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The sites of extragastrointestinal granuloma formation in Crohn’s disease are numerous.1 As the association of the spleen has been recorded on only one previous occasion,2 I wish to highlight this occurrence and to draw attention to a possible association with aseptic abscess formation.
A 34-year-old man, with a history of rectal bleeding, abdominal pain and weight loss, on undergoing sigmoidscopy, was found to have mucosal congestion, extensive erythema with granularity, patchy mucopurulent exudates, multiple small ulcers and a patchy cobblestone mucosa affecting the sigmoid colon, but with rectal sparing. Microscopic examination showed mixed acute and chronic inflammation with ulceration and crypt abscess formation, but no evidence of granuloma formation, dysplasia or malignancy. The appearances were consistent with inflammatory bowel disease, but not diagnostic for either Crohn’s disease or ulcerative colitis. A year later, the patient was readmitted with severe left upper quadrant pain, and on laparotomy was found to have an enlarged spleen with a small amount of free blood in the peritoneal cavity lateral to the spleen. A splenectomy was performed and microscopic examination showed marked sinusoidal congestion and a single granuloma containing small numbers of neutrophils centrally, but without necrosis (fig 1).
Crohn’s disease is a chronic, relapsing disease primarily affecting the gastrointestinal tract.1 Extraintestinal manifestations include cutaneous (metastatic) lesions, pulmonary, gallbladder, liver, skeletal muscle, breast, bone, joint and skeletal muscle involvement.1,3–7 Such manifestations can be concurrent with, precede or follow episodes of Crohn’s disease. Association of the spleen in Crohn’s disease is rare, however, and only one previous case has been reported.2 The patient was a 42-year-old man, with a 10-year history of Crohn’s disease, who presented with hepatosplenomegaly, fever and left upper quadrant pain. Non-caseating granulomas were present in the liver and bone marrow biopsy and the colonic biopsy specimen showed mild Crohn’s colitis. Association of the spleen was indicated by splenomegaly, which resolved after treatment with high-dose prednisolone. This case, therefore, seems to be the first one to histologically prove an association of the spleen by granuloma formation in Crohn’s disease, although the splenomegaly in this patient was more probably caused by sinusoidal expansion. Aseptic abscesses occurring in the spleen and other organs were documented in six patients with Crohn’s disease by Macaya et al.7 These aseptic abscesses had a granulomatous pattern and consisted of central suppuration surrounded by a histiocytic and giant-cell reaction, usually in palisaded order. These authors suggest that the condition may be related to neutrophilic dermatosis (Sweet’s disease), a cutaneous neutrophilic disease that sometimes complicates Crohn’s disease. This case with a non-caseating epithelioid granuloma containing only a small number of neutrophils confirms the association of the spleen in Crohn’s disease. The additional presence of a neutrophilic component raises the possibility of a relationship with aseptic abscesses and altered local cytokine production in the pathogenesis of splenic granulomas in Crohn’s disease.
Competing interests: None declared.
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