History
A 27-year-old gentleman with ileocolonic Crohn’s disease and perianal involvement has previously been well controlled with azathioprine. He had an episode of disease flare and was started on infliximab for treatment of his active lumimal disease. His tuberculin skin test was negative and his chest X-ray was normal prior to starting an anti-TNF agent. Two weeks after starting infliximab, he develops a fever up to 38.5°C.
•Fever 38.9°C, haemodynamically stable, SaO2 98-100% on RA.
•Hydration is satisfactory.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•Chest examination reveals crepitations and decreased air entry in the left upper zone.
•Abdominal examination reveals a soft, non-tender abdomen.
•Perianal examination reveals no active perianal disease or signs of infection.
•No signs of oedema.
Investigations
•CBC is normal.
•Liver function tests are normal (for preparation of future anti-TB treatment).
•ESR >120mm/hr.
•CRP 200mg/L.
What are the possible causes of his fever given his history of Crohn’s?
•Infective causes (with the use of immunosuppressive therapy, there is a high risk of infection. Infective causes must be considered in patients on immunosuppressive therapy. In Asia, with the high prevalence of tuberculosis [TB], reactivation of latent TB must be ruled out):
–intra-abdominal collections;
–perianal abscess;
–opportunistic infections due to underlying immunosuppression;
–reactivation of TB or active TB.
•Fever due to underlying active Crohn’s disease.
What further investigations would you perform?
•Chest imaging (chest X-ray or CT thorax) to confirm the presence of consolidation (Figure 5.1).
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