Abstract
Crohn’s disease is a granulomatous systemic illness with extra-intestinal manifestations. Of these extra-intestinal manifestations, lung involvement (0.4%) is the rare manifestation. Bronchopulmonary signs and symptoms are underrecognized, so suspicion should be high when granulomas are seen in lung biopsies. We report the case of a 27-year-old female who presented with bilateral pleuritic chest pain and shortness of breath. Chest X-ray showed left lung masses measuring up to 3.3 cm in the greatest dimension with right mid lung nodular opacity. Given the possibility of metastatic disease, positron emission tomography CT (PET-CT) scan was done, which showed activity in multiple liver lesions and multiple bilateral lung nodules. Both liver and lung biopsies were done, which showed multiple necrotizing and non-necrotizing granulomas. The patient was discharged home on antibiotics and antifungals. Few months later, she presented with loose stools and abdominal pain. CT scan of the abdomen and pelvis showed diffuse colonic wall thickening concerning for colitis. Colonoscopy showed ulcerated mucosa involving multiple parts of the colon. Biopsy of the colon showed mild to moderate acute colitis with submucosal non-necrotizing epithelioid granulomas, consistent with Crohn’s disease.
Highlights
Crohn’s disease (CD) is a granulomatous systemic illness with intestinal and extra-intestinal manifestations
Subclinical alterations in lung function have been demonstrated in at least half of adults with CD, clinically significant lung disease is extremely rare with an overall prevalence of 0.4% [1]
Among all the pulmonary manifestations, the presence of granulomas should be most concerning for CD
Summary
Crohn’s disease (CD) is a granulomatous systemic illness with intestinal and extra-intestinal manifestations. We present the case of a 27-year-old female patient with no significant past medical history. She presented with bilateral pleuritic chest pain and progressive shortness of breath. PET-CT scan showed activity in multiple liver lesions and multiple bilateral lung nodules. Given the possibility of lung metastasis, a liver biopsy was done that showed benign liver parenchyma with multiple necrotizing and non-necrotizing granulomas (Figure 2). Follow-up CT scan of the chest without contrast was done that showed interval increase in size and number of bilateral pulmonary nodules (Figure 3). Transbronchial biopsy of the left lung lower lobe was performed, which showed fragments of benign lung tissue with mild cellular interstitial inflammation, non-necrotizing granulomata, and organizing pneumonia (Figure 4). The patient was started on steroids, Humira (adalimumab) and 5 mercaptopurine, and is doing well currently
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