Page 24 - Delaware Medical Journal - September 2016

Immunomodulatory Therapy and an Insidious Presentation of a Large Intra-Abdominal Abscess Emily Au; Ahmad Al-Taee, MD; Muhammad B. Hammami, MD
Crohn’s disease is a disorder characterized by transmural inflammation which can potentially affect any part of the gastrointestinal tract from the mouth to the perianal area. Crohn’s disease is a systemic disease characterized by a relapsing remitting course, with variable intestinal and extra-intestinal complications. Abdominal and pelvic abscesses are not an uncommon complication of Crohn’s disease occurring in 10-30 percent of all patients.
We present the case of a 21-year-old male with Crohn’s disease presenting with a massive abdominal abscess, whose diagnosis was delayed given lack of typical symptoms. Shortly after initiating therapy with Prednisone and Adalimumab
he presented with worsening abdominal distention. Cross sectional imaging of the abdomen with IV contrast (Figure 1) demonstrated a 34cm x 23 cm x 11 cm rim-enhancing fluid collections in the abdomen and pelvis consistent with a large intra-abdominal abscess. He underwent an exploratory laparotomy, abdominal washout, and wound vacuum placement. Five liters of purulent fluid were aspirated and cultures grew citrobacter, veillonella and candida glabrata. A bowel perforation was suspected as the etiology for abscess formation; however magnetic resonance heterography (Figure 2) was unremarkable. He was treated with appropriate antibiotics, antifungal agents, and was started on Aprisa. His course was complicated with recurrence of intra-abdominal abscesses and a colocutaneous fistula for which he underwent an open sigmoidectomy with a diverting loop colostomy. After confirmation of healing with repeat imaging, he was started on Infliximab. The loop colostomy was later taken down and a colorectal anastomosis was performed with an uneventful postoperative course. He followed as an outpatient and continues to do well on Infliximab.
Most abscesses are picked up in their early stages given characteristic symptoms; however in presence of immunosuppressive therapy the host immune system can be suppressed leading to delayed diagnosis. The presence
of a massive intra-abdominal purulent fluid collection of this size has not been described on our review of the literature. Furthermore, despite the abscess taking up most of the abdominal cavity, the fairly limited symptom burden highlights the importance of having high degree of clinical suspicion for infectious complications in Crohn’s disease patients even when classical symptoms are not present.
Key words: Crohn’s disease, intra-abdominal abscess, tumor necrosis factor alpha (TNF-alpha) immunomodulatory therapy
Introduction Crohn’s disease is a disorder characterized by transmural

gastrointestinal tract from the mouth to the perianal area. The prevalence of Crohn’s is upwards of 322 cases per 100,000 persons
in North America, with an incidence of 20.2 per 100,000 person- years.1 Crohn’s disease is a systemic disease characterized by a relapsing remitting course, with variable intestinal and extra-intestinal complications. Abdominal and pelvic abscesses are not an uncommon complication of Crohn’s disease occurring in 10-30 percent of all patients.2 Most abscesses are picked up in their early stages given
characteristic symptoms; however in presence of immunosuppressive therapy host immune system can be suppressed leading to delayed diagnosis. We present a case of a patient with Crohn’s disease presenting with a massive abdominal abscess (Figure 1), the largest ever reported, whose diagnosis was delayed given lack of typical symptoms. We discuss the pathophysiology of abscess formation in Crohn’s disease and comment on features that should raise suspicion for occult abscess in this patient population. This work highlights the importance of having high degree of clinical suspicion for infectious complications in Crohn’s disease patients even when classical symptoms are not present.
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Del Med J | September 2016 | Vol. 88 | No. 9
Abstract