Here's my view from home in Vermont. We still have snow here!

…. to all the new members of ihaveCrohn’s…Adam and I were talking on the phone today about our goals for this site, and I went on and found 12 members! Wow. We are happy you found us, and hope you can use the site for an extra community for those of you have have Crohn’s or other IBDs, like UC or celiac disease….. and/or if you are a caregiver.¬† It is great to have Adam’s support for this new site–he is also the founder of ihaveuc.com. So, please post and tell us your stories…. and if you have suggestions, we are all for it.

Glad we have actual members! This site is private and only¬† open to registered members, as it is important to feel comfortable, esp when talking about IBD…

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Metastatic Crohn Disease: Clearance with Metronidazole

A 59-year-old white man presented with a 1-month history of a mildly itchy rash on his arms, upper thighs, and back that began shortly after clearing brush around the exterior of his house. A physical examination revealed erythematous papules and plaques on his arms with scattered papules on his trunk and upper legs (Fig 1). Some of the plaques on his arms had an annular configuration, with scattered thin crusts. A medical history revealed that he was currently being treated for Crohn disease of his terminal ileum and colon with 6-mercaptopurine (100 mg daily); he had also completed a course of prednisone and metronidazole 3 months before onset of the rash. He had no history of previous cutaneous lesions. The initial clinical diagnosis was contact rhus dermatitis, and a skin biopsy specimen was taken from a plaque of his left forearm before treatment. The patient was initially treated with topical steroids, including fluocinonide and clobetasol creams. The skin biopsy revealed noncaseatng granulomas with perivascular, interstitial, and periadnexal lymphocytic inflammation. Special stains were negative for fungi, acid-fast bacilli, and bacteria. Polarizing microscopy did not reveal foreign bodies. A chest radiograph was normal, and a tuberculosis skin test was nonreactive. Pathologic review by the Armed Forces Institute of Pathology supported a diagnosis of MCD.2 Because there was no improvement with topical steroids, the patient was placed on a tapered course of prednisone for 2 weeks. He partially responded to this therapy, but relapsed soon after completion. Treatment was changed to metronidazole 500 mg three times daily for 2 weeks, then twice daily for 6 weeks. He noticed improvement within 2 weeks, and at 6 weeks was completely clear of lesions (Fig 2). No side effects, including paresthesias, were reported. Metronidazole was discontinued, and he remained clear of rash for 3 months. He then developed ten 4-mm, scaly, mildly itchy papules on the dorsal surfaces of his forearms, and metronidazole 500 mg twice daily was restarted. He was completely clear of lesions in 10 days, at which time he discontinued treatment on his own because of an upset stomach. He remained clear of rash at follow-up 2 months later.

Numerous therapies for MCD have been used, including surgical excision, topical steroids, oral prednisone, azathioprine, cyclosporine, sulfasalazine, tetracyclines, oral tacrolimus, infliximab, mesalamine, and oral metronidazole.1, 3, 4 In a study of 26 patients with perineal Crohn disease, all patients cleared with oral metronidazole 20 mg/kg/day. Tapering of this dose often led to recurrences that responded to retreatment with metronidazole. The main side effect was paresthesia.5

The cause of MCD remains unknown, but may involve antibody cross reactions between skin and gut antigens with deposition of immune complexes in the skin.1, 2 The antibiotic effect of metronidazole against anaerobic bacteria in the intestinal tract may also improve MCD by reducing bacterial antigens that might cross react with skin antigens.6

Oral metronidazole was an effective treatment for MCD in this patient without significant side effects, and a minor flare responded rapidly to retreatment.

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National Cooperative Crohn’s Disease Study: Results of Drug Treatment

Summers RW, Switz DM, Sessions JT Jr, Becktel JM, Best WR, Kern F Jr, Singleton

The response of active and quiescent Crohn’s disease to prednisone,
sulfasalazine, or azathioprine has been studied in 569 patients in a
placebo-controlled, randomized, multicenter cooperative trial. The response of
active symptomatic disease to prednisone or sulfasalazine was significantly
better than to placebo. Response to azathioprine was better than to placebo, but
the difference did not reach conventional levels of statistical significance.
Patients with colonic involvement were especially responsive to sulfasalazine,
and those with small bowel involvement were especially responsive to prednisone.
Patients’ drug therapy immediately before entry to the study significantly
affected subsequent response. For patients with quiescent disease, none of the
drugs was superior to placebo in prophylaxis against flare-up or recurrence.
There is less than a 5% risk that a clinically significant prophylactic effect of
any of the drug regimens was missed.

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