Fever of Unknown Origin in an Immunosuppressed Patient with Crohn’s Disease: An Unusual Cause

CASE REPORT A33-year-old female with perforating ileal Crohn’s disease (CD) with two prior intestinal resections secondary to symptomatic stenoses was hospitalized at our institution for evaluation of abdominal pain and fever of unknown origin (FUO). She was taking adalimumab 40 mg subcutaneously weekly for treatment of her Crohn’s disease. She presented with a chief complaint of acute severe epigastric abdominal pain and watery diarrhea, associated with shortness of breath, diaphoresis, and palpitations. She described the pain as episodic and short-lived, resolving within minutes of onset. Temperatures ranged from 99 to 102 degrees Fahrenheit (F) with no clear pattern. On examination, she was noted to have marked epigastric tenderness. Initial laboratory studies were unrevealing. Her adalimumab was held upon admission to the hospital and broad spectrum antibiotics (piperacillintazobactam and vancomycin) were started. An abdominal ultrasound showed a hypoechoic mildly enlarged liver without evidence of gallstones or acute cholecystitis; however a sonographic Murphy’s sign was noted. Blood cultures grew Pseudomonas species, not aeruginosa and Candida guilliermondii. A hepatobiliary scan (HIDA) was normal with a gallbladder ejection fraction of 79%. Multiple stool studies for typical and atypical organisms were negative. Endoscopic evaluation including a colonoscopy to the terminal ileum showed no evidence of active Crohn’s disease. Upper endoscopy revealed Candida Esophagitis for which intravenous fluconazole was started. Biopsies taken for Herpes simplex virus (HSV) and Cytomegalovirus (CMV) were negative. CT enterography with oral and A CASE REPORT