Pulmonary Sarcoidosis in a Patient with Crohn's Disease.

SESSION TYPE: ILD Global Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 01:30 PMINTRODUCTION: Sarcoidosis and Crohn's disease (CD) are characterized by granulomatous inflammation with heterogeneous systemic presentations. These diseases are rarely reported in the same patient, particularly in Latin America.CASE PRESENTATION: A 52 year-old caucasian male, non-smoker, with a four-year history of CD controlled with mesalazine (1600mg/day) presented with unremitting non-productive cough for 3 months, without hemoptysis, fever or weight loss. He had no improvement despite empiric use of antibiotics and inhaled steroids. A chest HRCT showed multiple nodules (less than 8 mm) distributed irregularly (Figure 1a), perihilar and carinal lymphadenopathy (largest 1.2 cm). Pulmonary function testing showed mild obstructive disease without broncodilator response and normal DLCO. A thoracoscopic biopsy of median lobe and interlobar lymphonode yielded chronic granulomatous inflammation, areas of infarct, without malignancy but it was felt to be inconclusive; stains and cultures were negative for tuberculosis and fungi. A chest HRCT done 6-months later showed increase in lymphadenopathy (2.2 cm) with persistent pulmonary nodules. Patient developed mild dyspnea associated to dry cough. ESR was 28mm3, reactive C protein was 5.6mg/dl; P-ANCA, C-ANCA, ANA and HIV were negative. ACE level was normal. We performed a fiberoptic broncoscopy 8-months after first presentation, which revealed non-caseating chornic granulomatous inflammation suggestive of sarcoidosis on transbronquial biopsies (TBB) and transneddle (Figure 2). Colonoscopy showed no signs of active CD. We augmented immunossupression with mesalazine (2400mg/day) and initiated corticosteroids (60mg/day) for 3 months. He had complete resolution of the respiratoy symptoms and decrease in lung nodules and lymphadenopathy on repeated chest HRCT (Figure 1b). Corticosteroids were tapered gradually to 5mg/day over another 3 months and patient remains well.DISCUSSION: Sarcoidosis stage II was confirmed by TBB in a patient of CD after some delay but responded well to corticotherapy. Most of the few cases of co-diagnosis reported in the literature had the confirmation of inflammatory bowel disease (IBD) preceding that of sarcoidosis. Although IBD may have direct pulmonary manifestations, the differential diagnosis must include drug toxicity by immunosuppressive agents (e.g. sulfasalazina, 5-aminosalicylate and mesalazine), opportunistic infections, and other granulomatous pulmonary diseases, such as hypersensitivity pneumonitis and sarcoidosis.CONCLUSIONS: A high level of suspicion for sarcoisosis is necessary for correct diagnosis of these two conditions simultaneously, once some pathophysiological evidence favors an association.1) Barr GD, Shale DJ, Jewell DP. Ulcerative colitis and sarcoidosis. Postgrad Med J. 1986 May;62(727):341-52) Black H, Mendoza M, Murin S. Thoracic manifestations of inflammatory bowel disease. Chest. 2007 Feb;131(2):524-323) Kallel L, Fekih M, Ben Ghorbel I, Chelly I, Houman H, Filali A. A rare case of systemic sarcoidosis followed by Crohn's disease: a fortuitous association or etiopathogenic link? Presse Med. 2010 Jan;39(1):148-50DISCLOSURE: The following authors have nothing to disclose: Ana Thereza Rocha, Marina Cabral, Eduardo SadNo Product/Research Disclosure InformationUniversidade Federal da Bahia, Salvador, Brazil.