Pulmonary Manifestations of Inflammatory Bowel Disease (IBD) in Patients With Late-Onset IBD

Abstract

Background: pulmonary manifestations are uncommon in IBD. We report 3 different pulmonary manifestations in patients with late onset IBD to show that they may be more prone to pulmonary complications. Patient #1: A 45 year old male developed frequent loose stools with streaks of blood. Colonoscopy demonstrated diffuse colitis extending from the distal colon to the distal ascending colon. Biopsy demonstrated chronic active colitis with extensive ulceration and inflammation. The patient was diagnosed with Ulcerative Colitis and started Mesalamine. Over a 3 month period the patients symptoms continue to worsen despite increased doses of Mesalamine and a trial of oral corticosteroids. The patient was started Azathioprine. Two weeks later the patient presented for dyspnea and was diagnosed with a pulmonary embolus. He was discharged from the hospital on Warfarin. He continued Warfarin therapy for 12 months with no further reported evidence of thrombus formation. Patient # 2: A 71 year old male developed hematochezia. 71. A flexible sigmoidoscopy demonstrated ulcerated mucosa concerning for IBD. He was started on mesalamine for 3 months without benefit, so it was stopped. He then developed a perianal fistula, requiring fistulotomy 14 months later. Colonoscopy showed segmental colitis in the sigmoid. The patient developed dyspnea and was referred to the pulmonary clinic. Pulmonary function tests showed mild restrictive disease and a CT chest showed bibasilar and right middle lobe honeycombing. The patient remained off medications for colitis and had spontaneous symptomatic improvement of his shortness of breath. A chest x-ray 16 months later showed no evidence of interstitial disease. Patient #3: A 51 year old male, with ulcerative colitis, was on prednisone and mesalamine for approximately for 7 years with good control. Because of a flare he was started on azathioprine, but developed fever and dyspnea. A chest x-ray showed bibasilar consolidation and a CT chest showed extensive ground glass opacities bilaterally in the upper lobes. He underwent broncho-alveolar lavage (BAL) and transbronchial biopsies. The BAL cultures showed Staph aureus without symptoms; the transbronchial biopsies showed cryptogenic organizing pneumonia. Azathioprine was stopped, prednisone and mesalamine were continued. Prednisone was tapered and follow up CT chest showed a near resolution of his organizing pneumonia Discussion: Patients #1 and #2 developed pulmonary symptoms close to diagnosis. Patient #3 developed symptoms nearly 7 years after diagnosis, during a flare. These cases demonstrate the importance of looking for pulmonary symptoms in older patients diagnosed with IBD, especially during onset and acute flares.