S4977 Colobronchial Fistula Complicating Severe Crohn’s Colitis

Introduction: We report the case of a 19-year-old man with Crohn’s colitis complicated by a colobronchial fistula. He initially presented to a local emergency department with severe diarrhea and hyponatremia. Stool studies were negative for C. difficile but positive for Shigella and Campylobacter and Azithromycin was initiated. Case Description/Methods: He was re-evaluated 4 days later in the emergency department for worsening symptoms with computed tomography scan showing colonic wall irregularity and cecal dilation up to 12.6 cm concerning for toxic megacolon. Stool studies were then positive for C. difficile toxin by polymerase chain reaction. Tachycardia and leukocytosis of 15,000 were noted. Oral vancomycin was initiated. A month later he returned to the emergency department with diarrhea, new dyspnea, and non-productive cough. Laboratory studies showed a hemoglobin of 6.7, platelets 570, and albumin of 1.4. Repeat computed tomography showed diffuse mucosal hyperenhancement and a new fistula tract arising from the splenic flexure trans-diaphragmatically with dense consolidation of the left lung at this location and a pleural effusion. He was admitted to the hospital, started on broad spectrum intravenous antibiotics, kept NPO, and started on TPN as albumin had fallen to 0.8. A balloon occlusion retrograde barium enema showed featureless colonic mucosa and a colobronchial fistula extending from the superior portion of the splenic flexure. A diverting ileostomy was recommended but initially deferred. Flexible sigmoidoscopy for tissue diagnosis was performed as well as pre-biologic testing. Pathology showed changes consistent with primary IBD, confirming a diagnosis of Crohn’s colitis. Infliximab was initiated at 5 mg/kg and steroids were avoided. Thoracic surgery was consulted due to progression of the pleural effusion and a chest tube was placed. A second 5 mg/kg dose was given on day 3. He rapidly improved, remained on oral vancomycin, and a diet was resumed. Albumin had improved to 2.1, TPN and broad spectrum antibiotics were discontinued, and azathioprine 50 mg was added. He was transferred to a regional center where a diverting loop ileostomy was completed. At outpatient follow-up 6 weeks after transfer, he had gained 20 pounds, had normal hemoglobin and platelet counts, and albumin was 4.5. At 1 year follow-up, he maintained a normal weight, had good ileostomy function, and was attending college. Discussion: This case underscores the importance of recognizing inflammatory colitis, aggressive medical therapy, and a multidisciplinary approach to care of complex IBD patients.