Severe Flare Of Mild Ileocolonic Crohn'S Disease Associated With Fecal Microbiota Transplantation Requiring Diverting Ileostomy

Patients with inflammatory bowel disease (IBD) are at increased risk of developing C. difficile infection (CDI). Fecal microbiota transplantation (FMT) is an effective therapy with high success rate in preventing recurrent CDI (rCDI). However, IBD patients have decreased response, with reports also suggesting potential IBD flare post-FMT. We present a case of mild ileocolonic Crohn's disease(CD) in a patient treated with FMT for rCDI who subsequently developed severe steroid-refractory flare requiring surgical intervention one-week post-FMT. A 35-year old male with history of refractory ileocolonic CD and rCDI presented with watery diarrhea and abdominal pain. His medical history included non-response to therapies including thiopurines, methotrexate, infliximab, adalimumab, and vedolizumab, ultimately requiring multiple diverting ileostomies complicated by disease flare upon ileostomy takedown. The patient had an ileostomy takedown four months before presentation while on ustekinumab maintenance therapy with complete mucosal healing noted while diverted. On presentation, the patient had elevated inflammatory markers (C-reactive protein (CRP)=2.2mg/dL; erythrocyte sedimentation rate (ESR)=35mm/hr) and C difficile PCR and stool bacterial pathogen studies were negative. His previous CDI episode was two months prior, with corresponding increase in clinical symptoms improved on vancomycin. To prevent future CDI recurrences, FMT was performed via colonoscopy, which revealed mild pancolitis (Figure 1). Ustekinumab was also increased to every 4 week dosing. Two days after FMT, the patient returned with fever, abdominal pain and bloody stools. CRP and ESR were elevated to 12.7mg/dL and 58mm/hr. Stool studies were negative for infection. Sigmoidoscopy one week following FMT demonstrated punched-out ulcerations in the sigmoid and descending colon, negative for CMV(Figure 2). Solumedrol was given for 5 days but due to worsening symptoms and continued CRP elevation with inability to wean to oral steroids, diverting ileostomy was performed. Since then, he has not had further CDI relapse and is continuing ustekinumab maintenance therapy in hopes of maintaining remission after ileostomy takedown.2100_A Figure 1. Colonic Mucosa Prior to FMT2100_B Figure 2. Colonic Mucosa 1 week following FMTWith increasing use of FMT for rCDI in IBD patients, it is important to understand risk factors associated with post-FMT IBD flare and to determine optimal patient selection and timing of FMT and IBD treatment in this patient population.