Inflamed Bowels, Now Inflamed Lungs: A Case Report of Pulmonary Necrobiotic Nodules in Crohn's Disease

Abstract

SESSION TITLE: Pulmonary Manifestations of Systemic Disease 3 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pulmonary necrobiotic nodules have been described as a rare extraintestinal manifestation of Crohn’s disease. We report imaging and pathological findings of this rare disease entity. CASE PRESENTATION: A 21-year-old gentleman with a longstanding history of Crohn’s disease presented with 2 weeks of right-sided pleuritic chest pain, associated with a dry cough. He did not report fevers, night sweats, abdominal pain or diarrhea. The patient had achieved remission of his Crohn's disease for 11 years with adalimumab, which was discontinued 2 months prior to presentation due to concerns of developing secondary lymphomas. He was then transitioned to mesalamine, after which he experienced a self-limited episode of Crohn’s disease exacerbation. On presentation, he was hemodynamically stable. Physical examination was notable for right-sided chest tenderness. Laboratory investigations showed an elevated erythrocyte sedimentation rate of 33 mm/hr and D-dimer of 535 µg/mL. A computed tomography (CT) scan of the chest showed multiple nodular appearing opacities bilaterally (figure 1). Lung biopsy revealed areas of parenchymal necrosis with necrotizing granulomas. The necrosis was basophilic, which contained nuclear debris and eosinophils with the surrounding inflammatory infiltrates (figure 2). Gram stain, acid-fast bacilli stain, fungal stain and tissue culture were all negative. Angiotensin-converting enzyme level was normal. Cytoplasmic antineutrophil antibodies titer was 1:40, myeloperoxidase and proteinase-3 antibodies were not detected. The differential diagnosis was primary vasculitis versus Crohn’s disease associated necrobiotic nodules. The lack of systemic manifestations lowered the suspicion for active vasculitis. The patient had an uneventful recovery. Mesalamine was changed to vedolizumab. Repeat chest CT scan 2 months later showed marked reduction in size and number of the pulmonary nodules. 5 months after presentation chest CT showed complete resolution of the previously noted pulmonary nodules. DISCUSSION: Our case demonstrates a rare pulmonary complication related to Crohn’s disease exacerbation, which is the development of pulmonary necrobiotic nodules. We suspect that this was the consequence of therapy de-escalation. Our hypothesis is supported by the complete resolution of pulmonary nodules following therapy re-escalation. CONCLUSIONS: Even after achieving Crohn's disease remission for a long period of time, therapy de-escalation still carries the risk of triggering unexpected pulmonary manifestations. Physicians should consider risks versus benefits of alternate therapy. In clinical practice, it is important to maintain a broad differential diagnosis, especially in patients with conditions affecting multi-organ systems. Reference #1: Warwick, G., Leecy, T., Silverstone, E., Rainer, S., Feller, R., & Yates, D. H. (2009). Pulmonary necrobiotic nodules: a rare extraintestinal manifestation of Crohn's disease. European Respiratory Review, 18(111), 47-50. DISCLOSURE: The following authors have nothing to disclose: Mahmoud Ahmed, Laurie Lerner No Product/Research Disclosure Information