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P-163 Pulmonary Manifestations At Time of Diagnosis of Crohn's Disease: Report of Two Pediatric Cases

BACKGROUND: Inflammatory bowel disease (IBD) is a systemic disorder and extra-intestinal manifestations (EIM) are very common. Although there is mounting evidence showing a relationship between pulmonary involvement and IBD, respiratory tract disease as an EIM continues to be under recognized. Reported pulmonary complications include inflammation of the small and large airways, pulmonary parenchymal disease, serositis, and pulmonary embolism. Involvement can predate the diagnosis, occur at time of diagnosis, or develop later in the disease course. It can also be associated with treatments, infections and auto-immune disorders. We present 2 pediatric patients with Crohn’s disease (CD) and pulmonary manifestations near the time of initial intestinal disease symptoms. The first patient presented with parenchymal disease predating the diagnosis of CD. The second patient sustained a non-traumatic pneumothorax related to pleural blebs around the time of diagnosis. METHODS: Case Report. RESULTS: A 15 year old female presented with cough, fever, and weight loss. Chest computed tomography (CT) showed multiple left lung masses with cystic change. IV antibiotics (ceftriaxone and vancomycin) were given. An infectious etiology was not identified. Spirometry was normal. Her respiratory symptoms and her pulmonary involvement by CT improved, but did not resolve. Over the next 3 weeks, she developed diarrhea, weight loss, vomiting, and worsening abdominal pain. She had a microcytic anemia, elevated ESR and hypoalbuminemia. Upper gastrointestinal series showed jejunal thickening. Gastrointestinal endoscopy showed granulomatous gastritis, duodenitis, active, chronic ileitis, and pan-colitis. She responded well to induction with corticosteroids and maintenance of remission with 6mercaptopurine was achieved. Repeat chest CT showed the lung lesions had resolved. A 15-year old male presented with pleuritic chest pain, weight loss, and poor appetite. Laboratory evaluation demonstrated microcytic anemia and elevated ESR. An incidental small pneumothorax with pleural bleb formation was seen in the left lung base on abdominal CT. Also, there was extensive thickening of the ileum and an adjacent 1.3 cm extraluminal fluid collection. Ciprofloxacin and metronidazole were given. Due to increasing chest pain and fatigue, he was admitted and treated with oxygen. Ileitis was found on gastrointestinal endoscopy and biopsies confirmed acute and chronic inflammation consistent with CD. Induction with corticosteroids improved the clinical situation but mild disease activity remained. Oral budesonide and methotrexate have led to clinical remission. There are no lingering pulmonary symptoms. The pneumothorax and pleural abnormalities resolved on follow up imaging. Spriometry is planned to evaluate for airway disease. CONCLUSIONS: Pulmonary manifestations of CD are infrequently seen in adults and pediatrics, yet there is a growing awareness of the relationship and spectrum of complications. The timing of respiratory disease is variable and can manifest before, after or during the time of diagnosis. These 2 cases highlight the need to consider CD as a potential cause of parenchymal lung disease and pneumothorax even in patients without known IBD. In patients with known IBD, prompt recognition and treatment of pulmonary disease are essential to prevent potential destructive and irreversible pulmonary changes. Figure. No caption available.