A83-01 Gut Feeling in the Lungs: A Case of Pulmonary Necrobiotic Nodules in a Patient Receiving Ustekinumab for Crohn’s Disease

Introduction

Pulmonary necrobiotic nodules are a well-recognized but rare extraintestinal manifestation of inflammatory bowel diseases. It presents as pulmonary nodules on imaging, often with cavitation, and is more commonly associated with ulcerative colitis. Diagnosis can be challenging, especially in the setting of concomitant immunosuppression due to clinical and radiological overlap with other common conditions like infections, drug induced sarcoid like reaction (DSLR) , and malignancy.

Case Presentation

A 24-year-old female with a known history of Crohn’s disease on Ustekinumab for 2 months presented with hemoptysis and chest pain. Chest X-ray showed an oval-shaped lesion with central lucency on the periphery of the right middle lung field. Further evaluation with computed tomography (CT) of the chest revealed multiple bilateral cavitary nodules predominantly in the lower lobes. Infectious workup, including bacterial, fungal, acid-fast bacillus cultures, T spot, Fungitell, Histoplasma, Blastomyces, Coccidiomycosis, Cryptococcosis, and Aspergillus was negative. Vasculitis panel was negative. Initial bronchoscopic biopsy showed a single non-necrotizing granuloma. Due to concerns for DSLR, her Ustekinumab was held, and she was started on a steroid taper. She was subsequently hospitalized one month later for worsening cough and brownish sputum, with a CT chest demonstrating worsening of her bilateral nodules. Thus, she underwent repeat bronchoscopic evaluation, which showed poorly formed granuloma, mixed inflammatory cells, and a granular necrotic debris background consistent with necrobiotic nodules. She was rechallenged with a higher dose of steroids with radiologic improvement of her cavitary lung lesions.

Discussion

Crohn’s disease can present with a spectrum of pulmonary manifestations, including airway diseases, interstitial lung disease, and serositis. Although more commonly seen in ulcerative colitis, necrobiotic nodules are a rare pulmonary manifestation of Crohn’s disease. Our case underscores the diagnostic challenge associated with necrobiotic nodules. Distinguishing between different etiologies of pulmonary nodules can be challenging because differences may be subtle and sometimes overlapping. Pulmonary necrobiotic nodules are highly responsive to treatment with oral steroids, often with complete radiologic resolution. Thus, high suspicion and early detection remain key to reducing further morbidity.

This abstract is funded by: None