2088 A Rare Case of Postoperative Recurrence of Crohn’s Disease Associated With Abdominal Actinomyces and Bacteremia

Abstract

INTRODUCTION: We present a rare case of actinomyces bacteremia in a 27-year-old woman with fistulizing Crohn's ileocolitis who presented with acute abdominal pain in the setting of sepsis & microperforations 6 weeks after extensive bowel surgery. CASE DESCRIPTION/METHODS: The patient's Crohn's disease was diagnosed 10 years ago, treated initially with 6-MP, azathioprine, 5-ASA & later with biologics & steroids all of which provided minimal relief. Prior to undergoing surgery, she had daily complaints of RLQ abdominal pain with MRI suggestive of significant ileocolitis with fistulae. She underwent successful ileocolectomy & fistula stricturoplasties with remarkable improvement in symptoms in the 3 weeks post-op. However, 6 weeks post-op her condition worsened again with new onset of pain, fever, tachycardia, hypotension and imaging concerning for perforated bowel. She was thus readmitted with admission blood cultures revealing Actinomyces odontolyticus bacteremia. Abdominal CT showed possible small perivesicular fluid collection. Repeat blood cultures on antibiotics remained sterile & the patient was discharged on antibiotics. Local anaerobic cultures from the neo-terminal ileum on repeat colonoscopy with biopsy 6 weeks post-op were also found to be sterile, with no evidence of actinomyces on pathology indicating possible clearance of local infection on antibiotics. DISCUSSION: We describe an unusual complication of Crohn’s disease: abdominal Actinomyces infection presenting with bacteremia. Actinomyces spp. are anaerobic gram-positive bacilli, most commonly found as part of normal flora of the oral cavity; it can also colonize the pharynx, other parts of the GI tract, GU system and the skin. It becomes virulent if introduced into deeper tissues through disruption of mucosal surfaces. Actinomyces often mimics other intra-abdominal conditions such as Crohn’s through the formation of fistulas & sinus tracts. The patient’s postoperative Crohn’s recurrence at the neo-terminal ileum confirmed on imaging paired with positive blood cultures in the setting of sepsis, raises a strong suspicion of infection due to Actinomyces spp. as the cause for worsening Crohn’s disease. This case suggests that abdominal actinomyces infection can be an unusual complication of Crohn’s disease and presents a diagnostic dilemma for clinicians given overlapping clinical & imaging findings. Gram stain and anaerobic culture remain the gold standard for the diagnosis of actinomyces & penicillin is usually the treatment of choice.