Fever and chills with nausea and dry cough

The patient is a 51-year-old Indian male with a history of Crohn's disease presented to The Johns Hopkins Hospital with relapsing fever and chills with nausea and dry cough.

The patient was first diagnosed with Crohn's disease 10 years ago when he had diarrhea and bloody stools. Colonoscopy and small bowel follow through at the time showed diffuse involvement of the small bowel. The patient was treated with multiple different immunosuppressive regimens (including Pentasa, 6-MP, Imuran, Cipro, Flagyl, and Cellcept); but due to side effects and ineffectiveness, these were discontinued. Three years ago, the patient was started on Remicade (Infliximab) three doses every six weeks. Since then, patient had intermittent fever that typically abated after two to three weeks with administration of Remicade. After his last dose of Remicade, three weeks prior to this admission, the patient was admitted with jejunoileitis and started on total parenteral nutrition (TPN). The patient did well on TPN and became afebrile; hence, he was discharged.

However, one week prior to this admission, patient started to develop fever and chills. The fever and chills continued to worsen and he developed nausea, vomiting, slight abdominal pain and dry cough. Patient denied melena, diarrhea, hematemesis, hemoptysis, dysuria, hematuria, shortness of breath, arthralgia, night sweats or loss of consciousness.

Crohn's disease; kidney stones; dyslipidemia; hypercalcemia; positive PPD test 25 years ago, status post BCG vaccination as a child.

Patient had refused surgical exploration or resection of bowel stricture.

His sister with Hashimoto thryoiditis
Family history of dyslipidemia

He is a neuroscience professor. He denies tobacco and ethanol abuse or IV drug use. He is married and lives in Virginia. No recent travel history noted.

3 Remicade infusions every 6 weeks
Prednisone daily (40 mg every morning and 20 mg every night)
Methotrexate 25 mg weekly

Metronidazole, 6-MP, and Imuran which caused pancreatitis.

See HPI

• The patient is a thin male in no acute distress.
• Vital signs: T=38.5 C, HR=84, RR=20, BP=119/75.
• Head and Neck: Sclerae anicteric, oropharynx clear, no lymphadenopathy, no thyromegaly. Fundoscopic examination normal. Neck supple.
• Lungs: Clear to auscultation
• Cardiovascular: Regular rate, no murmurs, rubs or gallops
• Abdomen: Soft and non-tender. Bowel sounds present.
• Extremities: No edema or rashes.
• Neurologic examination: No cranial nerve abnormalities, No focal motor or sensory deficits.

Initial routine lab results were significant for normal white count of 5,730 (nl 4,500-11,000) with increased immature granulocytes of 270 (nl 0-50). The liver function tests showed ALT 33 (nl 0-40), AST 64 (nl 0-37), and Alkaline Phosphatase 152 (nl 30-120).
Other labs were normal on admission.

A chest CT showed multiple 1-2 mm nonspecific but probably benign nodules in both lungs (Image 1).

A small bowel series demonstrated long segment of ileum with wall thickening and narrowing (Image 2). The jejunum and terminal ileum were normal.

An abdominal CT showed marked bowel thickening with focal narrowing consistent with Crohn's disease and a probable fistula (Image 3).The liver was visualized and unremarkable.

During the hospital stay, the urine, blood, and central line cultures for this patient were negative. Expectorated sputum was cultured. Despite IV antibiotics, the patient continued to have recurrent high grade fevers and high white counts reaching 42,000. He then developed acute abdominal pain with melena and decreased hematocrit.

What is your differential diagnosis for his signs and symptoms?
What diagnostic procedure would you suggest?