Case presentation

A 62-year-old man with advanced fistulizing Crohn’s disease complicated by enterocutaneous and vesicocutaneous fistulas presented with several days of worsening foul-smelling drainage and surrounding erythema at a suprapubic fistula site. He denied fever, chills, nausea, or vomiting. His medical history included prior colectomy with colostomy creation, a previously healed stage 3 sacral pressure injury, chronic kidney disease, hypertension, chronic pain syndrome, limited mobility, and housing instability. His Crohn’s disease was being managed with mesalamine.

Day 1 was defined as the day of presentation and the beginning of a single continuous hospitalization. The patient was afebrile and hemodynamically stable on admission. Laboratory testing during hospitalization demonstrated mild leukocytosis and anemia. Computed tomography of the abdomen and pelvis showed a complex vesicocutaneous fistula extending from the bladder to the anterior abdominal wall without a drainable abscess. He was admitted for multidisciplinary management involving colorectal surgery, infectious disease, gastroenterology, urology, wound care, case management, and social work. Gastroenterology discontinued mesalamine after determining that it was unlikely to provide meaningful benefit in advanced fistulizing disease.

During the initial wound assessment, the patient was found to have a recurrent sacral pressure injury that was clinically classified as stage 3. The wound bed consisted predominantly of granulation tissue, with focal yellow slough and dark eschar at the margins that did not obscure the overall extent of tissue loss (Figure 1). No exposed bone or clinical evidence of osteomyelitis was present. The patient had experienced one previous sacral pressure injury, which had healed before this admission. Management of the recurrent wound included regular assessment, dressing changes, frequent repositioning, and consultation with the wound-care team.

Figure 1: Clinical appearance of the recurrent stage 3 sacral pressure injury during hospitalization.

A lateral abdominal-wall cutaneous opening with an adjacent wound was also present, consistent with the patient’s known left vesicocutaneous fistula site (Figure 2). A deep culture obtained from the suprapubic fistula on Day 3 grew moderate methicillin-resistant _Staphylococcus aureus _(MRSA). Blood cultures obtained during the initial evaluation showed no growth after 100 hours, and imaging demonstrated no drainable abscess. In view of the patient’s clinical stability and chronic fistulous disease, Infectious Disease considered the wound-culture result more consistent with colonization than active infection and recommended monitoring without antibiotics.

Figure 2: Clinical appearance of the left lateral abdominal-wall fistula site during hospitalization.

Nutritional supplementation was added on Day 24 and included Juven, one packet twice daily, and Nepro, one can with meals. The patient also received a regular-consistency diet restricted to 2 g of sodium and 2 g of potassium. Serum albumin increased from 2.5 g/dL on Day 43 to 3.0 g/dL on Day 47 and remained near that level through Day 50. Laboratory testing on Day 43 showed hyperchloremia, a serum carbon dioxide level of 12 mmol/L, and a normal anion gap, consistent with a non-anion-gap metabolic acidosis. Renal function remained stable, and the carbon dioxide level increased to 24 mmol/L by Day 49, supporting a transient metabolic disturbance rather than progressive renal dysfunction. Clinically relevant serial laboratory findings are summarized in Table 1.

Hospital day | WBC (×10⁹/L) | Hemoglobin (g/dL) | Sodium (mmol/L) | Potassium (mmol/L) | Chloride (mmol/L) | CO₂ (mmol/L) | Anion gap (mmol/L) | BUN (mg/dL) | Creatinine (mg/dL) | Calcium (mg/dL) | Albumin (g/dL)
Reference range | 4-11 | 13.5-17.5 | 136-145 | 3.5-5.1 | 98-107 | 21-31 | 5-15 | 7-25 | 0.7-1.3 | 8.6-10.3 | 3.5-5.7
Day 11 | 11.3 | 8.5 | - | - | - | - | - | - | - | - | -
Day 26 | 10.7 | 10.1 | - | - | - | - | - | - | - | - | -
Day 28 | 10.4 | 9.1 | - | - | - | - | - | - | - | - | -
Day 34 | 11.7 | 8.6 | - | - | - | - | - | - | - | - | -
Day 43 | - | - | 135 | 4.2 | 112 | 12 | 11 | 14 | 0.91 | 8.1 | 2.5
Day 44 | - | - | 136 | 3.9 | 108 | 17 | 11 | 13 | 0.87 | 8.2 | 2.5
Day 45 | - | - | 137 | 3.7 | 110 | 20 | 7 | 13 | 0.9 | 8.5 | 2.6
Day 47 | - | - | 138 | 3.9 | 105 | 19 | 14 | 15 | 0.91 | 8.8 | 3.0
Day 49 | - | - | 139 | 3.9 | 102 | 24 | 13 | 14 | 0.71 | 8.5 | 2.9
Day 50 | - | - | 139 | 3.8 | 106 | 24 | 9 | 13 | 0.7 | 8.6 | 3

Subsequent assessments of the sacral pressure injury showed no clinical evidence of worsening infection or need for surgical intervention. Discharge planning included coordination of outpatient follow-up with Gastroenterology for continued management of his Crohn’s disease, as well as with colorectal surgery and wound care. Case management and social work assisted with planning and placement. At the time of this report, the patient remained hospitalized while placement in a skilled nursing facility was being pursued because of his housing instability. Consequently, whether the proposed discharge plan would maintain continuity of wound care or preserve the patient’s inpatient wound status could not be evaluated.