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Inflammatory Bowel Disease and Treatment With Associated Pulmonary Vasculitis: A Case Report FREE TO VIEW

Abhay Vakil, MD; Hineshkumar Upadhyay, MD; Chetan Doodhia, MD; Viral Patel, MBBS; Kelly Cervellione, PhD; Alan Fein, MD
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Richmond Hill, NY

Chest. 2013;144(4_MeetingAbstracts):904A. doi:10.1378/chest.1690460
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SESSION TITLE: Miscellaneous Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Ulcerative colitis, a chronic inflammatory syndrome also commonly presents with extra-intestinal manifestations, and sometimes involves the lung. These include bronchiectasis, ILD, organizing pneumonia, serositis, pulmonary embolism, infections and treatment induced complications. Associated vasculitis has been attributed to underlying auto immune mechanisms and TNF alpha inhibitors which are increasingly used for the treatment of IBD not responding to conventional therapies. Cases with TNF alpha inhibitors associated vasculitis have also been reported. We report a case of 42 year-old woman with ulcerative colitis, who developed pulmonary vasculitis after starting adalimumab therapy that improved after institution of systemic steroid therapy, despite continuation of adalimumab.

CASE PRESENTATION: A 42-year-old woman with 10 year history of ulcerative colitis(UC), requiring colectomy 6 years ago, relapsed 1 year ago. After trying conventional medications, adalimumab was started 6 months ago, and her UC was controlled. However, she developed productive cough, low grade fever, chills, fatigue, joint pain and weight loss. Physical examination revealed bilateral rales with decreased air entry, oxygen saturation 93 % on room air. CT chest revealed bilateral diffuse nodular consolidations. Bronchoalveolar lavage cultures were negative. VATS biopsy revealed acute septal inflammatory process characterized by subtle microvascular injury accompanied by mixed pericapillary infiltration with immune complex deposition. All immunologic, connective tissue disorder and vasculitis work-up including ANCA, ANA, complement levels and auto-antibodies were negative. She was started on 60 mg oral Prednisone therapy, following which she showed rapid radiologic clearings and resolution of all symptoms except productive cough. She continued to be on adalimumab and steroids were tapered over 2 months.

DISCUSSION: Pulmonary vasculitis is an unusual; but well documented complication of ulcerative colitis. While the focal consolidation and ground glass infiltrates more likely represents infectious pneumonia, organizing pneumonia and interstitial pneumonitis must be considered. In this case immune complex deposition was associated with capillaritis. While vascualitis could be related to the TNF inhibitor adalimubab, resolution following initiation of corticosteroids despite continuation of this drug suggests vasculitis was directly related to IBD.

CONCLUSIONS: Vasculitis needs to be included in the differential diagnosis of pulmonary infiltrates in patients with active UC.

Reference #1: Extraintestinal considerations in inflammatory bowel disease. Levine JB, Lukawski-Trubish D Gastroenterol Clin North Am. 1995 Sep;24(3):633-46.

Reference #2: Clinical and radiological characteristics of lung disease in Inflammatory bowel disease, Eur Respir J 2000; 15: 41±18

Reference #3: Pulmonary Involvement in Inflammatory Bowel Disease Ann Thorac Surg 2007;84:1748-1750

DISCLOSURE: The following authors have nothing to disclose: Abhay Vakil, Hineshkumar Upadhyay, Chetan Doodhia, Viral Patel, Kelly Cervellione, Alan Fein

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