title: Fungal sacral osteomyelitis as the initial presentation of Crohn's disease of the small bowel: report of a case.
abstract: 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.
authors.affiliation: Department of General Surgery, University of Wisconsin Hospital and Clinics, Madison 53792, USA.
authors.forename: N
authors.initials: N
authors.lastname: Armstrong
authors.forename: M
authors.initials: M
authors.lastname: Schurr
authors.forename: R
authors.initials: R
authors.lastname: Helgerson
authors.forename: B
authors.initials: B
authors.lastname: Harms
mesh_terms: D000038:Abscess / Q000209:etiology*; D002176:Candida albicans / Q000302:isolation & purification*; D002177:Candidiasis; D003106:Colon / Q000473:pathology; D003424:Crohn Disease / Q000150:complications* / Q000382:microbiology; D005260:Female; D005269:Femur / Q000473:pathology / Q000601:surgery; D006801:Humans; D008875:Middle Aged; D010019:Osteomyelitis / Q000209:etiology* / Q000382:microbiology* / Q000628:therapy; D010532:Peritoneal Diseases / Q000209:etiology*; D012447:Sacrum / Q000382:microbiology