Granulomas Galore: Concomitant Granulomatous Infections in a Patient With Crohn's Disease

Tumor necrosis factor (TNF)-alpha inhibitors are effective biologics in the treatment of inflammatory bowel disease; however, they increase susceptibility to opportunistic infections. We report a case of a 74-year-old female with Crohn's disease who developed concomitant pulmonary tuberculosis (Mycobacterium tuberculosis [MTB]) and Histoplasmosis capsulatum infection while on adalimumab. Co-infection is rare in patients on TNF-alpha inhibitor therapy, and most cases have been reported in patients with human immunodeficiency virus (HIV). This was a challenging case for diagnosis and treatment due to indistinguishable presenting symptoms of both infections, similar laboratory and radiographical findings, and a clinical course complicated by drug-drug interactions and worsening of symptoms despite therapy.