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. Plain Language Summary: Crohn’s disease is a chronic inflammatory condition of the digestive system with no cure that often leads to repeated surgeries for complications like strictures and difficult-to-manage fistulas, especially in the rectovaginal area. We report the case of a 31-year-old Brazilian woman with a complex rectovaginal fistula due to active Crohn’s disease for twelve years. Despite multiple failed surgeries and a recommendation of rectal amputation, she opted for a non-myeloablative autologous hematopoietic stem cell transplantation. Four years post-transplantation, she has no active Crohn’s disease, no passage of gas or feces through the vagina, and normal bowel function. A literature review found no previous descriptions of rectovaginal fistula closure with hematopoietic stem cell transplantation. This case suggests that hematopoietic stem cell transplantation can be a successful treatment for complex rectovaginal fistulas in Crohn’s disease patients who decline radical surgery, with sustained improvement observed four years post-transplantation. The presence of a fistula does not contraindicate the procedure.