Metastatic Crohn Disease in a Spinal Cord Injury Patient Without Gastrointestinal Manifestation

Abstract

A case is presented of cutaneous metastatic Crohn disease (CD) manifesting in a spinal cord injury (SCI) patient as multiple perianal, perigenital, and periostomal cutaneous ulcerations and a chronic anocutaneous fistula without any gastrointestinal (GI) involvement.The patient is a 65-year-old man with SCI T6 ASIA B secondary to postoperative spinal cord infarct in 2001 who presented to the outpatient clinic with the chief complaint of multiple perianal, perigenital, and periostomal wounds. The patient's history was significant for an emergent colectomy with colostomy in 2001. At that time, he presented to the emergency department with a 24-to 48-hour history of acute onset severe and worsening left lower quadrant pain. Patient was found to have free air in the abdomen and was taken to surgery to have emergent exploratory laporotomy. The surgery revealed an abscess in the left lower quadrant. The abscess was formed by the pelvic wall, the bladder, and the anterior surface of the midsigmoid colon. The patient underwent a partial colectomy with colostomy. Cultures of the abscess revealed the presence of Escherichia coli. The pathology of the resected colon showed only mild diverticulosis and no signs of carcinoma or inflammatory bowel disease.The patient tolerated the procedure well until postoperative day 4, when he developed acute weakness in the lower extremities bilaterally. Magnetic resonance imaging of the thoracic and lumbar spine was performed and revealed increased signal on fluid-attenuated inversion-recovery imaging consistent with a spinal cord infarct. He was managed conservatively and underwent intensive inpatient rehabilitation, eventually discharged to home with a T6 ASIA B SCI secondary to spinal cord infarct. Functionally, he was modified independent in terms of mobility at the wheelchair level, independent in activities of daily living, and continent of bowel and bladder with intermittent catheterization management.In December 2004, the patient was found to have an abdominal abscess, which was explored via laparotomy and drained by a general surgeon. In April 2005, he developed an anocutaneous fistula, which was worked up by the clinicians in the General Surgery and Gastroenterology services initially. A fistulogram in April 2005 demonstrated enterocutaneous fistula from the sigmoid colon. At that time, the clinicians in General Surgery decided on conservative management. The patient remained in stable condition without surgical intervention, until he presented to clinic with nonhealing wounds in the perineal region. The wounds were thought to be pressure related. Initial wound management with bed rest, pressure relief, silver sulfadiazine, and calcium alginate yielded minimal improvement in these ulcerations (Figure 1).The patient was seen by the dermatology service, and biopsy of these lesions was recommended. On biopsy of the cutaneous lesions, findings were highly suggestive of metastatic CD (infiltrate containing sarcoidal granulomas, polarization negative for doubly refractile material) (F...

Inflammatory bowel disease—An enemy of neurogenic bowel management in patients with spinal cord injury

“…To our knowledge, there are only two published case reports of patients with IBD and SCI, which focus on diagnostic challenges, and not on bowel management programs. 11,12 A case-control study evaluated colonoscopy findings in patients with SCI, yet IBD was not specifically adressed. 13 Both SCI and IBD can lead to several gastrointestinal signs and symptoms affecting the patient's activity and QoL.…”

“…The literature is scarce regarding the prevalence, characteristics, and clinical approach to SCI patients with IBD. To our knowledge, there are only two published case reports of patients with IBD and SCI, which focus on diagnostic challenges, and not on bowel management programs 11,12 . A case–control study evaluated colonoscopy findings in patients with SCI, yet IBD was not specifically adressed 13 …”