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Ann Thorac Surg 2007;84:1748-1750. doi:10.1016/j.athoracsur.2007.05.056
© 2007 The Society of Thoracic Surgeons
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Case Reports

Pulmonary Involvement in Inflammatory Bowel Disease

Aman S. Coonar, MD, FRCS(CTh)a,*, David M. Hwang, MD, FRCPCb, Gail Darling, MD, FACSa

a Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
b Department of Pathology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada

Accepted for publication May 15, 2007.

* Address correspondence to Dr Coonar, Thoracic Surgery, Papworth Hospital, Cambridge, CB23 8RE, England, United Kingdom (Email: aman.coonar{at}papworth.nhs.uk).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Clinically significant pulmonary involvement in inflammatory bowel disease is uncommon, and presentation to thoracic surgeons is rare. A literature review found no such cases in the cardiothoracic surgery network (CTSNET) journals. We describe a patient presenting with a lung mass presumed to be lung cancer that ultimately transpired to be pulmonary involvement of inflammatory bowel disease.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Inflammatory bowel disease is a multisystem disease. Abdominal features may be in remission while extra-abdominal features continue. Clinically significant pulmonary manifestations are not common and rarely present to surgeons.

A 59-year-old woman was referred with an abnormal chest x-ray (Fig 1). She had a 60 pack-year smoking history and a family history of cancer. She had undergone breast augmentation with silicone implants 16 years before. A diagnosis of Crohn’s disease had been made 8 years previously and her bowel symptoms were in remission. Possible extra gastrointestinal manifestations included low back pain and mild plantar fasciitis. Her medications were prednisone and mesalasine. Computed tomographic scan identified a right lower lobe lesion consistent with a primary neoplasm (Fig 2).


Figure 1
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  		Fig 1. Chest x-ray showing linear opacification of the right lung and density behind the right breast. Left hilum is prominent. Bilateral breast implants.

 

Figure 2
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  		Fig 2. Computed tomographic chest scan shows transverse section with lung window settings showing mass of the right lower lobe.

 
Bronchoscopy was normal and needle biopsy only identified necrosis. Because of a high suspicion of cancer she underwent surgery. At thoracotomy the lesion was found to be boggy rather than hard. She underwent a right lower lobectomy and wedge resection from the upper lobe and a lymph node dissection. She had an uneventful recovery. Pathologic examination found no evidence of malignancy but did identify necrosis, inflammation, and granulomas (Fig 3). Microbiological cultures were negative.


Figure 3
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  		Fig 3. Photomicrograph from the resected lung showing a granuloma with central necrosis and surrounding inflammation (hematoxylin & eosin stain, 100x magnification).

 
She made an excellent clinical recovery and was reviewed as an outpatient where she remained well with no evidence of recurrence. She continued to smoke. Four years after her initial surgery she developed fresh radiologically similar right lung abnormalities. The possibility of malignancy or other serious pathology was considered and she was referred for computed tomographic-guided needle biopsy. Again necrotizing granulomatous inflammation was found, and all investigations for infection were negative.

Given the history, even though her Crohn’s disease was in remission elsewhere it was considered that the most likely diagnosis was a pulmonary manifestation of inflammatory bowel disease.


   Comment
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 Abstract
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 Comment
References
 
Manifestations of inflammatory bowel disease outside of the gut are known. Pulmonary involvement in inflammatory bowel disease is recognized by subspecialists, but because of its rarity, it is uncommonly seen by thoracic surgeons. No such cases describing pulmonary surgery were found in a search of the cardiothoracic surgery network (CTSNET) journals.

Chronic inflammation may affect the lungs. This may be subclinical, manifesting only as pulmonary function abnormalities that may be found even when patients are in gastrointestinal remission [1]. Associated respiratory abnormalities include bronchial hyper-responsiveness, bronchiolitis [2], bronchiectasis, pulmonary fibrosis [3], alveolar hemorrhage, infiltrates, nodules, cavitation, organizing pneumonia, tracheobronchitis, airway stenosis [4], bronchiolitis obliterans [5], pleuritis [6], and fistulae. The clinical course is variable. Tissue biopsy may be required to make the diagnosis.

Clinical and radiologic appearances may suggest other diagnoses such as infection or neoplasia, and these may coexist. Pulmonary changes may also arise as a consequence of treatment. The appearances may suggest another chronic disease process such as sarcoid or vasculitis. Occasionally the pulmonary presentation of disease may be acute and fulminant, leading to respiratory failure [7].

Chronic inflammation is associated with neoplasia and this raises the question of whether there is an increased risk of lung cancer with inflammatory bowel disease. Crohn’s disease is generally associated with increased smoking rates and lung cancer rates, whereas there is a negative association for ulcerative colitis [8].


   References
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 Abstract
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 References
 

  1. Herrlinger KR, Noftz MK, Dalhoff K, Ludwig D, Stange EF, Fellermann K. Alterations in pulmonary function in inflammatory bowel disease are frequent and persist during remission Am J Gastroenterol 2002;97:377-381.
  2. Vandenplas O, Casel S, Delos M, Trigaux JP, Melange M, Marchand E. Granulomatous bronchiolitis associated with Crohn’s disease Am J Respir Crit Care Med 1998;158(5 Pt 1):1676-1679.
  3. Mahadeva R, Walsh G, Flower CD, Shneerson JM. Clinical and radiological characteristics of lung disease in inflammatory bowel disease Eur Respir J 2000;15:41-48.
  4. Kuzniar T, Sleiman C, Brugiere O, et al. Severe tracheobronchial stenosis in a patient with Crohn’s disease Eur Respir J 2000;15:209-212.
  5. Haralambou G, Teirstein AS, Gil J, Present DH. Bronchiolitis obliterans in a patient with ulcerative colitis receiving mesalamine Mt Sinai J Med 2001;68:384-388.
  6. Faller M, Gasser B, Massard G, Pauli G, Quoix E. Pulmonary involvement in IBD: pulmonary migratory infiltrates and pachypleuritis in a patient with Crohn’s disease Respiration 2000;67:459-463.
  7. Lamblin C, Copin MC, Billaut C. Acute respiratory failure due to tracheobronchial involvement in Crohn’s disease Eur Respir J 1996;9:2176-2178.
  8. Thomas GAO, Rhodes J, Green JT. Inflammatory bowel disease and smokingA review. Am J Gastroenterol 1998;93:144-149.




This Article
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Gail Darling
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