Gut-Lung Connection: Pulmonary Necrobiosis in Inflammatory Bowel Disease

Abstract

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Inflammatory bowel disease (IBD) is an idiopathic disease that causes inflammation of the gastrointestinal tract and includes ulcerative colitis and Crohn’s disease. Overt respiratory manifestations of IBD are unusual, but bronchiectasis, organizing pneumonia, and eosinophilic pneumonia have been reported. Cavitary lung nodules are rarely seen in IBD. In this report, we present a case of Crohn’s disease-associated pulmonary necrobiosis. CASE PRESENTATION: A 67-year-old woman with Crohn’s disease on adalimumab presented with four weeks of cough, hemoptysis, and dyspnea. Computed tomography (CT) of the chest revealed nodular cavities with consolidation (Fig. 1). Laboratory evaluation for Cryptococcus, Aspergillus, Coccidioides, Histoplasma, and Mycobacterium tuberculosis was unrevealing. Autoimmune serologies (antinuclear antibody, anti-neutrophil cytoplasmic antibodies, rheumatoid factor, and SSA/SSB) were negative. A bronchoscopy with bronchoalveolar lavage was performed with negative bacterial, fungal and mycobacterial cultures. An initial CT-guided biopsy did not reveal any organisms or malignant cells. Video-assisted thoracoscopic surgery (VATS) biopsy of the right middle and lower lobes was performed, with pathology showing airway-centered inflammation with secondary granulomas, abscess formation, and necrosis (Fig. 2), consistent with a diagnosis of pulmonary necrobiosis. She was started on infliximab, which caused an infusion reaction. She was then placed on prednisone and mycophenolate mofetil, with resolution of the cavitary lesions. DISCUSSION: Extra-intestinal manifestations of IBD are not commonly seen in the lung, and pulmonary necrobiosis has only been described in isolated case reports. Necrobiotic lung nodules are sterile nodules that can cavitate and histologically are composed of abscesses filled with necrotic debris and inflammatory cells. The association between bowel disease activity and the lung lesions has been controversial in the literature, as the nodules have been reported to precede, be coincident with, or follow the diagnosis of IBD. Pulmonary necrobiosis responds well to corticosteroids though the duration of treatment remains unknown. CONCLUSIONS: There should be a high index of suspicion for the development of pulmonary disease in the setting of IBD, and IBD should be considered in the differential of cavitary lung nodules. Reference #1: El-Kersh K., et al. Pulmonary necrobiotic nodules in Crohn’s disease: a rare extra-intestinal manifestation. Respir Care 2014;59(12):e190-e192. DISCLOSURE: The following authors have nothing to disclose: Nancy Hsu, Yusaku Shino No Product/Research Disclosure Information