San Juan City Hospital San Juan, PR, United States
Kyomara Z. Hernandez-Moya, MD, MPH, Juan M. Garcia-Puebla, MD, Arnaldo A. Nieves-Ortiz, MD, Ivan A. Rivera-Nazario, MD, Arnaldo Rojas-Figueroa, MD, Ricardo Fernandez, MD, Ricardo A. Hernandez, MD San Juan City Hospital, San Juan, Puerto Rico
Introduction: Inflammatory bowel disease, as Ulcerative Colitis and Crohn’s, are disorders of chronic inflammation of the gastrointestinal tract associated with extraintestinal manifestations in 10.4% of affected patients. Pulmonary involvement is rare and often overlooked. Respiratory changes can include small airways, vascular diseases or serositis, and other lung findings can develop in the course of IBD, but only few reports have demonstrated uncommon pleural manifestations.
Case Description/Methods: Case of a 47 y/o woman with Ulcerative Colitis on Mesalamine and Infliximab evaluated at ER with shortness of breath and night sweats. Referred compliance to medications, and still experienced abdominal pain and occasional bloody diarrhea. Vital signs were normal, asides from oxygen desaturation of 75%. Physical examination with diminished breath sounds and chest Xray showed bilateral pleural effusions, worse on right side. Patient was admitted for thoracentesis which yielded 1L of pleural exudative fluid. Culture, cytology, fungal and tuberculosis analyses were negative. Chest CT revealed mediastinal diffuse non calcified nodules, and bronchoscopy with biopsy was notable for macrophages with negative cytology. Due to effusion recurrence, thoracoscopy with pleural biopsy was done revealing necrotizing granulomas. Rarely, necrobiotic nodules have been described in IBD, and workup for tuberculosis and rheumatologic conditions were requested, all with normal results. Low dose steroids were started, and 4 month follow up chest CT still showed lung nodules. Bronchoscopy was performed again, with biopsy positive for non-caseating granulomas, compatible with sarcoidosis. In some cases, sarcoidosis can develop after anti TNF inhibitors, as Infliximab, mostly if used in rheumatological pathologies, less common in IBD. Pleural sarcoidosis is rare and effusions are usually exudates, as in this case. Therefore, Vedolizumab was started with optimized steroids resulting in marked pulmonary improvement and complete remission of UC.
Discussion: Pleural involvement by IBD or associated conditions like sarcoidosis is a rare extraintestinal presentation since only few cases have been reported. Although uncommon, unilateral, exudative pleural effusions can be directly related to both conditions. It is important to establish awareness and early identification of this manifestation that can be life-threatening to provide adequate management and treatment plans, avoid further complications and provide a better standard of care.
Disclosures: Kyomara Hernandez-Moya indicated no relevant financial relationships. Juan Garcia-Puebla indicated no relevant financial relationships. Arnaldo Nieves-Ortiz indicated no relevant financial relationships. Ivan Rivera-Nazario indicated no relevant financial relationships. Arnaldo Rojas-Figueroa indicated no relevant financial relationships. Ricardo Fernandez indicated no relevant financial relationships. Ricardo Hernandez indicated no relevant financial relationships.
Kyomara Z. Hernandez-Moya, MD, MPH, Juan M. Garcia-Puebla, MD, Arnaldo A. Nieves-Ortiz, MD, Ivan A. Rivera-Nazario, MD, Arnaldo Rojas-Figueroa, MD, Ricardo Fernandez, MD, Ricardo A. Hernandez, MD. P0609 - A Rare Clinical Case of Ulcerative Colitis Presenting With Unexpected Pulmonary Findings, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.