A Case of Polymicrobial Septicemia Unraveling to Be Due to Colovesical Fistula

Abstract

Introduction: Fistula is a rare outcome of complicated diverticular disease (2%). We present a case of septicemia with known diverticular disease and recurrent urinary tract infections (UTIs) that turned out to be due to colovesical fistula. Case Report: A 57-year-old white male with history of liver cirrhosis, alcoholism, benign prostatic hypertrophy, and recurrent UTIs for 1 year presented with altered mental status. He denied history of pneumaturia and fecaluria. Vital signs: temperature 104° F, heart rate 118 bpm, respirations 26 breaths/min, and blood pressure 120/54 mmHg. No abdominal tenderness, mass, or ascites noted. Admission labs revealed white cell count 1.9 x 103 cm, platelets 85 x 103/μL, total bilirubin 5.2 mg/dL, INR 1.8, creatinine 1.09 mg/dL, lactate 3.4 mg/dL, and bicarbonate 16 mEq/L. Urine was cloudy and positive for blood, leukocytes, and bacteria. Vancomycin and cefepime were initiated after obtaining blood and urine cultures. Blood cultures grew pan-sensitive Escherichia coli and streptococcal infantarius, while urine culture was positive for pan-senstive Klebsiella pneumonie. After acute management of sepsis, further work-up was initiated to investigate the source of infection in light of polymicrobial septicemia in setting of recurrent UTIs. CT abdomen with PO and IV contrast showed air fluid level in the bladder that was suggestive of thickened bladder and a possible fistulous tract between sigmoid colon and bladder. Previous CT scan showed severe diverticular disease with no prior history of diverticulitis. Urology was consulted and poppy seed test was performed. He was given 1.25 ounce of poppy seeds mixed with a 6-ounce serving of yogurt orally. Poppy seeds were seen in urine in next 24 hours. This confirmed the abnormal fistulous tract between colon and bladder. No surgical intervention was done due to sepsis. The patient continued on broad spectrum antibiotics with no significant improvement. The patient later developed acute respiratory distress syndrome and opted for comfort measures. Unfortunately, other causes of colovesical fistula, such as malignancy, could not be ruled out. Discussion: Colovesical fistula is a rare complication and should be considered in differential diagnosis in patient with history of diverticular disease, recurrent UTIs, and poly-microbial sepsis. CT abdomen with contrast and poppy seed test are preferred diagnostic tools. Poppy seed test is highly sensitive and cost-effective. Early fistulectomy with open or laparoscopic approach is the treatment of choice. Early correction of fistula may improve mortality and morbidity in patients not responding to broad spectrum antibiotics.