Use of Ustekinumab in a Patient With Penetrating Crohn’s Disease Complicated With Sacral Osteomyelitis
Background:
Ustekinumab is an immunosuppressive medication that works by inhibiting Interleukin-12 and 23; therefore, it has a possible side effect of risk of infections. We will report a case of a patient with Crohn’s disease complicated with sacral fistula and consequent osteomyelitis, with a good clinical outcome using ustekinumab.
Methods:
Male, 33 years old, Brazilian, diagnosed with Crohn’s disease A2L3B3p in 2013. He underwent ileocolectomy in 2013 due to perforation of the terminal ileum, used azathioprine from 2013 to2018, and started ustekinumab in 2018 due to worsening of symptoms, but opted to discontinue it on his own volition in 2019. In 2021, he presented fibrotic stenosis at the anastomotic site, concurrent with impervious inflammatory stenosis of the sigmoid colon, which was accompanied by a fistulous connection to the sacral region, osteomyelitis, anal stenosis, and multiple perianal fistulas. He subsequently underwent anal dilation with semen passage, and was started on long-term antibiotic therapy for osteomyelitis treatment. Following multidisciplinary discussion, ustekinumab was started two months after implementing antibiotics. Despite the normalization of inflammatory markers, due to fibrotic stenosis of the anastomosis, he developed a fistula connecting the jejunum and the anastomotic site from 2022. As a therapeutic measure, he underwent enterectomy with ileocolectomy with Mikulicz 1 ileocolostomy.
Results:
Colonoscopy performed i February 2023 showed endoscopic remission with resolution of sigmoid stenosis and scarring of the excised colon segment. Magnetic resonance imaging of the lumbosacral spine performed in March 2023 showed resolution of the osteomyelitis and the fistula between the sigmoid and the sacrum. The patient underwent uneventful ileocolostomy closure in August 2023. He is currently maintaining clinical and endoscopic remission, with regular use of ustekinumab.
Conclusions:
In general, it is not recommended to start any immunosuppressive medication during an active infection. However, the decision to initiate, persist or discontinue the medication must be based on several factors, such as the severity of the infection and the potential for treatment, the patient’s overall health status, the assessment of the medication’s risk-to-benefit ratio, and whether or not there are other therapeutic alternatives. According to Regueiro’s pyramid, which stratifies therapeutic medications for the management of inflammatory bowel disease (IBD) in terms of safety, ustekinumab exhibits a favorable safety profile within the spectrum of immunobiological medications. It is recommended for patients with predisposing risk factors and a history of recurrent infections. However, it is worth noting that initiating treatment in the presence of an active infection is an uncommon scenario and requires adequate monitoring of the patient’s clinical status. Despite the recognized safety of ustekinumab in patients with predisposing risk factors, there is limited evidence regarding the utilization of the drug in the context of an active infection. The favorable evolution of our patient may suggest a therapeutic possibility and better efficiency in the treatment of patients with the same clinical profile.
