A DIFFERENTIAL OF PULMONARY NODULES UNTOLD: NECROBIOTIC LUNG NODULES IN THE SETTING OF CROHN'S DISEASE

Abstract

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Crohn's disease (CD) has been rarely associated with varying forms of inflammatory lung disease.(1) Increasing in concern is its rare association with necrobiotic lung nodules (NLN). The objective of this report is to describe a rare case of lung nodules found to be NLN in the setting of CD. CASE PRESENTATION: A 36 year old Caucasian female presented with a history of cough productive of thick green sputum, chest pain, subjective fever, fatigue and night sweats. Past medical history included hypertension, hypothyroidism, and diarrhea under investigation. Physical examination was significant for swollen painful joints, nail pitting and a pruritic rash on her palms.Chest computed tomographic (CT) imaging revealed multiple bilateral nodular opacities (Figure 1), two of which were cavitating. Serologic workup for an underlying cause of her cavitary lesions revealed negative ANA, C-ANCA, P-ANCA, acid-fast bacilli smear, fungal battery and culture. Sputum culture revealed rare germinating yeast and few candida albicans for which she was started on a 21-day course of fluconazole. As she showed no signs of improvement, bronchoscopy and broncho-alveolar lavage were performed. Findings revealed abundant bland cells in favor of benign bronchial hyperplasia with no evidence of malignant cells.A subsequent VATS and surgical wedge biopsy of right upper and middle lobe nodules was performed. Histopathology revealed an acute and organizing lung injury with necrobiotic nodules consisting of neutrophilic abscess, scattered histiocytes and giant cells. Serologies for Saccharomyces cerevisiae IgA and IgG were positive, suggestive of underlying CD.She was started on prednisone (40mg daily), which led to marked improvement in her symptoms. She was also treated with infliximab infusion and azathioprine while her steroid course was tapered. A follow up CT-chest at six months showed resolution of her lung nodules. DISCUSSION: This was a case of a 36-year-old Caucasian female who presented with NLN in the setting of CD. It is a rare presentation with only seven cases reported previously. Histologically, NLNs are composed of sterile aggregates of inflammatory cells with necrosis, as was seen with our patient.(1-3) Both cavitating and non-cavitating lung nodule presentations have been described on radiographic imaging.(2) Treatment with steroids or mesalamine has been associated with disease resolution, with infliximab reserved for disease refractory to systemic steroids.(1-3) CONCLUSIONS: This case highlights the importance of awareness of NLN as a differential of pulmonary nodules in persons with suspected CD. REFERENCE #1: El-Kersh, Fraig M, Cavallazzi R et al. Pulmonary Necrobiotic nodules in Crohn's Disease: A rare extra-intestinal manifestation. Respir Care. 2014 Dec;59(12):e190-2. REFERENCE #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. REFERENCE #3: Sanjeevi A, Roy H. Necrobiotic nodules: A rare pulmonary manifestation of crohn's disease. Am J Gastroenterol. 2003 Apr;98(4):941-3. DISCLOSURES: No relevant relationships by Tanya Marshall, source=Web Response No relevant relationships by Joseph Parambil, source=Web Response