A Rare Presentation of Crohn's Disease: A Case Report

Crohn's disease (CD) is a chronic, transmural inflammatory disorder that may affect any segment of the gastrointestinal tract and is frequently associated with extraintestinal manifestations, including hepatobiliary complications. Pyogenic liver abscesses (PLAs) represent a rare extraintestinal manifestation and are exceptionally uncommon as the initial presentation of CD, with only a few cases reported to date. We describe a previously healthy 39-year-old man, an active smoker, presenting with five days of fever, shivering, myalgias, anorexia, and constipation. On admission, he was febrile, tachycardic, underweight, and had hepatomegaly with diffuse abdominal tenderness. Laboratory studies revealed leukocytosis, microcytic anemia, elevated inflammatory markers, mild cholestatic changes, and deficiencies in folic acid and vitamin D, suggesting malnutrition. Serologies for hepatitis B and C and HIV, as well as autoimmune liver panels, were negative. Abdominal ultrasound and subsequent CT imaging identified four liver abscesses, the largest measuring 5.8 cm, and terminal ileum wall thickening with reactive mesenteric lymphadenopathy. Blood and aspirate cultures grew Streptococcus intermedius, prompting tailored antibiotic therapy and percutaneous drainage. Given the absence of known abdominal pathology, colonoscopy was performed and revealed marked ileocecal congestion and ulceration. Although biopsies showed nonspecific inflammatory activity without granulomas, elevated fecal calprotectin, positive anti-Saccharomyces cerevisiae antibodies, and imaging characteristics consistent with skip lesions strongly supported the diagnosis of CD. Because the active infection precluded initiation of immunosuppressive therapy, the patient underwent exclusive enteral nutrition and smoke cessation with gradual resolution of the abscesses under targeted antibiotics. Once the infection cleared, ustekinumab was initiated. At three months, the patient demonstrated weight recovery and clinical remission and has since remained asymptomatic. PLA is markedly more frequent in patients with CD than in the general population, although its appearance as the initial disease manifestation is rare. This case adds to the limited number of reported CD-associated PLAs and is notable for the absence of preceding intestinal symptoms. Early etiological investigation of PLA, especially in young patients without comorbidities, is essential for timely diagnosis and management. Moreover, the coordinated care provided through a Home Hospitalization Unit contributed significantly to treatment adherence and improved prognosis.