Case Report: A unique case of a retroperitoneal abscess during pregnancy complicated with an ileo-sigmoid-vesical fistula in a patient with active Crohn’s disease

Patient information and clinical findings

The patient was a 28-year-old female, with no past surgical intervention and no known family history of inflammatory bowel disease. She was diagnosed in France with an inflammation of the last 10 cm of the ileum leading to the diagnosis of a Crohn’s disease and was treated with an initial dose of 50 mg/day of prednisolone and 50 mg/day of azathioprine for 8 weeks. As her symptoms started to fade, prednisolone dose was progressively decreased to 5 mg/day.

At first visit, the primary concern of the patient was the continuous sciatic pain and an inability of her to lift her leg, with no fever. She reported having had an episode a high fever and kidney pain while on holiday in Tunisia two weeks earlier. Recurrent urinary infections and abdominal stiffness were retrieved at her monthly examinations during her pregnancy follow-up and with elevated C-reactive protein levels of 225 mg/l (normal range <5 mg/l). Because of the pregnancy, limited imaging options were available, and ultrasounds could not give a clear diagnosis. Instead, appendicitis and kidney stones were proposed several times. After pneumaturia and fecaluria appeared, MRI was performed and finally revealed the presence of a retroperitoneal abscess and an ileo-sigmoid-vesical fistula.

Timeline of diagnostic and therapeutic interventions

The time elapsed between the first complaint and the resolution of the underlying cause of the symptoms was 18 months. This patient was diagnosed by several specialties and in different countries as the case happened during the relocation of the patient to a new country. For these reasons, this timeline is based on reported facts from the patient and from the images, lab analyses and reports she could provide. The case happened in 2012, and this patient has been followed up for eight years.

February 2011: Patient complains from high fever, abdominal pain and is diagnosed by ultrasound with a right kidney dilation. She is given paracetamol 500 mg every 6 hours and 500 mg oral ciprofloxacin every 12 hours for 7 days.

March 2011: Patient complains for the first time of sciatic pain, crualgia and inability to lift right leg, while having no fever. She is taking 5 mg/day prednisolone and 50 mg/day azathioprine for Crohn’s disease management. CT-scan for L3–L4 is normal, ultrasound is normal, gynecological examination is normal, hip X-ray is normal. Abdominal CT-scan shows dilation of right ureter and stenosis against the terminal ileum. She is prescribed 500 mg paracetamol every 6 hours.

April 2011: Patient moves to Qatar.

May 2011: Patient continues complaining from sciatic pain and flexing incapacity, when pregnancy is discovered. The patient decided by herself to discontinue azathioprine at this point, but was followed up with a family medical doctor to maintain doses of prednisolone at 5 mg/day. At first emergency hospital admission, patient presents with severe abdominal pain, with right lower abdominal stiffness and a C-reactive protein levels showing an inflammation of the ileum region leading to the diagnosis of appendicitis. Appendectomy is proposed but the patient refuses surgery.

July 2011: Patient is admitted to hospital with severe kidney pain, general fatigue and paleness. She was taking 500 mg paracetamol every 6 hours. Urine had an abnormal brown and cloudy urine color, which lead to the diagnosis of a urinary infection and beginning of pyelonephritis, confirmed by ultrasound. Augmentin (amoxicillin 250 mg and clavulanic acid 125 mg) is prescribed with a dose of 1g every 12 hours for 7 days.

November 2011: The patient is admitted for pre-term labor. Patient is under the same antibiotic and dose as in July 2011 for the recurrent urinary infections and does not present symptoms. Tocolytic medication is given to stop contractions.

January 2012: The patient is admitted for normal labor; however, fetal distress required emergency C-section. The baby weighed 2400 g, but with a good Apgar score and did not need NICU.

February 2012: The patient complains of severe urinary infections and pneumaturia; cystoscopy is normal. She is on auto medication with 500 mg paracetamol every 6 hours. She is again treated with Augmentin (amoxicillin 250mg and clavulanic acid 125mg) at a dose of 1g every 12 hours for 7 days.

May 2012: Colonoscopy is performed but it was not possible to reach the terminal ileum. A few days after the colonoscopy, the patient is admitted to emergency with vomiting, high fever, severe abdominal pain. Ultrasound and CT-scan show inflammation of the right iliac fossa, leading to diagnosis of appendicitis. The patient is convinced of having a fistula. She refuses surgery and is treated Flagyl (metronidazole hydrochloride) 250 mg twice daily for 7 days.

June 2012: The patient reports fecaluria and is admitted for an MRI examination that reveals the presence of a retroperitoneal abscess and an ileo-vesical fistula. She travels to her home country (France), where a new MRI reveals that the fistula is actually an ileo-sigmoid-vesical fistula. She is treated with total parenteral nutrition for 30 days, and with a combination of 500 mg metronidazole IV and 400 mg ciprofloxacin IV every 12 hours for 4 weeks, after which ileo-colo resection was performed. An ileostomy was maintained for four months before anastomosis.