- 8 Symptoms of Crohn’s Disease That Don’t Affect Digestion
- Understanding Non-Digestive Symptoms of Crohn’s Disease
- Spontaneous remission of Crohn’s disease following a febrile infection: case report and literature review
- Fever and Night Sweats
- What other conditions can cause fever and night sweats?
- How common are fever and night sweats?
- How is fever evaluated?
- How are night sweats evaluated?
- How is fever treated?
- How can I manage night sweats?
8 Symptoms of Crohn’s Disease That Don’t Affect Digestion
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Gas, bloating, diarrhea, nausea: You’re probably all-too familiar with these common Crohn’s disease symptoms, especially if they strike on a regular basis. Yet because Crohn’s disease is a systemic or whole-body condition, its symptoms could extend beyond your digestive system.
“Crohn’s disease is a body-wide disease that is caused by excessive inflammation,” says Nirmal Kaur, MD, director of the inflammatory bowel disease center at Henry Ford Health System in Detroit. “Some people with Crohn’s disease only have inflammation in the bowel, but about 30 percent to 40 percent of people have what are called extra-intestinal manifestations, or Crohn’s disease symptoms outside of their gastrointestinal tract.”
In most cases, the treatments for non-digestive symptoms of Crohn’s are the same as the treatment for bowel-related symptoms: primarily medication. These medications may include aminosalicylates (for mild cases), immunosuppressive agents, biologic therapies, and corticosteroids. For most people, they work well for all Crohn’s symptoms. “Most people notice that when their digestive Crohn’s disease symptoms are treated, their non-digestive symptoms get better as well,” Dr. Kaur says.
Understanding Non-Digestive Symptoms of Crohn’s Disease
Here are eight symptoms of Crohn’s disease that show up outside of the digestive tract, why they occur, and how they can best be managed.
Increased arthritis risk. Because of the inflammation associated with the disease, up to 25 percent of people with Crohn’s also develop arthritis, according to the Crohn’s & Colitis Foundation of America. “This arthritis risk is highest in the larger joints, such as the knees, elbows, and wrists, which is called peripheral arthritis,” Kaur says. “But arthritis can show up anywhere in people with Crohn’s disease.” Usually if the Crohn’s is treated, the arthritis improves as well.
Increased osteoporosis risk. “People with Crohn’s disease are at higher risk for osteoporosis than the general population is,” says Mariam Fayek, MD, attending physician in the Center for Women’s Gastrointestinal Health at Women & Infants Hospital of Rhode Island in Providence. “The chronic inflammation of Crohn’s disease leads to increased bone loss, and people with Crohn’s are also more likely to be vitamin-D deficient, both which contribute to osteoporosis risk.”
This vitamin D deficiency occurs partly because the portion of the bowel that absorbs vitamin D is diseased. Another contributor to an increased osteoporosis risk is steroid use, specifically the drug prednisone, which thins the bones. “Prior to the 1990s, there weren’t many therapies for Crohn’s disease outside of prednisone, so many people with Crohn’s disease who are older in age received a lot of this drug and now have osteoporosis,” Kaur says. Prednisone is still used as a temporary therapy for moderate to severe Crohn’s when other treatments don’t work, increasing osteoporosis risk in some younger people with the condition as well.
To reduce the risk for osteoporosis:
- Avoid prolonged use of prednisone
- Perform regular weight-bearing exercises
- Avoid smoking
- Minimize alcohol and caffeine
- Eat a healthy, balanced diet
“You should also get your vitamin D levels checked and have regular bone density tests,” Dr. Fayek says.
Skin conditions. Crohn’s disease can cause certain skin conditions, including erythema nodosum, which is characterized by tender red nodules on the legs and shins, and pyoderma gangrenosum, which are large painful ulcers. “These skin conditions are caused by the inflammatory process of Crohn’s disease, and the treatment for them is to treat the Crohn’s disease, sometimes along with topical therapy by a dermatologist,” Kaur says. Another possible skin condition is psoriasis. Although psoriasis appears to be a skin disease because of its red patches covered with silvery scales, it’s actually an inflammatory disease. It’s also linked to arthritis and Crohn’s disease by way of psoriatic arthritis, an inflammatory joint disease that can cause bone and joint damage.
“Some of the medications used to treat Crohn’s disease increase the risk of non-melanomatous skin cancers and melanomas,” Fayek says. For instance, azathioprine and mercaptopurine may increase the risk for basal and squamous cell carcinomas of the skin, she adds, and biologic agents such as the anti-TNF class of drugs may increase the risk for melanomas. Always apply sunscreen, minimize excessive sun exposure, and get yearly skin checks by a dermatologist when on these medications, Fayek says.
“People with Crohn’s disease can become anemic and experience fatigue because of blood loss and inflammation,” Fayek says. “Fatigue can also be associated with depression, which is common in people with chronic conditions such as Crohn’s disease.”
Vitamin D deficiency can also contribute to fatigue, as can the body-wide inflammation that may go along with Crohn’s disease. “Taking vitamin D and iron supplements and effectively treating Crohn’s disease can all help to ease fatigue,” Kaur says.
Canker sores. While mouth sores aren’t a common symptom of Crohn’s disease, Crohn’s inflammation can involve any part of the GI tract, from the mouth to the rectum. “Severe oral involvement may present with aphthous ulcers or pain in the mouth and gums,” Fayek says. These painful mouth sores usually occur during Crohn’s flares and appear on the gums or the underside of the tongue. In addition to regular Crohn’s treatment, oral pain-relief rinses or gels, an oral antibiotic rinse, or corticosteroids may help.
Fever and infection. “Fever can be a symptom of Crohn’s disease because of the low-grade inflammation associated with the disease,” Fayek explains. “A fever is particularly concerning if someone is taking drugs for Crohn’s that suppress the immune system.”
Some people with severe Crohn’s disease can develop abdominal abscesses from the inflammation extending through the wall of the intestine to the abdominal cavity, Fayek explains. “Patients on immunosuppressive medications are particularly at risk for certain fungal infections and reactivation of tuberculosis,” she says. If you have a fever over 100.5 degrees Fahrenheit, she says, you should contact your gastroenterologist right away. If the source of the fever is an infection, you’ll likely be treated with antibiotics.
It’s important for people with Crohn’s who are on immunosuppressive therapy to be up to date on their vaccines, Fayek says. However, live, weakened virus vaccines should not be given to people on immunosuppressive therapy; they can and should receive the following inactivated vaccines:
- A yearly flu vaccine.
- Certain pneumonia vaccines. (Talk to your doctor about which ones should be offered to people starting immunosuppressive therapy.)
- DTaP (diphtheria, tetanus, and pertussis), which should be given as a booster, particularly if it’s been more than 10 years since your last vaccine.
Other inactivated vaccines include: the hepatitis A vaccine, Haemophilus influenzae type B (Hib), meningococcus, and HPV vaccine, Fayek says.
Your doctor can help you determine what kind of vaccination schedule you should follow.
Migraines. Some people with Crohn’s disease or ulcerative colitis can get migraine headaches, which are thought to be rooted in inflammation. Once people take medications for other symptoms of Crohn’s disease, their migraine headaches usually also improve, Kaur says.
Eye infections. “There are two types of eye conditions that can occur in people with Crohn’s disease, and both are emergencies,” Kaur says. The first is episcleritis, which is irritation and inflammation of the episclera, a thin layer of tissue that covers the white part of the eye. “Episcleritis is extremely painful, and it makes the eye very red,” she says. The second is uveitis, which is inflammation of the uvea, the middle layer of the eye. “Uveitis causes distinct pain,” Kaur says. Sudden redness, blurred vision, and light sensitivity are other possible symptoms, according to the American Academy of Ophthalmology. “Both eye conditions are rare, but if you have Crohn’s disease and experience any eye pain or redness, call your doctor or head to the emergency room right away.”
Like the digestive symptoms of Crohn’s disease, these non-digestive symptoms are more likely to crop up during a flare or if your Crohn’s is severe. If you have Crohn’s disease and experience any of these symptoms, talk to your doctor promptly to get the care you need.
Spontaneous remission of Crohn’s disease following a febrile infection: case report and literature review
In the present case, the patient was diagnosed with Crohn’s 13 years before the infection-associated remission, although she was symptomatic with the disease at least 17 years before this remission. The patient’s only preceding remission was that following small bowel surgery; otherwise the patient had never been symptom-free and ever-present were symptoms including chronic fatigue, bone and abdominal pain, painful and swollen joints, blisters and ulceration and a poor appetite causing her to be chronically underweight. The patient continues to struggle with these many symptoms which have not been effectively controlled despite intensive medical management.
Lobel and colleagues reported on an interesting series of four Crohn’s disease and one ulcerative colitis remission that followed febrile infections . The patients’ fevers, usually high, were of two weeks or greater in duration. In four of five cases, no etiology for the fever could be determined, and in the fifth patient, the infection resulted from a perforation of an ileocolic anastomosis and intraabdominal, perihepatic and peripancreatic abscesses. None of the infections were respiratory in nature. There were four females with Crohn’s disease (age range 24 to 31 years) and one 34 year old male with ulcerative colitis. Reported remissions were of 2-10 years in duration with no recurrences at the time of reporting, although three subjects remained on maintenance therapy subsequent to their remissions. All patients were taking 6-mercaptopurine (6MP) at the time of remission and the authors hypothesized that fever along with 6MP-induced leukopenia was an important factor in the remissions.
A therapy to stimulate the innate febrile immune response in inflammatory bowel disease dates back to Arthur Hurst, who in 1921 experimented with a dysenteric bacterial serum therapy for one of his patients with ulcerative colitis. Hurst would later report that there was no recurrence when he last saw the patient 15 years later . Hurst, who subsequently treated many more ulcerative colitis patients with this therapy, summarized several of his notable findings . First, he found that intramuscular injections were beneficial, but less frequently than intravenous injections; although he did raise the concern that an anaphylactic reaction may occur following intravenous injection of the vaccine. He further observed that rapid recovery was most likely in the early stages of disease, but could occasionally be very striking in long standing cases. Finally, he noted that recurrence was much reduced if treatment was continued until the sigmoidoscope shows no trace of inflammation, even if symptoms had already disappeared for some weeks.
Based on the preliminary findings of Hurst, in the 1920s and 1930s Burrill Crohn (who first characterized regional ileitis or Crohn’s disease ) experimented using various intravenous therapies for the treatment of ulcerative colitis. He stated that in approximately 45% of cases there was a persistent cessation of symptoms and restitution to a normal state. Crohn made some interesting observations on the use of Hurst’s immunotherapy, which he used regardless of whether or not dysentery organisms could be detected in a patient’s blood :
“A severe febrile reaction was welcomed. A certain degree of anaphylactic shock was regarded as more beneficial than deleterious. The most beneficial results were seen in those patients in whom the intravenous injection of serum resulted in immediate serum shock analogous to a non-specific protein reaction and in those who showed late serum sickness with urticaria and even joint manifestations. The use of polyvalent anti-dysentery serum seemed to give us best results.
In order to determine whether the effect of this serum was a specific or a non-specific one, we attempted, in a number of cases, to duplicate the results by the intravenous injection of typhoid vaccine, such representing a convenient and direct method of nonspecific protein therapy. Some fairly good results were seen. Other miscellaneous methods of treatment were tried at various times in the course of years, these methods including autogenous vaccines of fecal organisms, Bargen’s serum and vaccine, transfusions, etc., some with good results, many of them without any noticeable effect. It would seem that among the various types of intravenous therapy, no one item seemed to have a specific effect upon the disease. It soon became obvious that any protein agent which would produce a protein shock and a febrile reaction, could bring about a beneficial change in the chronic course of this disease. The change from the slow, lethargic chronicity into a sudden flare-up induced by the protein therapy of whatever type, frequently seemed to alter the long drawn-out course of the malady. After several severe protein shocks, the temperature would frequently subside, diarrhea gradually and more slowly diminish until constipation was achieved and the general health of the patient, appetite, strength and weight began to show steady improvement.”
Following World War II, new treatment options became available including antibiotics and corticosteroids. By that time, Crohn had discontinued using bacterial vaccines for his patients with inflammatory bowel disease in preference to surgery, which initially seemed to lead to a very high cure rate: “The percentage of surgical cures is high, even when reckoned conservatively, and it is grossly well over 80 per cent .” Although in subsequent years, it became apparent to Crohn that recurrences following surgery were not uncommon, and similarly, other promising therapies failed to meet initial expectations .
The possibility exists that other factors may have been responsible for the patient’s remission. For example, the antibiotic cephalexin could have played a role, although some facts warrant against such a possibility. The patient had been on cephalexin for many days without any effect on her symptoms, and following disease recurrence the rechallenge with cephalexin had no impact on her symptoms. As to the surgery, by the time the operation for her fistula had taken place, her Crohn’s symptoms had already abated and therefore it was an unlikely factor in her remission. In contrast to the case series by Lobel, the acute infections that were associated with remissions were of a longer duration than in the present case; however, they also correspondingly produced remissions of a much longer duration.
In the present case, the complete remission was unusual for this patient due to a long history of severe and poorly controlled disease. Moreover, the remission associated with the patient’s febrile infection is analogous to other reports of spontaneous or induced remissions following fever. In fact, the prompt improvement noted in these reports, and in the present case, provides further support for the hypothesis that the innate immune response plays a key role – an adaptive immune response would require a longer time period to develop. Strategies that try to suppress the immune system or those that try to eradicate or displace harmful bacteria have shown limited efficacy. An alternative approach would be to develop therapies that specifically activate the innate febrile immune response, and thereby attempt to reassert immune system control over pathogens or harmful indigenous flora.
Fever and Night Sweats
Fever is an increase in your body’s temperature in response to disease or infection.1 Fever is a common symptom of moderate or severe Crohn’s disease and of ulcerative colitis, the two main forms of inflammatory bowel disease (IBD).2,3 The fever probably develops as part of the inflammatory process.4 Fever also can be a side effect of several medications that treat IBD. In particular, it is a side effect of sulfasalazine, azathioprine, 6-mercaptopurine, and infliximab.2,4 Fever may be a sign of some complications of IBD. It can indicate that you have an abscess. It also can be a sign of toxic megacolon.
Night sweats are another symptom of changes in your body temperature. Normally, your body is most comfortable when the surrounding air is within a certain temperature range (thermoneutral zone).5 Inflammation may move this range upward. Therefore, instead of being comfortable when the air around you is 72°F, you suddenly feel cold. You get the chills and start to shiver, which raises your body’s core temperature. When the inflammatory signals settle down, the thermoneutral zone decreases too. Suddenly, your body is too warm! In response, you begin to sweat to lower your body temperature.
If you have woken up drenched in sweat and needing to change your pajamas, you know what night sweats are. There is very little research about night sweats.5 Yet many people with IBD report this symptom.6 One theory is that the level of inflammatory signals fluctuates throughout a 24-hour period.5 This could explain why night sweats occur. However, there is no science to prove this. Another theory is that certain people are more aware of night sweats than others.5 People with IBD often have trouble sleeping. If you are waking up more frequently at night for other reasons, you may be more likely to notice sweating.
What other conditions can cause fever and night sweats?
Fever is a symptom of many conditions, including infections, malignancies, and autoimmune disorders.7 The cause of most fevers can be readily diagnosed and treated. Often, fevers get better on their own.7
Night sweats are also non-specific. People report night sweats related to cancer, infection, and hormone changes.8 They can be related to some medications, changes in blood sugar levels, pregnancy, and some mental health problems.
How common are fever and night sweats?
A year-long survey of 704 people with inflammatory bowel disease showed that 24% of people with Crohn’s disease and 15% of people with ulcerative colitis had fever or night sweats in any 3-month period.6
Unsurprisingly, fever or night sweats were most common among people whose IBD was active throughout the year. More than 38% of people in this group had fever or night sweats. For people who cycled between periods of activity and recovery during the year, 18.6% had fever or night sweats. Interestingly, 6.1% of people with inactive disease during the year had fever or night sweats.6
How is fever evaluated?
Normal body temperature is about 98.6°F, but it fluctuates throughout the day.9 It is usually highest in the evening and during a menstrual period.1 Your body temperature may be warmer after exercise or eating, due to high heat or humidity, or when you are emotional.1
In adults, a fever is a body temperature of 100.4°F or higher.9
A child’s body temperature can be measured in the rectum, mouth, or armpit. Temperatures that indicate fever are:1
- Measured in the rectum: ≥100.4°F
- Measured in the mouth: ≥99.5°F
- Measured under the arm: ≥99°F
Fever could be a sign that your IBD is flaring up.10 It may be necessary to see your health care provider for evaluation and change in medication.10
How are night sweats evaluated?
Your health care provider may do blood tests to check for an increase in inflammation. Increased inflammation could be a sign of a IBD flare, but can also indicate other conditions that cause night sweats.8
It is possible that your provider will order additional tests to rule out some of the common causes of night sweats, such as tuberculosis or HIV infection. Based on your history and other symptoms, your provider may choose to do additional tests.
How is fever treated?
General advice for a fever is to drink plenty of fluids. Do not bundle up with extra layers of clothing or bedding. This can cause your temperature to rise higher. Set the room to a comfortable temperature.1
Acetaminophen (Tylenol) may be a better option than ibuprofen (Motrin, Advil) for treating a fever.10 There is concern that taking ibuprofen (a non-steroidal anti-inflammatory drug or NSAID) could worsen a IBD flare. Ask your health care provider what type of over-the-counter medications you should take for a fever.
Fever plus bloody diarrhea, pain, abdominal swelling, rapid heart beat, dehydration, or low urine output could be serious. These are symptoms of toxic megacolon, a rare but life-threatening complication of Crohn’s disease and ulcerative colitis. If you have these symptoms, seek medical care right away.
How can I manage night sweats?
Waking up because of night sweats can increase your fatigue. Try to get cleaned up and comfortable without turning on the lights or getting out of bed. Tips to help you get more rest include:11
- Wear light weight pajamas and use light covers.
- Keep the bedroom cool or use a fan.
- Sleep on 1 to 2 towels. You can just discard the towel, avoiding the need to change your sheets.
- Keep an extra set of pajamas in arms reach of your bed.