recognition vital for proper treatment. A biopsy is the diagnostic gold standard and should be done immediately. Heightened clinical awareness is key, as SS may appear before any GI symptoms in IBD cases.