Bowel Associated Dermatosis Arthritis Syndrome

Background: Bariatric surgery is the most effective weight loss therapy available for patients with morbid obesity and can be considered when non-operative means such as diet and exercise, nutritional counseling, and weight loss programs have failed. Gastric bypass surgery may produce malabsorptive or surgical complications, which can result in nutritional deficiencies as well as syndromes related to bacterial overgrowth in the blind loops of bowel created, known as Bowel Associated Dermatosis Arthritis. Case Presentation: A 37-year-old female presented with a pruritic rash for 3 months. It was initially located on her inner thighs and spread to involve her feet, groin, abdomen, arms, and hands. She complained of intense vaginal itching as well. She had been treated unsuccessfully with multiple agents that included oral and topical antifungals, permethrin 5% cream, triamcinolone cream, and cetirizine without improvement in her itching. She had a history of gastric bypass surgery for obesity 6 months prior to onset of the symptoms. Her past medical history was significant for type 1 diabetes mellitus, diabetic neuropathy, hypertension, hyperlipidemia, rheumatoid arthritis, depression, and hypothyroidism secondary to I131 ablation for Graves disease. Examination revealed eczematous plaques on her hands, feet, and ankles with confluent erythema on the lower legs that partially blanched. Erythema and edema of the tongue, and fissures of the oral commissure with erythema were noted as well. The findings were consistent with a nutritional deficiency. She was started on crushed B vitamins, Zinc, and Vitamin C. Improvement of the glossitis, angular cheilitis, and rashes were noted with no new petechiae seen at one-week follow-up. Nine months later, we were again consulted on this patient for a recent onset of painful skin abscesses that were being treated with incision and drainage, intravenous vancomycin, and topical mupirocin. After incision and drainage, the lesions were noted to be healing poorly and were more painful. Examination revealed eczematous plaques with sharply defined borders on the upper and lower extremities, including the palms and soles, and trunk. An exquisitely tender erythematous nodule with central pustule and crust was seen on the left occipital scalp. Histopathologic examination of the scalp nodule showed psoriasiform hyperplasia with a focal area of ulceration along with a diffuse infiltrate of neutrophils throughout the dermis. PAS, Fite, and Brown-Brenn stains were negative. The histopathology was consistent with bowel-associated dermatosis-arthritis syndrome. She was treated with broad-spectrum antibiotics and colchicine. Following successful treatment of this patient's skin manifestations caused by complications secondary to her bariatric surgical procedure, the patient continued to lose weight despite adequate dietary caloric and protein intake. Her bypass procedure was reversed, and the patient's skin eruptions completely resolved. Conclusion: This case demonstrates the complications that can arise because of alterations made in the gastrointestinal anatomy. With a limited number of cases, bowel-associated dermatosis-arthritis is a clinically important syndrome to recognize because these patients, as was our patient, can be subjected to non-therapeutic repeated incision and drainage procedures.