Crohns without the Colon: A Multidisciplinary Approach to a Rare Presentation

Summary: A 39-year-old male with a 20 year history of Crohn’s Disease (CD) was referred to dermatology for 2-year history of significant lip swelling. The patient’s CD was initially managed with infliximab until 9 years prior, when he reached clinical remission and discontinued all therapy. Follow-up colonoscopy demonstrated continued lack of colonic involvement. However, right lower lip swelling and diminished sensation for 2 years progressed to left lower lip and gum involvement, inhibiting articulation of speech. Examination revealed lower lip vermilion swelling, doughy in consistency, and gingival hyperplasia of the anterior mandibular dentition most pronounced over the right mandibular incisors causing significant calculus buildup. Intralesional Kenalog provided temporary, minimal improvement. Oral and maxillofacial surgery (OMFS) biopsied the lower lip which demonstrated squamous epithelium with chronic inflammation and non-caseating granulomas, confirming oral CD. Therapeutic intervention with biologic therapy is being considered given biopsy-proven cutaneous involvement. CD is a chronic granulomatous disease of the gastrointestinal tract that has extraintestinal manifestations, including oral ulcers, gingivitis, periodontitis and vegetative pyostomatitis [1,2]. Isolated oral CD without GI involvement is rare. While oral manifestations may be the first presenting symptoms of CD in 5-10% of patients, oral symptoms in otherwise clinical remission have rarely been reported [3].