A Case of Salmonella Enterocolitis Unmasking Crohnʼs Disease

Abstract

Introduction: Inflammatory bowel disease (IBD) and salmonella enterocolitis can initially be difficult to differentiate given overlap of clinical manifestations. We present a middle-aged female with cultureproven salmonella enterocolitis and bacteremia that did not improve with antibiotics and was found to have Crohn's disease (CD) on endoscopy. Case:A 44 year-old female with history of allergic rhinitis presented to an outside hospital for one week of abdominal pain, vomiting, and watery diarrhea. She purchased piglets around the same time and her husband and daughter had a similar diarrheal illness but recovered. She was found to be in septic shock and transferred to our hospital for a higher level of care. She was admitted to the ICU and treated with meropenem and ciprofloxacin for multi-drug resistant salmonella enterocolitis and bacteremia. As she began to improve, she was transferred to the floor but began having melena/hematochezia. EGD showed many superficial non-bleeding esophageal ulcers and colonoscopy revealed ulcerations from the distal ileum to the transverse colon. Rectal bleeding continued and required repeat colonoscopy with placement of two hemoclips to a bleeding vessel at hepatic flexure where severely friable and nodular mucosa of the right colon was found. Esophageal biopsies revealed HSV esophagitis and colon biopsies showed crypt architectural distortion and crypt abscesses suggestive of IBD. Given no improvement on antibiotics, she was started on prednisone for a presumed IBD flare with resolution of rectal bleeding. Discussion: IBD and infectious gastroenteritis, especially in the acute setting, may have similar presentations both clinically and endoscopically, making it difficult to distinguish the two entities. When present concomitantly, recognition is further complicated. Salmonella infections are usually self-limited with a short duration of symptoms. Although endoscopy is usually unnecessary for diagnosis, it should be performed if symptoms persist to pursue other etiologies, including IBD. Clinicians should have a high suspicion for concomitant disease, in the setting of an extended salmonella disease course unresponsive to antibiotics, as unidentified IBD patients are at increased risk for illness progression.