Abstract

We present the case of a 38 year old male who presented with several weeks of respiratory complaints found to be the result of Crohn's Disease (CD) with Pulmonary Manifestations. His past medical history was significant for long standing CD and he was on immunosuppressive therapy with vedolizumab. Initial findings were concerning for Bronchopneumonia or a possible Metastatic Disease. Subsequent work-up eliminated infectious and cancerous etiologies. This included blood cultures, HIV, Quantiferon Gold Assay, PPD, and bronchial biopsy results. Furthermore, GMS, AFB, and Truant special stains were negative for fungal elements and mycobacteria.

Eventually, the patient underwent a VATS (video-assisted thoracoscopic surgery) biopsy, which revealed noncaseating granulomas with prominent neutrophilic microabscesses. This finding led to the differential diagnosis of either a vasculitis, or a pulmonary CD. The lack of cavitation, fibrinoid necrotizing epithelioid and eosinophilic granulomas, necrotizing granulomatous vasculitis, glomerulonephritic symptoms, and a negative ANCA essentially ruled out the diagnosis of eosinophilic granulomatosis with polyangiitis. Biopsy of the lung also did not reveal the characteristic geographic necrosis and acute and chronic inflammation changes which are typical of granulomatosis with polyangiitis. These findings ultimately led to the diagnosis of Pulmonary CD with pulmonary necrobiotic nodules. This is an extremely rare manifestation of the Inflammatory Bowel Syndrome and one that clinicians should have within their differential upon treating patients with long-standing CD and pulmonary complications.

Keywords: Internal medicine; Gastroenterology; Inflammatory bowel disease