Clinical Remission of Crohn's Disease and Closure of a Rectovaginal Fistula After Autologous Non-Myeloablative Hematopoietic Stem Cell Transplantation.

BACKGROUND

Crohn's Disease is a chronic, heterogeneous, recurrent and remitting inflammatory bowel disease that can affect any part of the digestive system. To date there is no cure for this disease. Clinical treatment aims to reestablish a balance and avoid crises that are common in an immune-mediated disease that promotes intestinal dysregulation. Anti-inflammatory medications, corticosteroids, immunosuppressants and biologics are part of the therapeutic arsenal for the disease. Obstructions, strictures and intestinal fistulas are complications that require repeat surgery in most patients. Fistulas in the anal or perianal regions are common with rectovaginal fistulas being a serious and complex complication that is difficult to control. Autologous hematopoietic stem cell transplantation can be employed for select patients with severe, refractory autoimmune diseases that have failed to respond adequately to conventional treatments.

CASE PRESENTATION: A 31-year-old Brazilian patient underwent several unsuccessful perianal surgeries for a complex rectovaginal fistula during her twelve years with active Crohn's Disease. Stool elimination was mostly through the vagina as she had rectal stenosis. Consequently, rectal amputation and permanent colostomy implantation were recommended but refused by the patient. Instead, she underwent a non-myeloablative autologous hematopoietic stem cell transplantation. Four years later, she is without active disease, with no manifestation of a rectovaginal fistula. Previous descriptions of rectovaginal fistula closure with hematopoietic stem cell transplantation were not found in a review of the literature.

CONCLUSION

For patients who refuse radical surgery, the presence of a fistula is not a contraindication for hematopoietic stem cell transplantation. The procedure provided progressive improvement not only with apparent cure of the Crohn's disease but with no manifestation of the rectovaginal fistula four years after the transplantation.