Nuisance Neighbors: Gut-Lung Cross Talk in a Case of Crohnʼs Disease

Abstract

Crohn's disease (CD) is a systemic illness with a plethora of extra-intestinal manifestations (EIM) affecting various organs, of which lungs are relatively rare. The clinicopathological patterns of pulmonary involvement consist of subclinical alterations, airway diseases, lung parenchymal diseases, pleural diseases and drug-related diseases. Tracheobronchial involvement is the most common respiratory presentation, whereas CD-related interstitial lung disease (ILD) is seen less frequently. A 41-year-old woman with a past medical history of CD (s/p subtotal colectomy) presented to the hospital for an enlarging ground-glass opacity (GGO) in her right middle lobe (RML) detected on routine CT abdomen for a CD workup six months back. She was asymptomatic, HR- 62/min, BP- 90/70 mm Hg, FEV1-122%, DLCO 106% on PFT. Contrast-enhanced CT chest showed the GGO in RML had increased in size from 21 x 18 mm to 28 x 18 mm and another GGO in the right lower lobe (RLL) increased in size from 5 mm to 12.4 mm. A robotic RML lobectomy with lymph node dissection and bronchoscopy, to rule out adenocarcinoma with lepidic growth, showed benign nodular lymphoid hyperplasia and a single perivascular epithelioid granuloma. A year later, her relapsing episodes of a cough and shortness of breath were managed with prednisone 20 mg for a probable pulmonary manifestation of CD. A non-contrast CT (NCCT) chest showed interval resolution of RLL GGO. A year later, she presented to the hospital with increasing cough, shortness of breath and a new GGO RLL (14 x 14 mm) on NCCT chest and is being managed with steroids with consideration of immunosuppression. In conclusion, pulmonary manifestations of CD present in a myriad of varieties often representing confounding diagnostic problems necessitating an extensive work-up. Thus, CD should be kept in the differential list in the case of unusual clinical symptoms and radiological signs of a pulmonary presentation. These infrequent, and sometimes life-threatening, EIM need to be considered when dealing with CD, to avoid further impairment of health status and alleviate patient symptoms by prompt recognition and treatment.2082_A Figure 1. Initial CT Abdomen & CT Chest2082_B Figure 2. CT Chest six months later2082_C Figure 3. NCCT Chest s/p lobectomy and most recent one