SESSION TITLE: Interstitial Lung Disease Case Report Posters II
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Crohn's disease (CD) is an inflammatory condition of unknown etiology that can affect any part of the gastrointestinal tract. Although the extra-intestinal manifestations most commonly affect musculoskeletal, ocular, and mucocutaneous systems, there is an increasing recognition of the pulmonary involvement with Crohn’s disease. Here, we present a case of Crohn’s disease associated with necrobiotic lung nodules.
CASE PRESENTATION: A 22-year-old African American male presented with abdominal pain, fever and bloody bowel movements. He underwent colonoscopy with multiple colonic and ileal biopsies which were consistent with active CD. Abdominal CT scan showed incidental left lower lobe cavitary and non cavitary lesions (Fig.1). Despite these findings the patient had no respiratory symptoms. QuantiFERON-TB Gold test, sputum for AFB smear and culture, serum fungal serologies and Antineutrophil cytoplasmic antibodies (ANCA) testing including anti-proteinase 3 (PR3) and anti-myeloperoxidase (MPO) were negative. Transthoracic needle biopsy was not diagnostic. Subsequently, the patient underwent left lower lobe wedge biopsy which was consistent with necrobiotic pulmonary nodules (Fig. 2). He was started on mesalamine and prednisone with improvement of his symptoms.
DISCUSSION: Respiratory involvement in inflammatory bowel disease (IBD) is more common with ulcerative colitis and can be grouped into three categories: 1. Airway inflammation that can affect both large and small airways causing tracheobronchial stenosis, bronchiectasis or bronchiolitis obliterans. 2. Interstitial lung diseases including organizing pneumonia, nonspecific interstitial pneumonitis and lung infiltrate with peripheral eosinophilia. 3. Rarely, necrotic lung nodules and serositis could be encountered.(1) Only few cases of necrobiotic pulmonary nodules in association with CD were reported.(2) Necrobiotic nodules can cavitate and have radiographic appearance similar to the cavitating nodules of malignancy, septic pulmonary emboli, autoimmune diseases such as granulomatosis with polyangiitis (Wegener’s granulomatosis), and infectious etiologies of the lung cavity especially fungal infections and tuberculosis. Histologically, the nodules are composed of sterile aggregates of inflammatory cells with necrosis and have a high degree of resemblance to pyoderma gangrenosum. Necrobiotic lung nodules usually respond to treatment with steroids but exclusion of an infectious etiology is mandatory.(1)
CONCLUSIONS: Despite being a rarity, necrobiotic pulmonary nodules should be considered in the differential diagnosis of lung nodules in patients with Crohn’s disease.
Reference #1: 1. Camus P, Colby TV. The lung in inflammatory bowel disease. Eur Respir J. 2000 Jan;15(1):5-10.
Reference #2: 2. Warwick G, Leecy T, Silverstone E, et al. Pulmonary necrobiotic nodules: a rare extraintestinal manifestation of Crohn's disease. Eur Respir Rev. 2009 Mar;18(111):47-50.
DISCLOSURE: The following authors have nothing to disclose: Karim El-Kersh, Rafael Perez, Mostafa Fraig
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