Fungal sacral osteomyelitis as the initial presentation of Crohn's diseaseof the small bowel - Report of a case

We report a unique case of Candida albicans sacral osteomyelitis in a 48 ye ar-old female with previously undiagnosed Crohn's disease. The patient was ill for one year with fatigue, weakness, and a 60-lb weight loss, At the ti me of presentation, she developed chills, fever, right lower quadrant abdom inal pain, and right knee pain. Physical examination was significant for a palpable right lower quadrant abdominal mass. A computed tomographic scan o f the abdomen and pelvis identified a large right-sided retroperitoneal mas s, severe right hydronephrosis, and air within the right sacrum. Findings a t laparotomy included small-bowel changes consistent with Crohn's disease, a multiloculated retroperitoneal abscess, and evidence of sacral osteomyeli tis. A right hemicolectomy with sacral debridement and placement of presacr al drains was performed. Bone cultures from the sacrum demonstrated a predo minance of C. albicans, in addition to coliforms and enterococcus. The pati ent was placed on amphotericin B and intravenous antibiotics, Because seria l computed tomographic scans of her pelvis demonstrated progression of her pelvic osteomyelitis to include the sacrum, right ilium, right acetabulum, and right femoral head, a repeat debridement with resection of the right fe moral head was performed. After 12 months of follow-up, she was doing well without medications and had no constitutional symptoms or radiographic evid ence of disease progression. This report illustrates a unique case of Crohn 's disease presenting as sacral osteomyelitis secondary to small-bowel fist ulization. Aggressive multidisciplinary surgical and medical management wer e the key to the successful management of this difficult case.