Introduction:
Celiac disease is an inflammatory disorder affecting subjects at any age and presenting with a broad spectrum of symptoms. In several cases, extra-intestinal symptoms are the only clinical manifestations or occur in conjunction with gastrointestinal symptoms.

Aim:
We present the case of a 47-year-old male admitted to our Internal Medicine Department, after a further episode of fever with chill, associated with headache and malaise.

Case study:
He had suffered from episodes of fever for about 20 years. At physical examination, gastrointestinal symptoms such as nausea, emesis, diarrheal and constipation, were absent.

Results:
Investigations were negative for malignancy, haematological disorders, autoimmune diseases, and inflammatory bowel disease; serological and culture tests were negative for common infectious diseases and parasitosis. Inflammatory markers were elevated (erythrocyte sedimentation rate 48 mm/h, C-reactive protein 185 mg/L), with the exception of normal procalcitonin levels. Colonoscopy demonstrated villous blunting, with biopsies consistent with a diffuse chronic inflammation in the lamina propria and significant intraepithelial lymphocytosis (MARSH II). Further investigations showed an advanced atherosclerotic peripheral disease, despite the low cardiovascular risk.

Discussion:
In celiac disease, the activation of gluten specific T cells in the gastrointestinal mucosa induces the activation of a pro-inflammatory pattern, which could contribute to the fever. The systemic inflammatory activation found in celiac disease was associated to a chronic vascular damage, both consisting in an increased arterial stiffness and intima-media-thickness.

Conclusions:
The delay in diagnosis of celiac disease could be associated to several complications, such as atherosclerotic progression.