SESSION TITLE: Miscellaneous Global Case Reports
SESSION TYPE: Global Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: This case report describes a rare presentation of Crohn’s disease and emphasizes the importance of lung nodules with eye and skin lesions, especially in patients without gastrointestinal manifestations.
CASE PRESENTATION: A 33-years-old Japanese female presented with one month of painful swelling of the dorsum of the bilateral foot. Her past medical history was only polycystic ovary syndrome. She had no smoking and alcoholic history. Vital signs were as follows: heart rate, 87 bpm; respiratory rate, 16 breaths per minute; blood pressure, 110/68 mmHg; temperature, 36.4℃; and oxygen saturation, 98% on room air. Physical examination revealed conjunctival congestion in the right eye, painful erythema nodosum on bilateral pretibial surface of the lower legs, and marked dorsal tenderness over the first through fourth metatarsophalangeal joints in both feet. Breathing and cardiac sounds were normal. Laboratory test values were as follows: white blood cells, 8,920/mm3; hemoglobin, 11.4g/dl; platelets, 445,000/mm3; serum C-reactive protein (CRP), 5.41 mg/dl; serum IgG 1940 mg/dl (normal, 800- 1600 mg/dl); another biochemistry and serology data were normal. The chest x-ray revealed multiple nodules on the right lower and left middle lung field. The chest CT scan revealed multiple irregular nodules with central low attenuation in the right middle, right lower, and left lower lobe of the lung. The patient underwent fiberoptic bronchoscopy that revealed normal endobronchial system, and transbronchial biopsy (TBB) was performed. The TBB sample from the right lower lobe showed alveolar septal infiltration of chronic inflammatory cells, alveoli filled with fibrin and foamy macrophage, and foci of organizing pneumonia. No epidermoid granuloma and microorganisms were identified. The pathological examination of skin biopsy specimen revealed subcutaneous adipose tissue infiltrate composed of lymphoid cells and histiocytes, without vasculitis, giant cells and microorganisms, and these findings were thought to be compatible with erythema nodosum. The colonoscopy revealed multiple longitudinal ulcers throughout the entire colon. Pathological examination of the ascending colon revealed focal ulcerations, and infiltration of inflammatory cells in the mucosa. The skin pathergy test was negative, and the HLA tests were positive for B40 and B55. The patient was diagnosed as having Crohn’s disease. Gastroduodenoscopy and small-bowel follow-through study were normal. The lung nodules had begun to show radiographic improvement before any treatment was started, but the patient was still symptomatic with painful swelling of bilateral foot. Treatment with sulfasalazine was started, however, her symptoms were not relieved. Therefore, daily 20 mg prednisolone (PSL) was started, following which her symptoms gradually began to show improvement.
DISCUSSION: The prevalence of pulmonary involvement in Crohn’s disease is unknown but indirect evidence suggests it is common, at least subclinically. High-resolution CT scanning of inflammatory bowel disease patients with respiratory symptoms may demonstrate bronchiectasis, bronchiolectasis and cellular bronchiolitis, even in the absence of lung function abnormalities. In our patient, TBB samples from lung nodule showed organizing pneumonia. However, the nodules had central low attenuation on chest CT images, therefore, there was a possibility that the nodules were necrobiotic nodules. Although more commonly seen in ulcerative colitis, necrobiotic nodules are a rare pulmonary manifestation of Crohn’s disease. The presentation in our patient was unique because she had no apparent gastrointestinal symptoms. The lung nodules had begun to show radiographic improvement before any treatment was started.
CONCLUSIONS: This patient’s presentation was unique in that Crohn’s disease caused multiple lung nodules without any gastrointestinal symptoms. This case highlights the importance of including Crohn’s disease in the differential diagnosis of multiple lung nodules with eye or skin manifestations.
Reference #1: Warwick G, et al. Pulmonary necrobiotic nodules: a rare extraintestinal manifestation of Crohn's disease. Eur Respir Rev 2009; 18: 111, 47-50.
Reference #2: Mahadeva R, et al. Clinical and radiological characteristics of lung disease in inflammatory bowel disease. Eur Respir J 2000; 15: 41-48.
Reference #3: Camus P, Colby TV. The lung in inflammatory bowel disease. Eur Respir J 2000; 15: 5-10.
DISCLOSURE: The following authors have nothing to disclose: Kohei Yoshimine, Kazunori Tobino, Hiroyuki Miyajima
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