3158 Sacral Osteomyelitis Secondary to Crohn's Disease

Abstract

INTRODUCTION: Increased ostomy output and abdominal pain can be concerning symptoms for patients with underlying gastrointestinal pathology such as Inflammatory Bowel Disease (IBD). While the acute etiology is often directly related to said underlying condition, alternative causes should remain on the differential diagnosis. The following is a case of sacral osteomyelitis as a result of direct extension from the gastrointestinal tract. CASE DESCRIPTION/METHODS: A 43 year old male with Crohn's disease complicated by recurrent fistula/abscess status post multiple colectomies with ileostomy and blind colostomy presented from a rehabilitation facility due to increased non-bloody watery ileostomy output and abdominal pain. He also presented with chronic rectal ulcers that appeared stable with scant purulent drainage. Vital signs were notable for hypotension and tachycardia that responded to fluids and empiric vancomycin and imipenem. Labs were notable for significantly elevated inflammatory markers, negative stool infectious panel, negative clostridium difficile, negative lactoferrin, white blood cell count of 23.9, and negative blood/urine cultures. Ileoscopy revealed colonization of the ileum and no source of high ostomy output was identified. Ileal biopsy revealed acute Crohn's enteritis. MRI pelvis fistula protocol revealed S5 osteomyelitis which was confirmed clinically by visualization in the OR. However, bone biopsy was negative in the setting of empiric antibiotic therapy. Patient was treated with approximately six weeks of vancomycin and ceftriaxone. He then followed up with Infectious Disease and had resolution of the infection and significant improvement in rectal ulcer drainage. DISCUSSION: Determination of the source of infection in patients with IBD can be challenging due to the inflammatory nature of the disease. Patients often present with systemic symptoms and non-specific complaints that could be mistakenly attributed to the underlying chronic disease. In any patient with fistulizing Crohn's presenting with sepsis, clinicians should have a high level of suspicion for osteomyelitis, especially in chronically debilitated patients with non-healing wounds. If routine infectious evaluation is unrevealing, clinicians should consider musculoskeletal infections due to direct extension from organic intra-abdominal processes. A broad differential diagnosis should be maintained for these Crohn's patients as multiple organ systems may be affected both directly and indirectly.