Unilateral, non-tender, vulvar swelling as the presenting sign of Crohn's disease: a case report and our suggestion for early diagnosis.

Dear Editor, We report a patient with metastatic Crohn’s disease (MCD) who presented with vulvar swelling preceding the diagnosis of gastrointestinal disease. Vulvar involvement of Crohn’s disease (CD) is rare and difficult to diagnose, especially when it precedes the onset of overt gastrointestinal symptoms. In our case, the diagnosis was enigmatic because no radiological and laboratory examinations gave a clue for diagnosis. Here, we suggest two diagnostic clues which may help early diagnosis of vulvar MCD after reviewing reported cases of MCD in children whose vulvar swelling or edema preceded gastrointestinal symptoms in the English-language published work. A 10-year-old girl presented to our dermatological clinic with a 1-month history of unilateral, non-tender, vulvar swelling. Before visiting our clinic, she had been treated with empirical antibiotics for 2 weeks at local pediatric and gynecological clinics under the impression of infectious disease but her vulvar swelling had not improved. She and her parent denied any trauma, sexual abuse or a history of infectious disease. She had no notable medical history and did not have any systemic symptom. Physical examination revealed non-tender, erythematous swelling on the left vulva (Fig. 1a,b) and small skin tags on the anal orifice (Fig. 1c). Height and weight percentiles were normal for her age. Laboratory test results were within normal range except for a slightly increased erythrocyte sedimentation rate of 18 mm ⁄h (reference range 0–15 mm ⁄h). Magnetic resonance imaging of the pelvis showed focally enhancing subcutaneous tissue on the anterior portion of the left labia majora which primarily suggested focal cellulitis (Fig. 1d). We prescribed cefprozil 250 mg ⁄day for 10 days under the impression of infection of the vulva.