ULCERATIVE COLITIS-INDUCED PLEURAL DISEASE

Abstract

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Fellow Case Reports INTRODUCTION: Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn's disease, are associated with a large number of extraintestinal manifestations. We are presenting a case of ulcerative colitis induced pleural disease CASE PRESENTATION: 21 y/o man with a history of ulcerative colitis (UC) on mesalamine who presented to the clinic with persistent cough. Two months prior to clinic presentation he visited the emergency department complaining of stabbing chest pain associated with dry cough. CTA chest at that time showed no pulmonary embolism. However, it showed bilateral pleural densities measuring up to 13 mm in depth and 22 mm in circumference. The patient denied travel to TB endemic areas. He is a current smoker with a 2-pack year history. Infectious workup was unremarkable for TB and histoplasmosis. His ESR and CRP were within normal limits. A two month follow up CT chest showed new pleural densities with enlargement of the old ones up to 18 mm in depth and 55 mm in circumference. Plan was for trans thoracic biopsy. Three weeks later at the time of biopsy, limited CT chest showed significant improvement in the bilateral densities and resolution of the patient's cough. Three months follow up CT chest showed complete resolution of the pleural based densities. DISCUSSION: Rarely, Inflammatory Bowel Disease (IBD) involves the pleural space and pericardium, causing inflammatory exudative pleural and/or pericardial effusions. Most patients are young, male, and have UC during the quiescent phase of the disease. The manifestations of pleural disease can be classified as: pneumothorax, pleural thickening, pleuritis, and pleural effusion (usually unilateral, an exudate with neutrophils, and may be hemorrhagic). Our patient didn't have a pleural effusion. Ongoing bowel inflammation is not a prerequisite for the onset of respiratory alterations, because bronchopulmonary disease that develops after colectomy has been reported. Pulmonary abnormalities in IBD can present years after the onset of bowel disease and can affect any part of the lungs. These may be overt or subclinical and do not correlate with the duration of IBD.Mesalamine may also induce pleural disease and its immunologically mediated. Cessation of the drug is needed sometimes, and the use of corticosteroids may be limited to patients with poor response or severe symptoms. Our patient continued to be on Mesalamine without further problems. Differentiating between Mesalamine and IBD related pleuritis can be challenging. However pleural or pericardial biopsies are rarely necessary and mostly will show nonspecific acute and chronic inflammatory changes. CONCLUSIONS: Pulmonary involvement should be considered when pleurisy developed in UC. Also Mesalamine-induced pleuritis is a real clinical entity and its pathogenesis is immunologically mediated. REFERENCE #1: Lu, Shuming MD, PhDa; Wang, Lihua MDb; Zhang, Weisheng MD, PhDc,*; Zhang, Zhuqing MDd; Liu, Lina MDa; Wang, Yingde MDa; Meng, Hua MDa,* Ulcerative colitis with acute pleurisy, Medicine: July 2017 - Volume 96 - Issue 30 - p e7630doi: 10.1097/MD.0000000000007630 REFERENCE #2: Alessandro Tozzi, MD, Maria Rosa Biagini, MD, Carlotta Rastelli, MD, Andrea Galli, MD, Donatella Baldi, MD, Stefano Milani, MD, Mesalamine-induced Pleuritis in a Patient with Ulcerative Colitis, Inflammatory Bowel Diseases, Volume 15, Issue 1, 1 January 2009, Pages 158–159 REFERENCE #3: Moeser A, Pletz MW, Hagel S, Kroegel C, Stallmach A. Lung disease and ulcerative colitis--mesalazine-induced bronchiolitis obliterans with organizing pneumonia or pulmonary manifestation of inflammatory bowel disease? Z Gastroenterol. 2015 Sep;53(9):1091-8. doi: 10.1055/s-0041-103377. Epub 2015 Sep 14. PMID: 26367026. DISCLOSURES: No relevant relationships by Yazan Addasi, source=Web Response No relevant relationships by Ian Jackson, source=Web Response No relevant relationships by Carolina Landeen, source=Web Response No relevant relationships by Ali Nayfeh, source=Web Response