A 48 Year Old Man with Cavitary Lung Lesions

1
A 48 Year Old Man with Cavitary Lung Lesions
Mark E. Willcox MD1, Michael H. Spinelli MD1,
Jorge E. Guerro MD2, Christina Reichner MD2
1Department of Medicine, Georgetown University
Hospital, Washington, DC 2Deparment of Pulmonary
and Critical Care Medicine, Georgetown University
Hospital, Washington, DC
Georgetown University
Abstract
Pathology
Radiology
Pathology of left lower lobe lesion Showing
several foci of abscess surrounded by organizing
pneumonia and bronchiolitis obliterans, some
abscesses show epithelioid granulomas and foreign
body-type giant cells in the surrounding area, no
evidence of malignancy. Many of the medium-sized
arteries are involved in an area of organizing
pneumonia with luminal obliteration and
re-canalization and some with inflammation within
the walls, however vessels away from the lesion
show no evidence of vasculitis.
A 48 year old man with fistulizing Crohns
disease presented with cavitary lung lesions
resistant to antibiotic therapy. The diagnosis
was made by VATS guided lung biopsy.
Fig. 1
Case Presentation
History of Present Illness A 48 year old
homeless African American male with fistulizing
Crohns disease presented to our emergency room
with two months of worsening arthralgias, fevers,
and cough. His cough was productive of small
amounts of dark green sputum associated with left
sided, pleuritic, chest pain. He denies
hemoptysis, dyspnea, emesis, night sweats, and
weight loss. The rest of his review of systems
was negative. Past Medical History Crohns
disease complicated by enterocutaneous and
enterovesicular fistulas requiring a colostomy
and urostomy. Past Surgical History Colostomy Ur
ostomy Debridement of groin cellulitis Social
History History of alcohol abuse History of
tobacco abuse - 30 pack years History of IVDU-
heroin and cocaine Used to work as a diesel
mechanic, but was homeless at time of
admission Has lived along the eastern seaboard
and as far south as Alabama. No travel outside
of the continental United States. Physical
Examination on Admission T 36.2 BP 125/67
HR 82 RR 14 SpO2 97 on RA Gen Alert,
oriented times three. African American male in
no apparent distress sitting comfortably in
bed. HEENT II- XII intact with muddy sclera, no
icterus, no JVP, no oral lesions with poor
dentition. No cervical lymphadenopathy CV
Regular rhythm and rate without murmurs, gallops,
or rubs Pulm Clear to auscultation
bilaterally Abd Normal active bowel sounds.
Soft, non tender, non distended without palpable
masses. Urostomy and ileostomy appear healthy
without signs of infection. Ext No clubbing,
cyanosis, or edema. No distal signs of embolic
phenomenon
Fig 1 Admission CXR showing a R middle lobe
lesion Fig 2 Chest CT on admission showing R
middle lobe cavitary lesion and L lower lobe
mass. Fig 3 Chest CT on hospital day nine
showing stable appearance of the R middle lobe
lesion with interval expansion and progression of
the L lower lobe lesion.
Pearls

• The differential diagnosis of cavitary lung
  lesions in patients with inflammatory bowel
  disease must include necrobiotic nodules,
  although this remains a diagnosis of exclusion.
• Ulcerative colitis is more commonly associated
  with pulmonary pathology, but lung manifestations
  are well documented in Crohns disease.
• VATS or open lung biopsy is likely necessary for
  definitive diagnosis of necrobiotic lung nodules.
• Treatment of these nodules may not require
  immunosuppression.

Necrobiotic Lung Nodules and Inflammatory Bowel
Disease

• Pulmonary manifestations of IBD
• Associated with full spectrum of pulmonary
  pathology
• UC more common than Crohns (88 vs. 12)
• Occur at any age, may affect more women than men
• Case reports exist of pulmonary manifestations
  preceding GI symptoms
• This is the 4th reported case of necrobiotic
  nodules in a patient with Crohn's disease

• Differential Diagnosis
• Immunocompetent
• Primary or metastatic neoplasm
• Pyogenic lung abscess
• Cavitating bacterial pneumonia
• Sarcoidosis
• Tuberculosis
• Vasculitides
• Immunocompromised
• Lymphoma
• Nocardia
• Histoplasmosis
• Blastomycosis
• Aspergillus spp.
• IBD associated nodules
• Outcomes
• Historically two patients improved with steroids
  while the other improved without specific therapy
• Our patient showed clinical and radiographic
  improvement after antibiotics but without
  immunosuppressive therapy

Pulmonary involvement in inflammatory bowel
disease6
References

• Black H, Mendosa M, Murin, S. Thoracic
  Manifestations of Inflammatory Bowel Disease.
  Chest 2007131(2)524532
• Camus P, Piard F, Ashcroft T, et al. The lung in
  inflammatory bowel disease. Medicine (Baltimore)
  1993 72(3)151-183
• Rodriguez-Roisin, R and Barberá, JA. Pulmonary
  Complications of Abdominal Disease. In Mason
  Murray Nadel's Textbook of Respiratory
  Medicine, 4th ed. Philadelphia, PA Elsevier
  Saunders, 2005 2223-2241
• Sanjeevi, A. and Roy, HK. Necrobiotic Nodules A
  Rare Pulmonary Manifestation of Crohn's Disease.
  Am J Gastroenterology 2003 98(4)941-943
• Freeman HJ. Davis JE. Prest ME. Lawson EJ.
  Granulomatous bronchiolitis with necrobiotic
  pulmonary nodules in Crohn's disease. Can J
  Gastroenterol 2004 18(11)687-690

Acknowledgments
We would like to thank Dr. Reichner and all of
the Pulmonary Critical Care staff that took part
in the care of our patient. Thoracic surgery for
timely VATS guided biopsy. The Georgetown
University Hospital Department of Pathology for
their wonderful pathology slides. Dr. Timpone and
Dr. Adams for all of the work they put into
research and the residency program at Georgetown
University Hospital.