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Pleural Fluid Analysis in a Patient With Pleuro-Myopericarditis and Crohn's Disease FREE TO VIEW

Erwin Moy, MD; Jaspreet Ahuja, MD; Joseph Mathew, MD; Pierre Kory, MD; Arthur Sung, MD; Patricia Walker, MD
Chest. 2011;140(4_MeetingAbstracts):26A. doi:10.1378/chest.1120055
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INTRODUCTION: The pulmonary complications of inflammatory bowel disease (IBD) have been well described in the past, including the rare manifestation of pleuritis and pleural effusions. The characteristics of pleural fluid in Crohn’s pleuritis have rarely been reported. We report a case of pleuritis and myopericarditis in a patient with Crohn’s disease.

CASE PRESENTATION: A 29-year-old woman with Crohn’s disease (CD) on mesalamine therapy presented to our institution with a 3-day history of progressively worsening dyspnea and pleuritic chest pain. The patient had been in her usual health until one week prior to admission when she developed a severe sore throat. Vital signs on admission were temperature 97.3 F, blood pressure 118/70, pulse 124 beats per minute, respiratory rate 26/min and pulse-oximetry 99% on 2L/min of oxygen via nasal cannula. Pertinent physical exam included decreased breath sounds at the bases bilaterally and a normal cardiac exam. Admission labs were significant for white blood cell count 22,900/cu.mm with 91% neutrophils, C-reactive protein (CRP) 28.3 mg/dL, sedimentation rate 86mm/hr and troponin 1.29ng/mL. Electrocardiogram revealed sinus tachycardia without ST-T wave changes. Chest radiograph revealed bilateral pleural effusions. CT scan of chest revealed bilateral loculated pleural effusions and cardiomegaly with moderate pericardial effusion. No pulmonary embolism was identified. Thoracic ultrasound of the left pleural effusion identified septations and stranding within the fluid. Pleural fluid analysis was significant for a pH of 6.9, WBC = 1100/ uL with 90% neutrophils, no eosinophils, LDH = 3327 U/L, glucose< 20 mg/dl, protein = 3.5 g/dl and amylase <30 U/L. Right sided pleural fluid analysis showed similar characteristics. An extensive panel of serology for rheumatologic and viral causes were negative. Microbiological cultures from the blood and pleural fluid were also negative. The patient was started empirically on vancomycin, piperacillin/tazobactam, and metronidazole and a chest-tube was placed for drainage of the left pleural effusion. An esophagram was performed and a fistula between the gastrointestinal tract and the thoracic cavity was ruled out. Transthoracic echocardiogram showed a small pericardial effusion, normal ventricular function and no vegetations. By day 3, a peak troponin level was noted to be 8.42ng/ml. The patient did not show any improvement in her pleurisy and shortness of breath symptoms despite broad antibiotic therapy. Methylprednisone and high dose aspirin were then initiated for treatment of presumed inflammatory pleuritis and myopericarditis related to Crohn’s disease. Within two days, the patient’s dyspnea and pleurisy improved and CRP decreased to 3.4 mg/dL. Colonoscopy was performed revealing mildly congested mucosa in the recto-sigmoid colon and the pathology was consistent with mild nonspecific inflammation.

DISCUSSION: IBD is known to produce a multitude of extraintestinal manifestations. The pulmonary manifestations of IBD are more common than generally appreciated and are quite varied. The large airways are the most common site with bronchiectasis being the typical pulmonary manifestation. Pleura, myocardium and pericardium are relatively uncommon locations for manifestations of IBD and the patients are typically male, with ulcerative colitis (UC). Pleuro-myopericarditis can also occur in the quiescent phase of inflammatory bowel disease as in our patient but no case reports to our knowledge have reported the characteristics of pleural fluid in these cases. Our patient was a female with CD, as opposed to UC, and had bilateral complicated pleural effusion with myopericardial involvement. The pleural fluid characteristics were similar to pleural effusions from other rheumatologic diseases like systemic lupus and rheumatoid arthritis, however laboratory tests to support these diagnoses were all negative. Such pleural fluid characteristics can also be seen in parapneumonic effusions, however the patient had no clinical symptoms of pneumonia and did not respond to antibiotic therapy. Our patient responded dramatically to anti-inflammatory therapy with steroids and aspirin as has been described in previous reports of pleuropericarditis.

CONCLUSIONS: Pleuro-myopericarditis can occur in the dormant phase of inflammatory bowel disease and present with exudative bilateral pleural effusions. This condition usually responds well to anti inflammatory therapy.

Reference #1 Patwardhan RV, Heilpern RJ, Brewster AC, Darrah JJ. Pleuropericarditis: an extraintestinal complication of inflammatory bowel disease. Report of three cases and review of literature. Arch Intern Med. 1983 Jan;143(1):94-96

Reference #2 Michèle Faller,Bernard Gasserb,Gilbert Massardc, Gabrielle Paulid,Elisabeth Quoix: Pulmonary Migratory Infiltrates and Pachypleuritis in a Patient with Crohn’s Disease. Respiration 2000;67:459-463

DISCLOSURE: The following authors have nothing to disclose: Erwin Moy, Jaspreet Ahuja, Joseph Mathew, Pierre Kory, Arthur Sung, Patricia Walker

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