P0618 - Lung Granuloma as an Unusual Presentation of Inflammatory Bowel Disease

Himmat Brar, MBBS¹, Sarah Glover, DO^2
1University of Mississippi Medical Center, Flowood, MS; ²University of Mississippi Medical Center, Jackson, MS

Introduction: Ulcerative colitis is an inflammatory disorder with ulcerative lesions throughout the gastrointestinal tract. Although extraintestinal manifestations are common, pulmonary manifestations are extremely rare, occurring in < 1% of patients. It is challenging to distinguish between atypical presentations of ulcerative colitis and other granulomatous diseases such as sarcoidosis.

Case Description/Methods: A 21-year-old female with a medical history of refractory seizures presented with 6-weeks of diarrhea, cough for 2 months and 30 lbs weight loss. She denied fevers or night sweats. She was seen at another hospital for abdominal pain and vomiting and was found to have a pulmonary nodule on her CT scan.
Her physical examination was significant for diffuse abdominal pain. Lab work showed hypokalemia with normal BUN and creatinine. Hb was 10.9, WBC 6.2 with a diff of N63L26M8E1B0 and platelet 358. Iron studies showed ferritin 1220, Fe 76, TIBC < 17. FOBT was negative. CXR showed alveolar opacification. CT scan revealed multiple cavitations, ground-glass opacities and nodular consolidation with the largest being 2.8x1.6 cm.

Further workup including rapid HIV, Quant TB and serial blood cultures was negative. TTE revealed no vegetation. She underwent bronchoscopy with BAL, with testing for bacterial and fungal cultures, AFB stain and culture, and viral cultures and cytology, all of which were negative. Rheumatologic workup with ANCA, ACE, ANA and anti-dsDNA antibodies was negative. The ACE level was normal at 22.

The lung biopsy showed noncaseating granulomas and chronic nonspecific inflammation. Special stains for fungi, periodic acid Schiff were negative, as were stains for AFB. Due to the lung biopsy showing granulomas, Sarcoid was considered a possibility but the ACE levels were low. Colonoscopy showed ulcers throughout the GI tract. The biopsy confirmed the diagnosis of Ulcerative colitis with ulcers with crypt abscesses involving the cecum, colon with rectal sparing. She was started on sulfasalazine with significant improvement in GI symptoms and her lung findings with size reduction and resolution of the lung nodules.

Discussion: The similarity between IBD and sarcoidosis is well determined as both have noncaseating granulomas involving multiple organs. Sarcoidosis can present as GI granulomas and IBD can present as lung granulomas, making diagnosis challenging. The differentiation can be made with ACE levels, which are elevated in sarcoidosis. The diagnosis is essential for definitive treatment.



Disclosures:


Himmat Brar, MBBS¹, Sarah Glover, DO². P0618 - Lung Granuloma as an Unusual Presentation of Inflammatory Bowel Disease, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.