Clinical Report: Palmoplantar Skin Lesions and Chest Pain in Crohn’s Disease

Overview

A 28-year-old man with Crohn’s disease in clinical remission developed palmoplantar pustular lesions, acneiform eruptions and acute anterior chest pain during infliximab–azathioprine therapy. Axial osteitis on MRI, together with the skin findings and exclusion of infection, supported anti-TNF-induced SAPHO syndrome over paradoxical psoriasis alone. Multidisciplinary treatment with NSAIDs, methotrexate and topical corticosteroids resolved chest pain and partially improved the skin lesions.

Background

Patients with inflammatory bowel disease can develop dermatologic manifestations that are related to the disease or to its treatment. TNF antagonists are associated with treatment-related skin lesions, including paradoxical psoriasis, which may present as palmoplantar pustulosis. SAPHO syndrome combines osteoarticular and cutaneous manifestations; in this case, chest MRI demonstrated manubriosternal bone marrow oedema. Distinguishing a skin-limited reaction from a syndrome involving osteitis was important to interpreting the patient’s presentation.

Data Highlights

Key Findings

• The patient developed intensely pruritic erythematous papules and pustules on the palms and soles with desquamation, followed by acneiform lesions on the back, face, scalp and postauricular regions.
• Acute chest pain was predominantly localised to the sternoclavicular and sternocostal joints, with pronounced costochondral tenderness.
• Cardiac investigations were unremarkable, while MRI showed manubriosternal bone marrow oedema and mild adjacent soft-tissue inflammation.
• Clinical and radiological findings, including axial osteitis, preceding palmoplantar pustulosis and subsequent acneiform eruptions, supported SAPHO syndrome; infectious causes were excluded by appropriate investigations and medical history.
• Topical corticosteroids improved the palmar and plantar lesions, supporting paradoxical psoriasis as a possible component, but that diagnosis alone did not account for the osteoarticular findings.
• After multidisciplinary assessment, NSAIDs, methotrexate and topical corticosteroids resolved chest pain and partially improved skin lesions. Infliximab was continued; intermittent topical corticosteroids were used, and chest pain did not recur.

Conclusion

In this patient, the combination of palmoplantar pustulosis, acneiform eruptions and MRI-confirmed axial osteitis supported anti-TNF-induced SAPHO syndrome. Chest pain resolved with medical treatment while infliximab was continued, with no reported recurrence of chest pain.

Related Resources & Content

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