S4999 Chasing the Fever: An Unusual Presentation of Crohn's Disease

Introduction: Classic symptoms of Crohn’s disease include abdominal pain, diarrhea, and fatigue. Fevers are also common and are associated with infectious complications, such as intra-abdominal abscesses. Lymphadenopathy may be observed in IBD but is typically regional, involving mesenteric and perienteric lymph nodes adjacent to affected bowel segments. This case illustrates an unusual presentation of Crohn’s disease, with recurrent fevers and cervical and axillary lymphadenopathy. Case Description/Methods: A 23-year-old man presented with 1 month of recurrent fevers and diarrhea. Social history included high-risk behaviors such as unprotected sex with multiple male partners and self-tattooing. He described 4-5 episodes of non-bloody diarrhea daily, fevers every 2-3 days, night sweats, and persistent cough. He was diagnosed with acute bronchitis and given a course of antibiotics and steroids, which temporarily improved his symptoms. Two months later, he re-presented with similar complaints. He was evaluated by Infectious Disease for fever of unknown origin. A work-up was completed to rule out infectious etiologies, rheumatologic conditions, and malignancy. Initial stool testing was negative but was positive for Shigella and Enteroinvasive E. coli 1 week later. Fecal calprotectin was 392 mcg/g. Computed tomography imaging demonstrated wall thickening and submucosal edema throughout the colon. GI was consulted. A colonoscopy demonstrated patchy erythema and small erosions throughout the colon and the terminal ileum. Random biopsies demonstrated moderately active colitis and ileitis with no chronicity. One month later, the patient was seen in GI clinic where he continued to complain of recurrent fevers, non-bloody diarrhea, but now had tender cervical and axillary lymphadenopathy. Repeat colonoscopy demonstrated similar endoscopic findings but biopsies now also showed chronic inflammation with no definitive architectural distortion. The patient was then given a course of steroids to treat for inflammatory bowel disease, which resulted in complete resolution of his symptoms. Discussion: This patient’s presentation with recurrent fevers and lymphadenopathy was likely due to evolving ileocolonic Crohn’s disease. Typically, these systemic symptoms are associated with infectious complications of IBD, but this patient improved without antibiotics. The patient’s fevers and extra-abdominal lymphadenopathy likely represents systemic immune dysregulation due to Crohn’s disease, which responded to steroids.