An 84-year-old-woman who was hospitalized in the dermatology clinic because of a painful, itchy, deep, pustule ulcer on the right leg consulted with us to investigate the etiology of iron deficiency anemia. According to the information we received from the patient, 1 month before admission there was mild erythema with a small area of erosion on the leg. It was diagnosed as cellulitis, and oral antibiotic therapy was started by the family practitioner. Even so, the lesion became larger, more pustule, and more painful (Figure 1). She was admitted to the hospital for further evaluation and treatment. Punch biopsy of the skin lesion showed diffuse neutrophilic infiltration. Cultures of the lesion were negative for infection. Pyoderma gangrenosum was diagnosed. Her medical history was unremarkable. Physical examination was normal except for the lesion. Laboratory findings showed normal biochemical tests and hemoglobin 9.1 g/dl, white blood cell count 15,000/mm³, platelet count 540,000/mm³, sedimentation rate 42 mm/hour, and C-reactive protein 7.8 mg/dl (normal <0.6 mg/dl). Serum iron and ferritin levels were low (21 [mu]g/dl and 7 [mu]g/L, respectively). Colonoscopy showed diffuse superficial ulceration, friability, and erythema of the mucosa throughout the entire colon, compatible with ulcerative colitis (Figure 2). Biopsy of the mucosa revealed active chronic ulcerative colitis.

FIGURE 1. A deep purulent ulceration with well-defined border on the right leg of the patient.

FIGURE 2. Severe colitis noted during colonoscopy. Colono scopic image of ulceration and inflammation of the colon.

Inflammatory bowel disease (IBD) is a clinically variable disorder with systemic effects. The usual bimodal age distribution of IBD is between 20-30 years and 50-80 years. Up to now, epidemiological data suggest that 10%-15% of IBD patients are older than 60 years at the time of diagnosis (Ananthakrishnan, McGinley, & Binion, 2009; Mir-Madjlessi, Taylor, & Farmer, 1985). A number of cutaneous changes are known to occur in the course of IBD, including erythema nodosum, perianal disease, erythematous eruptions, urticaria, and purpura (Binus, Qureshi, Li, & Winterfield, 2011). However, pyoderma gangrenosum is one of the more unusual extra-intestinal manifestations of IBD (Cullen, 1998).

In conclusion, IBD is associated with skin manifestation. Ulcerative colitis in the elderly may have an atypical presentation. In patients with pyoderma gangrenosum, the relationship to clinically silent ulcerative colitis should be kept in mind. Pyoderma may be the initial symptom and is caused by ulcerative colitis.

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