Progressive Evolution of Ulcerative Colitis Toward Axial Spondyloarthritis and Pyoderma Gangrenosum: Case Report and Critical Literature Review

Abstract

Inflammatory bowel disease (IBD) is a chronic inflammatory condition of multifactorial etiology that primarily includes ulcerative colitis (UC) and Crohn’s disease (CD). ¹ UC affects the colonic mucosa in a continuous pattern, whereas CD is characterized by a patchy, transmural involvement that can affect any segment of the gastrointestinal tract. ¹ Both entities typically follow a relapsing–remitting course and are associated with extraintestinal manifestations in up to 36% of cases, musculoskeletal involvement being the most frequent. ^2,3

The association between IBD and arthropathies has been recognized since the late 19th century. It is now understood that peripheral arthritis and IBD-related spondyloarthritis are part of the spectrum of seronegative spondyloarthritides, although HLA-positive variants have also been described. ^4,5 Peripheral arthritis is usually oligoarticular, asymmetric, and predominantly affects the lower limbs, while ankylosing spondylitis and sacroiliitis associated with IBD may progress independently of intestinal activity. ^6,7 Genetic factors such as
HLA-B27 and CARD15 polymorphisms, as well as mucosal immune mechanisms, have been implicated in the shared pathophysiology. ^8,9

In parallel, IBD is associated with several dermatological manifestations. Among these, pyoderma gangrenosum (PG) is an ulcerative neutrophilic dermatosis—rare but clinically significant—reported in up to 12% of IBD patients, most commonly in those with UC. ^10,11 PG presents as painful ulcers with violaceous borders and a chronic, relapsing course, whose pathogenesis involves innate immune dysfunction, abnormal neutrophilic recruitment, and overexpression of proinflammatory cytokines.^12,13

The management of extraintestinal manifestations in IBD remains a clinical challenge. Corticosteroids and immunomodulators are first-line therapies; however, anti-TNF biologics such as infliximab have demonstrated efficacy in simultaneously controlling intestinal inflammation, associated arthritis, and PG. ^14–17 Clinical  reports have even documented complete remission of refractory cutaneous lesions and significant improvement in IBD-associated spondyloarthritis following infliximab initiation.^18,19 Given the complexity of these patients, a multidisciplinary approach involving gastroenterology, rheumatology, and dermatology—with close monitoring of both intestinal and extraintestinal disease activity—is strongly recommended.^20,21

In this context, we present the case of a patient with ulcerative colitis, axial and peripheral spondyloarthritis, and pyoderma gangrenosum treated with infliximab, illustrating the clinicopathogenic interaction between IBD and its extraintestinal manifestations, as well as the importance of biologic therapy in comprehensive management.