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

We report a unique case of Candida albicans sacral osteomyelitis in a 48 year-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 time of presentation, she developed chills, fever, right lower quadrant abdominal pain, and right knee pain. Physical examination was significant for a palpable right lower quadrant abdominal mass. A computed tomographic scan of the abdomen and pelvis identified a large right-sided retroperitoneal mass, severe right hydronephrosis, and air within the right sacrum. Findings at laparotomy included small-bowel changes consistent with Crohn's disease, a multiloculated retroperitoneal abscess, and evidence of sacral osteomyelitis. A right hemicolectomy with sacral debridement and placement of presacral drains was performed. Bone cultures from the sacrum demonstrated a predominance of C. albicans, in addition to coliforms and enterococcus. The patient was placed on amphotericin B and intravenous antibiotics, Because serial 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 femoral head was performed. After 12 months of follow-up, she was doing well without medications and had no constitutional symptoms or radiographic evidence of disease progression. This report illustrates a unique case of Crohn's disease presenting as sacral osteomyelitis secondary to small-bowel fistulization. Aggressive multidisciplinary surgical and medical management were the key to the successful management of this difficult case.