Dear Editor,
Herein, we present a male patient with hidradenitis suppurativa (HS) who has amyloidosis and osteomyelitis, two rare complications of HS.
A 54-year-old male patient with HS was evaluated in our clinic due to an increase in the severity of his symptoms. In the anamnesis taken from the patient, it was learned that his complaints included recurrent painful discharge and swelling in intertriginous areas for 20 years. During this time, the patient received systemic antibiotics, isotretinoin, and underwent surgery on his lesions. The patient, who was followed up for Hurley stage III HS, had a history of previously diagnosed gastrointestinal (four years) and renal amyloidosis and was receiving hemodialysis (five years). The patient was started on adalimumab three years ago due to its effectiveness in the treatment of HS and amyloidosis.
In the dermatologic examination of the patient, draining tunnels were observed in the inguinal area and gluteal region (Figure 1). The patient’s laboratory tests revealed elevated acute-phase reactants (C-reactive protein: 103 mg/L, erythrocyte sedimentation rate: 110 mm/hr). Upon the patient’s description of severe pain and difficulty in movement in the lumbosacral region, a lumbosacral magnetic resonance imaging (MRI) was performed. When osteomyelitis and abscess structures were detected on MRI (Figure 2), adalimumab was discontinued, and ertapenem antibiotherapy (6 weeks) was prescribed. The patient’s adalimumab treatment was restarted after a regression was detected in his clinical complaints, laboratory tests, and MRI, and he continues this treatment.
Secondary systemic amyloidosis is caused by deposition of a distinctive non-immunoglobulin protein called amyloid A (AA), as a systemic complication of severe chronic inflammatory diseases, such as HS. Various pro-inflammatory cytokines, such as interleukin (IL)-1 and IL-6, have been reported to play a common role in the pathogenesis of HS and amyloidosis. Prolonged and severe HS can elevate serum AA levels, which may lead to amyloidosis. In cases of proteinuria and persistent diarrhea in HS patients, it is crucial to screen for amyloidosis. TNF-α inhibitors stand out as the preferred agents in the treatment of HS patients who have amyloidosis.1-3 HS cases with renal and gastrointestinal amyloidosis involvement have been reported in the literature.2, 3 Our case had both renal and gastrointestinal amyloidosis, and adalimumab was used in the treatment.
Osteomyelitis, one of the rare complications of HS, can develop because of trauma, hematogenous spread, or contiguous spread. MRI is an important imaging method in the evaluation of gluteal and inguinal HS lesions and in the detection of complications. Although osteomyelitis is known as one of the complications of HS, it has been rarely reported in the literature. Similar to our case, Mathew et al.4 detected osteomyelitis in two patients with Hurley stage III. Additionally, Blaizot et al.5 reported three HS patients with bacterial osteomyelitis of the sacrum and coccyx. HS patients who have significant acute-phase reactants elevation and severe pain should be monitored for osteomyelitis.
This case highlights the possibility of coexisting amyloidosis and osteomyelitis, rare complications of HS, and emphasizes the importance of recognizing these complications.
