Caught Between a Cough and a Hard Place: A Crohn's Conundrum with a Broncho-Esophageal Twist

Background:
Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract, known for its potential to cause various complications, including strictures, fistulas, and abscesses. Esophageal involvement in CD is rare, occurring in less than 1% of cases, and even more uncommon is the development of a broncho-esophageal fistula. Such cases present significant diagnostic and therapeutic challenges due to their rarity and potential for severe morbidity, including respiratory complications. This case report highlights a unique presentation of a broncho-esophageal fistula in a patient with ileocolonic Crohn’s disease, emphasizing the importance of multidisciplinary management and novel therapeutic approaches.
Methods:
A 34-year-old female with a history of ileocolonic Crohn’s disease, diagnosed in 2016, presented with progressive dysphagia and recurrent pulmonary infections. Her past medical history included small bowel obstruction requiring resection and ileocolonic anastomosis. Despite previous treatment with multiple biologics (including anti-TNF agents), the patient experienced either the development of antibodies or adverse reactions, leading to discontinuation of these therapies. In May 2023, she was admitted with persistent dysphagia. Endoscopy revealed esophagitis and multiple ulcerations, with biopsies showing acute inflammation and Candida infection. Subsequent imaging identified multiple esophageal fistulas, with 1 tract communicating with the bronchial tree, leading to multilobar lung abscesses and pneumonia. Despite antifungal therapy and esophageal dilations, the patient’s condition worsened, leading to further hospital admissions. Given her complex disease history and prior failures with anti-TNF therapy, treatment was initiated with an IL-23 inhibitor, a class of medication shown to be effective in managing CD, particularly in cases refractory to other biologic therapies. Nutritional support via a nasojejunal feeding tube was also implemented to promote healing of the fistula.
Results:
This case exemplifies a rare but severe complication of CD involving esophageal and bronchial communication. The development of a broncho-esophageal fistula in the context of Crohn’s disease is particularly rare and poses significant diagnostic challenges. The use of an IL-23 inhibitor represents a novel approach in this setting, especially given the failure of traditional therapies such as anti-TNF agents. This therapeutic strategy may offer a promising alternative for managing complex and refractory cases of CD, highlighting the evolving landscape of biologic therapies in IBD management. Multidisciplinary care is crucial in the management of such complex cases, involving gastroenterologists, thoracic surgeons, and infectious disease specialists. This approach ensures comprehensive care, addressing both the gastrointestinal and respiratory components of the disease.
Conclusions:
Broncho-esophageal fistula is an uncommon but serious complication of Crohn’s disease, with significant implications for patient morbidity and mortality. Early recognition, combined with a tailored therapeutic approach utilizing advanced biologics such as IL-23 inhibitors, is essential for improving patient outcomes. This case underscores the need for ongoing research into the pathogenesis and management of CD with atypical presentations, to better inform clinical practice and optimize patient care.