Gast-2. A new extraintestinal manifestation of Crohn's disease: nodular bronchus with eosinophilia.

Crohn's disease (CD) is associated with a variety of extraintestinal manifestations. Pulmonary complications occur in 0.21 % of cases and can involve the tracheobronchial tree or pulmonary parenchyma or pleura. We report herein the case of a patient with CD who developed bronchial nodules and eosinophilia. A 25-year-old Caucasian male with CD of 3 years' duration was hospitalized for fever, chills, and cough of 7 days' duration. His CD had been well controlled with mesalamine 1500 mg orally once per day. The fever ranged from 100 to 102[degrees]F and was continuous. His cough was non-productive, was associated with pleuritic pain in both sides of the chest and with dyspnea on mild to moderate exertion. The lung examination showed few crackles in left lower part of chest. The physical examination was otherwise normal. His complete blood count showed a leukocyte count of 21,000 cells/hpf. The differential showed 78% neutrophils, 12% lymphocytes, and 0.2% eosinophils. The blood count was otherwise normal. His chest x-ray showed patchy left lower lobe infiltrates. A computed tomogram of the chest showed peripheral infiltrates in the upper and lower lobes of both lungs with consolidation (versus atelectasis) in the lingula and right middle lobe. The presumptive diagnosis was community acquired bacterial vs viral pneumonia. He was treated with parenteral vancomycin, ceftazidime, and acyclovir. There was no change in fever or pulmonary symptoms and his eosinophil count rose to 2,000 cells/hpf. Subsequent bronchoscopy showed submucosal nodular lesions and ulcerations throughout the endobronchial tree. Sputum, blood, and urine cultures showed no growth. Serum titers for Histoplasma, Aspergillus, Cryptococcus, and Mycoplasma were normal. Western blot testing for HIV was negative. A five-test unit PPD skin test was normal. Serum angiotensin converting enzyme level was normal. Serum antinuclear antibodies and rheumatoid factor were absent. Stools were negative for ova and parasites. Histopathology derived from endobronchial biopsy of nodules showed evidence of acute and chronic inflammation and scattered, poorly formed granulomas. Biopsy taken during colonoscopy showed active colitis without crypt abscesses or granulomas. Parenteral methylprednisolone 60 mg every 8 hours produced abatement of symptoms within 48 hours. Oral prednisone 80 mg per day was administered for 2 weeks followed by dose tapering. Mesalamine was continued throughout the course. There was no recurrence of symptoms. Inflammatory bowel disease can be associated with pulmonary complications. The clinical, radiographic, and histologic findings suggested the presence of nodular bronchus with eosinophilia. This clinical constellation may represent a new extraintestinal manifestation of Crohn's disease.

Srinivas R. Puli, MD, Martin Alpert, MD, Evelio E. Sardina, MD, C. Mobin Khan, MD, and David Janssen, MD. St John's Mercy Medical Center, St Louis, MO.