Extraintestinal Manifestations of Crohn’s Disease in the Form of Pulmonary Nodules: A Case Report

Abstract

Crohn's disease is a systemic illness with a plethora of extraintestinal manifestations affecting various organs, of which the lungs are relatively rare. Pulmonary involvement may include airway diseases, lung parenchymal diseases, pleural diseases, or drug-related diseases. Tracheobronchial involvement is the most common respiratory presentation, whereas Crohn's disease-related interstitial lung disease is seen less frequently. A 41-year-old woman with a past medical history of Crohn's disease (status-post subtotal colectomy) presented to the hospital for an enlarging ground-glass opacity in her right middle lobe detected on routine computed tomography of the abdomen six months earlier. The opacity had increased in size from 21 x 18 mm to 28 x 18 mm and another ground-glass opacity in the right lower lobe increased in size from 5 mm to 12.4 mm. A robotic right middle lobectomy with lymph node dissection was done and bronchoscopy showed benign nodular lymphoid hyperplasia and a single perivascular epithelioid granuloma. A year later, her relapsing episodes of cough and shortness of breath were managed with prednisone, 20 mg, for a probable pulmonary manifestation of Crohn's disease. A non-contrast computed tomography of the chest showed interval resolution of the right lower lobe ground-glass opacity. A year after that, she presented to the hospital with increasing cough, shortness of breath, and a new right lower lobe ground-glass opacity (14 x 14 mm) on non-contrast computed tomography of the chest and has been managed with steroids with consideration of immunosuppression. In conclusion, pulmonary manifestations of Crohn's disease present in a myriad of varieties and often present confounding diagnostic problems necessitating an extensive work-up. Thus, Crohn's disease should be kept in the differential list in case of unusual clinical symptoms and radiological signs of idiopathic pulmonary presentations. These infrequent, and sometimes life-threatening, extraintestinal manifestations need to be considered when dealing with Crohn's disease to avoid further impairment of health status and alleviate patient symptoms by prompt recognition and treatment.

Pulmonary manifestation of inflammatory bowel disease: Two case reports

“…Currently, there is no established treatment for pulmonary involvement in IBD. Therefore, such patients often receive steroids or immunosuppressive/biologic agents after exclusion of pulmonary infection and discontinue medication administered for the treatment of IBD [ [19] , [20] , [21] , [22] , [23] ]. Although the response to systemic steroid therapy is generally good, the disease can be refractory in some cases and lead to repeated relapses.…”

“…no. Age/Sex Symptoms and/or physical findings Chest CT findings Histopathology of the lungs and method of tissue biopsy Status of UC/CD Therapy for UC/CD until the onset of pulmonary abnormalities Outcome [ 15 ] 17 years, female CD with severe malnutrition, diarrhea, perianal abscess (no respiratory symptoms) Tree-in-bud opacities predominantly in the bilateral lower lobes of the lung VATS with necrotizing granuloma and organizing pneumonia Active No medication Resolution of radiographic abnormalities [ 15 ] 14 years, female CD with chest pain and cough Bilateral pulmonary nodules with central cavitation VATS with necrotizing granuloma and organizing pneumonia Remission No medication (previously treated with infliximab and prednisone) Resolution of radiographic abnormalities [ 20 ] 77 years, female CD without respiratory or intestinal symptoms Bilateral pulmonary multiple masses VATS with marked fibrosis and non-caseating granulomas Remission No medication Resolution of radiographic abnormalities [ 21 ] 64 years, male 10-year history of CD with productive cough, dyspnea, and weight loss approximately 5 years after initial diagnosis Multiple pulmonary nodules VATS with scattered epithelioid granulomas Remission No medication (previously treated with mesalamine and occasional steroid therapy) Resolution of radiographic abnormalities [ 22 ] 17 years, female UC without respiratory or intestinal symptoms Bilateral pulmonary nodules, one of which included a central cavitation TBLB with macrophages in the alv...…”

Pulmonary Crohn’s Disease or Crohn’s Disease with Lung Sarcoidosis? A Case Report and Literature Review

“…This third category is greatly underestimated and underreported, which has led to the inclusion of DLCO (diffusing capacity for carbon monoxide) in routine evaluations of these patients in order to detect subclinical forms and institute inhaled steroid treatment [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ].…”

“…Kraft et al [ 26 ] published the first original report in 1976, presenting a batch of six patients with inflammatory bowel disease and a chronic purulent sputum. Numerous other authors have described respiratory impairment in inflammatory bowel diseases, implicitly in Crohn’s disease in over 15 reports with many more patients [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 18 , 19 , 23 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”

The Diagnostic Dilemma of Acute Granulomatous Hepatitis in a Patient With Crohn’s Disease: A Case Report and Review of Literature

“…Very rarely, these lung nodules may represent necrobiotic nodules, an unusual pulmonary manifestation of extraintestinal CD. 10 Furthermore, histopathological findings of hepatic sarcoidosis that encompass periportal fibrosis and chronic intrahepatic cholestasis are not pathognomonic for sarcoidosis and can also be present in CD-associated granulomatous hepatitis, 4,5 thus making a remarkable distinction between the 2 entities quite challenging. 4,11 The co-occurrence of sarcoidosis and CD is a rare phenomenon, though it has been described in the available literature.…”