Meningitis in a patient with previously undiagnosed Crohn's disease

To the Editor: Crohn’s disease (CD) is a chronic inflammatory bowel disease with variable clinical presentation. An aggressive fistulizing pattern is possible and over one-third of CD patients will experience recurring fistulas during their disease course.1 Fistulization is a manifestation of the transmural nature of this disease,2 but fistulas to the epidural space are quite unusual.3 Herein we report a case of a male patient who presented to the medical emergency department with meningitis. Physical examination revealed multiple perianal and an abdominal fistula and subsequent complementary studies confirmed the presence of CD. A 26-year-old man was admitted to the emergency room because of high fever, severe headache, acute confusion, nausea, and vomiting. On admission his body temperature was 39°C, heart rate 120, respiratory rate 16, and blood pressure 103/55 mmHg. On physical examination the patient was confused, not oriented to person, place, or time. Kerning and Brudzinski signs were present but no Babinski or clonus. Ophthalmologic examination revealed papilloedema. There was no otitis, pharyngitis, or sinusitis and heart/lung examination was normal. Abdominal and pelvic examination revealed a large abdominal cutaneous fistula in the lower right quadrant and multiple perianal fistulas. Laboratory results upon admission showed leukocytosis (WBC of 23.2 G/L with 92% of PMN), thrombocytosis (689 G/L), and increased C-RP levels (20 mg/dL to a normal of 1 mg/dL). A head computed tomography (CT) scan revealed diffuse cerebral edema and lumbar punction was not performed initially. The patient was given, empirically, intravenous meropenem, vancomycin, and metronidazole. Two days later a lumbar puncture was unsuccessfully tried. Since the clinical symptoms and signs were highly suggestive of meningitis and the patient was recovering very well with antibiotic treatment the lumbar puncture was deemed dispensable. When the patient recovered he revealed that the perianal fistulas appeared 7 years ago and the abdominal fistula in the last 6 months but he hid this findings from his family and never sought medical help. A certain degree of mental impairment was obvious. After full recovery, a colonoscopy was performed and revealed severe inflammation of the rectum with a small orifice at the posterior wall corresponding, probably, to a fistulous tract. A similar process of severe inflammation was also present at the terminal ileum. Endoscopic and histologic findings were compatible with CD. Severe transmural