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Peristomal Lesions in Crohn's Disease: Are They Always Fistulae?

A 34-year-old woman with ileocolonic and perianal Crohn’s disease received a loop ileostomy because of a supralevator abscess and multiple perianal fistulae. She was treated thereafter with dual immunosuppression by means of a TNF-α inhibitor (adalimumab) combined with azathioprine. About eight weeks after surgery, the patient developed peristomal inflammation with small oozing lesions. Peristomal fistula formation was suspected, and treatment was begun with ciprofloxacin and metronidazole, but there was no improvement. Her leukocyte count and CRP values were only mildly elevated. Ileocoloscopy revealed no more than a mild mucosal erythema without aphthous or ulcerative changes; there was no evident fistular opening. Ultrasonography and MR enterography did not reveal any fistula passageways either. Peristomal pyoderma gangrenosum was ruled out by skin biopsy. Swabs taken for microbiological diagnosis were positive for methicillin-resistant Staphylococcus aureus (MRSA). The lesions healed within two weeks after local antiseptic measures with octenidine and povidone-iodine.