Discussion

The most informative aspect of this patient’s course was the management of a recurrent stage 3 sacral pressure injury alongside advanced fistulizing Crohn’s disease. The patient’s course highlights the importance of addressing modifiable components of wound care while also considering whether those measures can be continued beyond the inpatient setting.

Several features of this patient's disease likely contributed to impaired tissue repair. Advanced Crohn's disease and enteric fistulas can combine to cause persistent inflammation, recurrent infection, prior intestinal surgery, and nutritional compromise [5-10]. Nutritional status therefore required particular consideration. This patient had persistent hypoalbuminemia (2.5-3.0 g/dL), supporting concern for nutritional and inflammatory burden; however, serum albumin alone does not establish nutritional status. Patients with Crohn's disease remain at risk for malnutrition because of reduced oral intake, malabsorption, increased metabolic demands, and prior intestinal surgery [5-8]. Pressure injury guidance recommends comprehensive nutritional assessment rather than reliance on a single laboratory value [1-3,16].

Prior reports describe different relationships between gastrointestinal disease and sacral wounds. Wang et al. described a patient with Crohn’s disease in whom rectal perforation led to a presacral abscess, gluteal extension, and sacral osteomyelitis requiring drainage and fecal diversion [17]. Kubota et al. reported a refractory sacral pressure injury associated with small intestinal bacterial overgrowth and severe nutritional deficiency that improved after treatment of the underlying malabsorption [18]. In our patient, the enterocutaneous and vesicocutaneous fistulas were anatomically separate from the sacral pressure injury, and there was no drainable abscess or clinical evidence of osteomyelitis. MRSA isolated from the suprapubic fistula was considered colonization rather than active infection. This case is therefore notable for the management of a recurrent pressure injury alongside advanced fistulizing Crohn’s disease, with housing instability adding complexity to discharge planning.

Effective outpatient wound management requires dependable access to dressings, nutrition, pressure redistribution, transportation, and follow-up [3,12,13,15]. Social risks are common among patients with inflammatory bowel disease [11,12,14]. They have been associated with greater disease activity, medication nonadherence, unplanned healthcare use, financial toxicity, and reduced continuity [11-14]. Given these associations, housing instability represented a potential barrier to consistent wound care in this patient, but its contribution to the wound’s recurrence cannot be established.

The recurrence was likely multifactorial. Chronic inflammation, fistulous disease with ongoing infection risk, reduced mobility, nutritional compromise, and housing instability were all relevant considerations, although the relative contribution of each cannot be determined. For future patients with similar barriers, discharge planning could include referral to medical respite or temporary housing programs that provide a stable environment for post-acute recovery, as well as linkage to food assistance, transportation services, medication-access support, and community sources of dressing supplies [12,14,15,19]. Wound care in unhoused populations is complicated by environmental exposure, limited storage for supplies, difficulty maintaining hygiene, and inconsistent access to follow-up [15]. Medical respite programs are designed for patients who no longer require hospitalization but remain too medically vulnerable to recover safely in a shelter or on the street; available evidence suggests that these programs may reduce hospital admissions, inpatient days, and readmissions [19]. Although these services were not implemented in this case, early assessment of eligibility and availability may support continuity of wound care after discharge.

Discharge readiness requires more than clinical stability and a written wound-care plan. It also requires determining whether the patient can realistically carry out that plan. Early coordination among wound care, nutrition services, social work, case management, gastroenterology, and primary care may help identify and address barriers before discharge.

Post-discharge wound outcomes and long-term follow-up were unavailable, so this case cannot determine whether the inpatient wound status was maintained after discharge or how much housing instability contributed to recurrence. The discussion of post-discharge continuity is therefore based on clinical reasoning and existing literature rather than an outcome demonstrated in this patient.