LAUSR

A 22-year-old Afghani migrant presented to his general practitioner with a 2-month history of oral ulcers and loose stools. He had no past medical history and took no regular medications. Aphthous ulcers affected the lips and buccal surfaces, with no ulceration elsewhere in the body (Fig. 1). The patient reported loose stools, 2–3 times per day, with intermittent per rectal bleeding but no mucus. He had no abdominal pain, arthralgia or ocular symptoms. His initial investigations demonstrated normal inflammatory markers. His faecal calprotectin measured 2290 mg/kg (normal <50 mg/kg). An oral swab returned a negative result for viral or bacterial pathogens. A course of oral antibiotics and anti-fungal therapy failed to improve his oral ulcers. The patient was subsequently referred for further investigation. A mouth ulcer biopsy and autoimmune screen were arranged. His serological autoantibody screen demonstrated a weakly positive desmoglein 3. Histopathology from the mouth ulcer biopsy demonstrated suprabasilar acantholysis with ‘tomb stoning’ (Fig. 1) and immunofluorescence demonstrated intercellular ‘fishnet’ staining with IgG and C3. The features were consistent with pemphigus vulgaris (PV), and the patient was commenced on prednisolone 50 mg. Gastroscopy was normal. Colonoscopy demonstrated continuous inflammationwithmucosal ulceration at 30–65 cm. Mucosal granularity and cobblestone appearance with scattered pseudo-polyps were noted with no strictures present. Histopathology demonstrated moderately severe actively inflamed colonic mucosa with marked crypt architectural distortion and moderate cryptitis. One early crypt abscess was noted. No fissuring ulceration, granulomatous change, necrosis or viral inclusions were present. The features were consistent with Crohn disease (CD). The patient failed to attend follow up outpatient appointments and then re-presented to the emergency department with refractory mouth ulcers and abdominal pain. On examination, he was febrile. His other vital signs were normal. Oral ulceration affected the lips and gingivobuccal sulcus. The abdominal and per-rectal exams were normal. General physical examination was unremarkable. Investigations demonstrated white blood cell count 15.9, C-reactive protein 186 and faecal calprotectin 1900 mg/kg. Stool cultures were negative. An oral swab returned a positive result for herpes simplex virus-1 and Candida. The patientwas treatedwith intravenous hydrocortisone, oral valacyclovir and nystatin, and topical oral therapy with lignocaine gel, dexamethasone mouthwash, betamethasone dipropionate and miconazole nitrate oral gel twice daily. After 5 days, the patient’s bowel symptoms