S4980 Pulmonary Granulomas in Crohn’s Disease: A Case Report

Introduction: Granulomas are inflammatory lesions consisting of an organized collection of macrophages and other immune cells, associated with infection or autoimmune conditions. Crohn’s disease (CD) is an autoimmune condition characterized by patchy areas of transmural inflammation occurring throughout the gastrointestinal tract with numerous extraintestinal manifestations, the most common being arthritis, erythema nodosum, and uveitis. We describe a rare case of multiple pulmonary granulomas secondary to active CD. Case Description/Methods: A 38-year-old woman with a 3 pack-year history of smoking and ileocolonic CD diagnosed at age 24 not on therapy presented with left shoulder pain and chronic cough. A chest computed tomography (CT) with intravenous contrast was performed which demonstrated >10 bilateral nodular/mass-like spiculated pulmonary lesions affecting all lobes with minimal peripheral ground-glass opacities. The largest such lesion was localized subpleurally at the posterior left base, measuring 4.3 cm. A biopsy showed a non-caseating granuloma with negative elastic fiber changes, negative bacterial and fungal stains/smears, and no evidence of malignancy. Mantoux test and ANA were negative, and C-reactive protein was 56.6. She was treated with antibiotics and improved but her pulmonary symptoms recurred after 6 months concurrent with a flare of her CD (calprotectin 1260). A repeat chest CT showed mild centrilobular emphysema, mild bronchiectasis, and 3 new lesions in the right lower lobe without significant adenopathy. A bronchoscopy of the right lower lobe was unremarkable with normal eosinophils. On a review of her previous biopsy, the consensus was that this was pulmonary CD. She received oral prednisolone followed by symptomatic relief on twice weekly intravenous infliximab. She then switched to risankizumab due to infliximab-induced hepatitis which resolved her gastrointestinal and pulmonary symptoms. At 3 years of follow-up, fecal calprotectin was 36 and repeat chest CT demonstrated resolution of most pulmonary nodules. Discussion: A pulmonary extraintestinal manifestations should be considered in a patient with CD and lung granulomas but can initially be mistaken for an infectious process. Once pulmonary CD is confirmed, the patient should also be investigated for a concurrent flare of their CD as literature review indicates that pulmonary manifestations are not always congruent with luminal disease activity. Steroids and biologics are used to manage CD-associated pulmonary granulomas.