S4910 Anticipating the Unseen: Foreign Body Ingestion Complicating Penetrating Crohn's Disease in a Non-Verbal Adolescent With Autism Spectrum Disorder

Introduction: Penetrating Crohn’s disease (CD) frequently necessitates coordinated medical and surgical management. In individuals with autism spectrum disorder (ASD), diagnostic and disease monitoring challenges arise due to communication limitations, atypical symptom presentation, and adherence. This case presents a rare complication of penetrating CD in an adolescent with ASD, marked by recurrent symptoms following initial clinical improvement. Case Description/Methods: A 17-year-old man with ASD presented with 2 weeks of abdominal pain, diarrhea, and weight loss. Computed tomography demonstrated terminal ileitis, a 15 cm stricture, ileosigmoid fistula, and abscess. Inflammatory markers were elevated (C-reactive protein 30 mg/L, fecal calprotectin 272 μg/g). He improved clinically on intravenous antibiotics and was discharged on oral antibiotics and exclusive enteral nutrition. Three weeks later, he re-presented with worsening abdominal pain and emesis. Colonoscopy demonstrated severe inflammation in the terminal ileum (TI), and biopsies were confirmatory for CD. Infliximab was initiated [10 mg/kg standard induction dosing at 0,2,6 weeks, then q8 week maintenance dosing], and he reached therapeutic trough drug levels [44 ug/mL at week 2, 38 ug/mL at week 6] with a robust clinical response. He achieved symptom control, but had difficulty complying with exclusive enteral nutrition at home, and 5 months later presented with recurrent abdominal pain. C-reactive protein increased to 109 mg/L), and repeat computed tomography revealed progression of inflammation in the TI and cecum with persistence of ileosigmoid fistula. After 1 month of bowel rest and total parenteral nutrition, he underwent laparoscopic ileocecectomy with removal of 20.5 cm ileum and 3.2 cm proximal colon. Intraoperatively, adhesions and a persistent fistula were identified, along with a foreign body- the extremity of an action figure embedded in the TI. He recovered well after surgery, experiencing no disruptions to infliximab regimen, and has remained in clinical and endoscopic remission. Discussion: This case provides important insights into the management of penetrating Crohn’s disease and comorbid ASD. A foreign body, initially suspected to be a loculated abscess on preoperative imaging was identified intraoperatively. This finding highlights the unique diagnostic challenges in this population and underscores the importance of maintaining a broad differential when interpreting symptoms and imaging in the setting of acute clinical change.