An Infrequent Extraintestinal Manifestation of Ulcerative Colitis: Pulmonary Necrobiotic Nodules

Abstract

Pulmonary necrobiotic nodules are a rare extraintestinal manifestation (EIM) of inflammatory bowel disease (IBD), which are often overlooked when diagnosing cavitary pulmonary nodules. We present this case to highlight the importance of a thorough differential diagnosis, which includes EIMs of ulcerative colitis (UC), in this case as necrobiotic nodules. Herein, we present a 25-year-old male patient with a history of poorly controlled UC who presented with fevers, left-sided abdominal pain, and bloody diarrhea. Imaging revealed cavitary pulmonary nodules without an infectious or malignant etiology. Lung biopsy and pathology confirmed a diagnosis consistent with necrobiotic nodules.

Cavitary lung nodules as an extraintestinal manifestation of ulcerative colitis

“…Additionally, both contain submucosal lymphoid tissue with aberrations in both innate and acquired immunity in disease pathogenesis hypothesised 3 11. Case reports have demonstrated responsiveness to steroids or immunomodulatory agents 5 6 10 12. This would be consistent with other extraintestinal manifestations of IBD, such as erythema nodosum or episcleritis, which usually parallel IBD disease activity and respond to treatment for the underlying bowel disease 1.…”

“…Extraintestinal manifestations of IBD are common, and while previously pulmonary involvement was felt to be rare, it is increasingly recognised 1 2. Pulmonary manifestations vary and include airways disease (bronchiectasis, tracheobronchitis, bronchiolitis and subglottic stenosis), parenchymal disease (organising pneumonia, nonspecific interstitial pneumonia and necrobiotic nodules), pleural disease (serositis) and pulmonary vascular disease (acute venous thromboembolism and chronic thromboembolic pulmonary hypertension) 3–5…”

“…While uncommon, necrobiotic lung nodules are well described in IBD and give a radiographic appearance of cavitating lesions with histopathology with sterile aggregates of inflammatory cells including multinucleated giant cells with necrosis 5 6 10. The concurrent use of immunosuppression often prioritises infectious aetiologies on the differential diagnosis of cavitary lesions, underscoring the importance of ruling out these entities and securing the correct diagnosis to guide treatment options.…”

Organizing Pneumonia and Ulcerative Colitis: A Relationship To Remember

“…Despite the fact that lung disease appears to be a rare extraintestinal manifestation of UC, a number of case reports have been published since the 1970s [ 5 ]. The pathophysiology of lung involvement in UC is still unclear; however, it could be explained by the fact that the colon and respiratory tract epithelium share a common embryologic origin and the same submucosal lymphoid tissue [ 3 ]. The severity of pulmonary manifestations can range from subclinical to more severe clinical forms.…”

“…These are known as extraintestinal manifestations. The musculoskeletal, dermatological, ocular, and hepatobiliary systems are the most frequently affected, while pulmonary involvement is uncommon [ 3 , 4 ]. The exact pathophysiological mechanisms underlying extraintestinal manifestations are still unknown [ 1 , 3 ].…”