Crohn's colitis and sarcoidosis

Crohn’s Disease Diagnosed in a Man with Sarcoidosis: Coincidence or Correspondence?

Crohn's disease and sarcoidosis are characterized by noncaseating granulomas, but rarely do they present in the same patient. Their coexistence presents a diagnostic challenge as they are often classified as clinically separate, despite their similarities. We present a case of a 59-year-old man previously diagnosed with pulmonary sarcoidosis who presented to the emergency room with abdominal pain and diarrhea. Colonoscopy revealed multiple ulcers in the colon, with histology in keeping with newly diagnosed Crohn's colitis. The patient had a good clinical response to initiation of steroid therapy and a tumor necrosis factor (TNF) inhibitor.

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

Liver involvement is not an uncommon extraintestinal manifestation of inflammatory bowel disease (IBD). IBD-associated liver diseases may have a variety of etiopathogenetic origins (including shared autoimmune pathogenesis, the effect of chronic inflammatory status, and adverse effects of drugs). Nevertheless, acute granulomatous hepatitis in the setting of Crohn’s disease (CD) is a rare clinical entity. It warrants, however, a careful assessment as both clinical and pathological features of Crohn’s-associated granulomatous hepatitis closely mimic extrapulmonary hepatic sarcoidosis, with considerable overlaps between the 2 diseases, which certainly makes a definitive diagnosis quite challenging. It is crucial to exclude infectious etiologies during the evaluation of acute granulomatous hepatitis, as inappropriate immunosuppressive treatment may cause a systemic flare-up of an underlying liver infection. We report a rare case of a 35-year-old female with a history of CD who presented with recurrent fevers, acute abdominal pain, and cholestasis. She was found to have acute hepatitis with noncaseating granulomas on liver biopsy. A comprehensive diagnostic workup did not ultimately prove a specific etiological culprit. The patient was treated with oral corticosteroids, and she demonstrated a positive clinical and laboratory response to the treatment. Our case highlights the diagnostic dilemma of acute granulomatous hepatitis in the setting of co-existent CD with a multisystemic syndrome. Granulomatous hepatitis represents a relatively rare manifestation of both extraintestinal CD and extrapulmonary sarcoidosis, with potential difficulties discriminating between the 2 entities on many occasions. The case also demonstrates the value of an interdisciplinary approach in the context of multisystemic disease to achieve the best outcome.

Granulomatous hepatitis in a patient with Crohn's disease and cholestasis

We describe a case of a 23-year-old woman with a history of Crohn's disease (CD), who initially presented with sepsis-like symptoms, subsequently developed severe cholestasis and following extensive inpatient workup was found to have non-caseating granulomas on her liver biopsy. Infectious aetiologies were excluded and the patient was treated with oral corticosteroids, which ameliorated but did not completely reverse the cholestasis. We review the differential diagnosis of hepatic granulomas and discuss the potential difficulties in establishing their exact aetiology in patients with CD.

Crohn's disease and sarcoidosis in siblings: follow-up of a published report with a new case and brief review of the literature

Reported in 1971 were the cases of three brothers, two of whom had developed sarcoidosis and the third Crohn's disease. That now presented concerns one brother who, 50 years after the diagnosis and successful treatment of his sarcoidosis, was found incidentally, at colonoscopy performed to exclude malignancy, to have Crohn's colitis in the absence of any symptoms attributable to this. The report concludes with a brief review of the literature.

Crohn's disease with pulmonary manifestations in children: 2 case reports and review of the literature

Crohn's disease (CD) is a chronic granulomatous disease of unknown etiology that affects primarily the gastrointestinal system but can be associated with extraintestinal manifestations. Latent pulmonary involvement in children with CD has been described, but symptomatic pulmonary disease has rarely been reported in children. In this review, we report two pediatric cases, one with pleural effusion at the time of CD diagnosis and the other with bilateral cavitary lesions in a previously diagnosed CD patient. We review the current literature and summarize the diagnosis and management of pulmonary involvement in CD. Awareness of these pulmonary complications of CD in children may lead to more prompt diagnosis, guide appropriate therapy, and decrease morbidity.

Tracheobronchial nodules and pulmonary infiltrates in a patient with Crohn's disease

Crohn’s disease is a granulomatous systemic disorder of unknown etiology. Obvious pulmonary involvement is exceptional. Tracheal involvement in Crohn’s disease is even more unusual, only a few cases have been reported to date. We herein report a rare case of tracheobronchial nodules and pulmonary infiltrates in both lungs as a complication of Crohn’s disease. A 42-year-old man underwent pancolectomy for multiple broken colon caused by Crohn’s disease. Forty days later pulmonary symptoms and radiologic abnormalities were noted. A search for bacterial (including mycobacteria) and fungal in the repeated sputum proved negative. The treatment consisted of intravenous antimicrobials for one month, but there was no improvement in pyrexia or cough and radiologic abnormalities. Fibreoptic bronchoscopy (FOB) was performed and revealed nodes in the trachea and the right upper lobe opening. Histopathology of tracheobronchial nodules and bronchial mucosa biopsy specimen both showed granulomatous inflammation with proliferation of capillaries and inflammatory cells. Oral steroid and salicylazosulfapyridine were commenced and led to marked improvement in symptoms and an almost complete resolution of his chest radiograph. Repeated FOB showed that nodes in the trachea disappeared and the ones in the right upper lobe opening diminished obviously. Crohn’s disease can be associated with several respiratory manifestations. The form of tracheal and bronchopulmonary involvement in Crohn’s disease is rare and responded well to steroids.

Multiple transverse colonic perforations associated with slow-release nonsteroidal anti-inflammatory drugs and corticosteroids: a case report

The patient was a 36-year-old woman with sarcoidosis and Sjogren's syndrome, and had been prescribed slow-release diclofenac sodium and prednisolone for the treatment of pain associated with uveitis and erythema nodosum. She was admitted to our emergency center with abdominal pain and distention. A chest X-ray showed free air under the diaphragm on both sides, and an emergency laparotomy was performed for suspected panperitonitis associated with intestinal perforation. Laparotomy revealed several perforations on the antimesenteric aspect of the transverse colon. The resected specimen showed 11 punched-out ulcerations, many of which were up to 10 mm in diameter. The microscopic findings were non-specific, with leukocytic infiltration around the perforations. She showed good postoperative recovery, as evaluated on day 42. The present case highlights the need for exercising caution while prescribing slow-release nonsteroidal anti-inflammatory drugs with corticosteroids to patients with autoimmune diseases, as such treatment may exacerbate intestinal epithelial abnormalities.

Sarcoidosis during infliximab therapy for Crohn's disease

Tumor necrosis factor-alpha (TNF-alpha) antagonists are effective for inflammatory diseases, such as Crohn's disease, rheumatoid arthritis (RA) and psoriasis. Although TNF-alpha antagonists are also useful for sarcoidosis, paradoxical occurrence of sarcoidosis or sarcoidal reaction may be observed. We report a Crohn's disease patient, who developed sarcoidosis during infliximab therapy. A 35-year-old man had been receiving infliximab for 7 months for Crohn's disease. He developed cough and fever, accompanied by an infiltrated erythematous plaque on his right knee. The chest radiography, skin biopsy and laboratory findings were all consistent with sarcoidosis.

Multiple pulmonary micronodules in a patient with Crohn's disease

Sarcoidosis is a terrific mimicker and can present in many different ways. The case of a middle-aged woman with Crohn's disease who attended the gastroenterology clinic for routine follow-up is presented. She had dry cough and breathlessness for a few weeks. A chest x-ray showed scattered multiple bilateral pulmonary micronodules. This finding on her chest x-ray posed a diagnostic challenge, especially in view of the fact that she was previously treated with immunosuppressants to control her Crohn's disease. A diagnosis of sarcoidosis was established by various tests including lung biopsy, which showed non-caseating granulomas. Within a few weeks of beginning systemic steroid treatment, improvement was noticed in symptoms and lung function tests.

An unusual case of Crohn's disease with unresponsive pleural exudates. Is Crohn's disease finally a systemic immunological disorder?

Crohn's disease has been infrequently associated with various respiratory manifestations. Reports of pleural effusions in Crohn's disease are even sparser, but differential diagnosis is rich, with causes either associated with the disease or being independent. Processes directly or indirectly related to therapy, entities overlapping with Crohn's disease in pathogenesis and common causes of effusions should all be considered, under the guidance of laboratory testing and imaging. We report here an unusual case of bilateral pleural effusions unresponsive so far to medical therapy, in a patient with long-standing Crohn's disease and several features of autoimmunity. A short review of the literature is presented, the differential diagnosis is outlined and the systemic immunological profile of Crohn's disease is discussed.

Severe airway stenosis associated with Crohn's disease: case report

Background

Symptomatic respiratory tract involvement is not common in Crohn's disease. Upper-airway obstruction has been reported before in Crohn's disease and usually responds well to steroid treatment.

Case presentation

We report a case of a 32-year old patient with Crohn's disease who presented with progressively worsening dyspnea on exertion. Magnetic Resonance Imaging of the chest and bronchoscopy revealed severe tracheal stenosis and marked inflammation of tracheal mucosa. Histopathology of the lesion showed acute and chronic inflammation and extended ulceration of bronchial mucosa, without granulomas. Tracheal stenosis was attributed to Crohn's disease after exclusion of other possible causes and oral and inhaled steroids were administered. Despite steroid treatment, tracheal stenosis persisted and only mild symptomatic improvement was noted after 8 months of therapy. The patient subsequently underwent rigid bronchoscopy with successful dilatation and ablation of the stenosed areas and remission of her symptoms.

Conclusion

Respiratory involvement in Crohn's disease might be more common than appreciated. Interventional pulmonology techniques should be considered in cases of tracheal stenosis due to Crohn's disease refractory to steroid treatment.

Bronchial hyperresponsiveness and analysis of induced sputum cells in Crohn's disease

With the aim of investigating the presence of latent inflammatory process in the lungs of patients with Crohn's disease, 15 patients with Crohn's disease were evaluated by spirometry, the methacholine challenge test, induced sputum, and skin tests for inhaled antigens. Serum IgE, erythrocyte sedimentation rate and hematocrit were also determined. The patients were compared with 20 healthy controls by the Mann-Whitney and Fisher exact tests. Their respiratory physical examination was normal. None had a personal or family history of clinical atopy. None had a previous history of pulmonary disease, smoking or toxic bronchopulmonary exposure. None had sinusitis, migraine, diabetes mellitus, or cardiac failure. Four (26.6%) of the patients with Crohn's disease had a positive methacholine challenge test whereas none of the 20 controls had a positive methacholine test (P = 0.026, Fisher exact test). Patients with Crohn's disease had a higher level of lymphocytes in induced sputum than controls (mean 14.59%, range 3.2-50 vs 5.46%, 0-26.92%, respectively; P = 0.011, Mann-Whitney test). Patients with Crohn's disease and a positive methacholine challenge test had an even higher percentage of lymphocytes in induced sputum compared with patients with Crohn's disease and a negative methacholine test (mean 24.88%, range 12.87-50 vs 10.48%, 3.2-21.69%; P = 0.047, Mann-Whitney test). The simultaneous findings of bronchopulmonary lymphocytosis and bronchial hyperresponsiveness in patients with Crohn's disease were not reported up to now. These results suggest that patients with Crohn's disease present a subclinical inflammatory process despite the absence of pulmonary symptoms.

Granulomatous tracheo-bronchitis associated with Crohn's disease

We report a rare case of diffuse tracheo-bronchitis as a complication of Crohn's disease. A young man with a long-standing history of Crohn's enterocolitis initially presented with epigastric pain and melena. Upper endoscopy revealed erythematous, edematous, and friable mucosa with erosions, particularly in the pyloric channel, causing gastric outlet obstruction, and a nonbleeding ulcer in the corpus of stomach. Biopsy of these lesions showed chronic gastritis and a noncaseating epithelioid granuloma, consistent with active Crohn's disease. The patient was treated with a course of corticosteroids and the gastric symptoms resolved. A few months later, he developed fever, cough, hemoptysis, and rash. Bronchoscopy demonstrated a markedly thickened and very inflamed trachea with extensive friable, whitish lesions and ulcerations. Histology showed severe noncaseating granulomatous inflammation. The patient improved with a 6-week oral, followed by an additional 4-week inhaled, corticosteroid treatment. Since then, he has been doing well without relapse of pulmonary symptoms for 2 years.

Granulomatous pulmonary disease in a child: an unusual presentation of Crohn's disease

Crohn's disease (CD) is a chronic inflammatory disorder of the bowel which may be associated with an extensive list of extraintestinal manifestations involving almost every organ system. The most common organs involved are the eyes, skin, joints, and liver. Symptomatic bronchopulmonary disorders have been reported only rarely in pediatric CD. We report on an 11-year-old child who had a recurrent cough and increasing dyspnea with exercise for 8 months before developing any gastrointestinal symptoms. He was demonstrated to have granulomatous inflammation of the lung, as well as of the gastrointestinal tract. Similarities between CD and sarcoidosis are discussed.

Pulmonary manifestations of inflammatory bowel disease

Extraintestinal manifestations of both Crohn's disease and ulcerative colitis (UC) have been well described, although pulmonary findings are often overlooked. We summarize the experience of more than 400 cases of pulmonary manifestations of inflammatory bowel disease (IBD). These manifestations will be categorized by disease mechanism into drug-induced disease, anatomic disease, over-lap syndromes, autoimmune disease, physiologic consequences of IBD, pulmonary function test abnormalities, and nonspecific lung disease. We intend to provide the clinician with a practical working update on the spectrum of pulmonary dysfunction associated with IBD.

Noninfectious lung pathology in patients with Crohn's disease

Lung involvement in Crohn's disease is not well characterized. We reviewed our experience with 11 lung biopsies (seven wedge and four transbronchial) from patients with Crohn's disease to study this association further. Negative cultures, special stains for organisms Gomori-methenamine-silver [GMS], acid fast), and polymerase chain reaction for (four cases) were required for inclusion. The group included five women and six men with a mean age of 47 years (range 13-84 years). A diagnosis of Crohn's disease preceded the lung disease in nine patients. In two patients the diagnosis of Crohn's disease followed the diagnosis of their pulmonary disease 1 and 15 months later. Radiologically, eight patients had diffuse infiltrates, two had bilateral nodular infiltrates, and one had a mass. Chronic bronchiolitis with nonnecrotizing granulomatous inflammation was present in four patients, one of whom was taking mesalamine. Two patients had an acute bronchiolitis associated with a neutrophil-rich bronchopneumonia with suppuration and vague granulomatous features. One patient on mesalamine had cellular interstitial pneumonia with rare giant cells. Four patients demonstrated organizing pneumonia with focal granulomatous features, two of whom were taking mesalamine, and one of these two responded to infliximab (anti-tumor necrosis factor) monoclonal antibody therapy. Noninfectious pulmonary disease in patients with Crohn's disease has variable histologic appearances, including granulomatous inflammation and airway-centered disease resembling that seen in patients with ulcerative colitis. Drugs may contribute to pulmonary disease in some patients.

Clinical significance of granuloma in Crohn's disease

Crohn's disease (CD) is diagnosed from information obtained clinically, pathologically, and radiologically. One important pathologic finding is a granuloma, which is helpful when a positive diagnosis of CD will affect treatment. Whether the presence of a granuloma has any clinical implication is not clear. We conducted a retrospective study to determine whether a granuloma found on a biopsy sample is associated with disease severity, fistulizing or perianal disease, frequent relapses, and extraintestinal manifestations. Eighty-two patients were identified who had a biopsy or bowel resection for CD between 1990 and 1994 at a tertiary referral center; 21 (25.6%) had a granuloma. This group was compared with a group of 61 patients without a granuloma. Forty-five percent were male (n = 37), mean age at diagnosis was 42.6 years (median, 39.5 years), mean disease duration at presentation was 8.8 years (median, 4.8 years), and mean follow-up duration was 2 years (range, 1 day to 10.2 years). No significant differences were demonstrated between the two groups by the Fisher exact test with regard to fistulizing or perianal disease, oral aphthous ulcers, disease severity, axial or peripheral arthralgia, episcleritis, anterior uveitis, erythema nodosum, or pyoderma gangrenosum.

Granulomatous lung masses in an elderly patient with inactive Crohn's disease

This is a case report of a 77-year-old female with Crohn's disease manifested by recurrent bowel obstructions, who required surgical resections on two occasions but no further medical treatment. She presented 2 years later with pulmonary infiltrates, hilar adenopathy, and multiple lung masses. Biopsies of the masses demonstrated noncaseating granulomatous inflammation and fibrosis similar to the pathology from her bowel resection. Six months later, these pulmonary lesions partially resolved without therapy. This case illustrates significant pulmonary manifestations of Crohn's disease in the absence of active gastrointestinal disease.

Granulomatous bronchiolitis associated with Crohn's disease

Symptomatic bronchopulmonary disorders have been only occasionally reported in Crohn's disease, although several studies have documented the possibility of latent involvement of the respiratory tract. We report the case of a patient with long-standing Crohn's disease who presented with acute transient chest pain and a recent history of mild dyspnea and nonproductive cough. Chest radiographs were normal, while high-resolution computed tomography demonstrated a mosaic pattern of attenuation that was consistent with a bronchiolar disorder. Pulmonary function tests showed mild airway obstruction and normal diffusion indices. Thoracoscopic lung biopsy demonstrated focal infiltration of the bronchiolar walls by mononuclear cells and non-necrotizing granulomas. To our knowledge, this is the first account of isolated granulomatous bronchiolitis in Crohn's disease. These findings suggest that a granulomatous inflammatory process of the bronchioles could be involved in the development of airway obstruction in patients with Crohn's disease.

Sarcoidosis presenting as granulomatous colitis

Sarcoidosis presenting solely as a granulomatous colitis is rare and appears identical to Crohn's disease. A 56-yr-old woman developed a Crohn's-like illness, which remitted after 5-ASA therapy. Two months later, she developed fever, adenopathy, muscle weakness, and peripheral neuropathy. A diagnosis of sarcoidosis was made after an extensive search for an infectious or rheumatological cause. This case illustrates the utility of serum angiotensin converting enzyme level in differentiating sarcoidosis from Crohn's disease.