MED-9. Crohn's disease presenting as a life-threatening retropharyngeal abscess.

Metastatic abscess formation is a rare complication of Crohn's disease. Retropharyngeal abscess as a complication of Crohn's disease has not been reported in the literature. A 34-year-old African American female with a medical history of mild asthma and iron deficiency anemia, presented with severe respiratory distress due to stridor. Her prodrome consisted of one month's duration of malaise, dysphagia, progressive dyspnea, severe sore throat, nausea and vomiting, 30-lb weight loss and 4 days of hematochezia. Patient looked toxic, was hypotensive, tachycardic and febrile with WBC 9,400 and 22% bandemia. She had cervical opisthotonus, an audible stridor and coughing which precipitated intermittent airway obstruction thus necessitating urgent endotracheal intubation accomplished by anesthesiology. A non-contrast CT scan of head and neck revealed a large retropharyngeal abscess that was surgically drained. Empiric antibiotic coverage was initiated pending blood and abscess cultures. Tracheostomy was performed on the fourth post-operative day to facilitate weaning from mechanical ventilatory support. A subsequent episode of massive hematochezia prompted an emergent colonoscopy, which revealed a blood-filled colon and deep "punched-out" ulcers throughout the proximal ascending colon with evidence of recent bleeding. The patient underwent a right hemicolectomy for massive persistent bleeding. Gross surgical pathology showed areas of superficial ulceration, and transmural chronic inflammatory changes consistent with Crohn's disease. Six days after the tracheostomy, the formation of a fistula tract was noted at the lower part of the tracheal stoma. The patient was treated with oral steroids and mesalamine for both the colitis and the fistulizing process and did well. When compared to enteral Crohn's disease, pulmonary involvement is much less common and therefore potentially under-diagnosed. Pulmonary involvement of Crohn's disease is notable for mucosal inflammation of the tracheo-bronchial tree, the pulmonary parenchyma, or pleural serositis. We hypothesize that this patient developed a laryngeo-cutaneous fistula at her tracheostomy site as a consequence of bronchopulmonary Crohn's disease. The primary symptomatology includes cough, hoarseness, wheezing, mucopurulent sputum and possibly upper airway obstruction characterized by stridor. The patient we describe here reported nonspecific symptoms of both a chronic systemic inflammatory disease and a chronic bronchitis culminating in airway obstruction. In summary, we report on a rare case of Crohn's disease initially presenting as a life-threatening retropharyngeal abscess.

Saima Ansari, MD, Shakeel Ahmed, MD, James Szalados, MD, Joanne Hessney, MD, and Michael Di Salle, MD. Unity Health System, Parkridge Hospital, Rochester, NY.