Evolving pulmonary symptoms in a patient with crohn's disease

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Crohn's disease is an inflammatory bowel disease (IBD) and often treated with immunosuppressant medications. Pulmonary issues may arise from association with IBD or medications used to treat IBD. CASE PRESENTATION: A 59-year-old man with Crohn's disease (on azathioprine and mesalamine) and diabetes mellitus presented with left lower lobe pulmonary nodules. He had a history of Grade I follicular lymphoma of the duodenum without evidence of disease. He had a flare of his Crohn's disease 3 months prior to presentation, along with several rounds of bronchitis (treated with azithromycin) and a tooth abscess (treated with clindamycin). He reported persistent non-productive cough with no dyspnea, pleurisy, wheezing or fevers. Image-guided biopsy of the pulmonary nodule revealed multifocal T-cell and plasma cell infiltrate with negative cultures. He was hospitalized locally for pneumonia and the nodules decreased after treatment with intravenous antibiotics. He presented 3 weeks later with weakness, fatigue, hoarseness and cough. Imaging showed decreased size of known left lower lobe pulmonary nodules, new multiple bilateral nodules, new left upper lobe collapse and subcarinal lymphadenopathy. Bronchoscopy revealed obstructing necrotic endobrochial lesions in the right upper and left upper lobe, and lymphadenopathy on endobronchial ultrasound. Bronchoalveolar lavage revealed Stenotrophomonas maltophilia and Acinetobacter baumannii complex, and cytology showed fungal hyphae without malignant cells. He was started on treatment with antibiotics and antifungals. Cytology from fine needle aspiration revealed no malignant cells and lymphoid tissue with negative flow cytometry. Pathology from the endobronchial lesions confirmed Epstein Barr Virus (EBV)-positive diffuse large B-cell lymphoma. DISCUSSION: Pulmonary lymphoproliferative disorders are rare entities, and risk factors include immunosuppression, autoimmune disorders, chronic inflammatory conditions and viral infections. EBV is thought to play a central role. Radiographic presentation may include multiple well-defined pulmonary nodules. A high index of suspicion and biopsy can confirm diagnosis. Our patient presented initially with pulmonary nodules, and although there was radiographic improvement, he developed lymphadenopathy and endobronchial disease consistent with EBV-related lymphoproliferative disorder. We suspect his lymphoma was related to Crohn's disease and immunosuppression as opposed to low grade lymphoma a decade prior. CONCLUSIONS: Although rare, EBV-related lymphoproliferative disorders may occur in IBD. Presentation may vary from well-defined pulmonary nodules to widely disseminated disease. Diagnosis with tissue biopsy is often needed. REFERENCE #1: Zhang H, Zhao S, Cao Z. Impact of Epstein-Barr virus infection in patients with inflammatory bowel disease. Front Immunol. 2022 Oct 28;13:1001055. doi: 10.3389/fimmu.2022.1001055. PMID: 36389673; PMCID: PMC9651941. REFERENCE #2: Siegel CA. Risk of Lymphoma in Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y). 2009 Nov;5(11):784–90. PMCID: PMC2886374. REFERENCE #3: Au V, Leung AN. Radiologic manifestations of lymphoma in the thorax. AJR Am J Roentgenol. 1997 Jan;168(1):93-8. doi: 10.2214/ajr.168.1.8976927. PMID: 8976927. DISCLOSURES: No relevant relationships by Sami Bashour No relevant relationships by Lara Bashoura No relevant relationships by Kathy Chan No relevant relationships by Saadia Faiz No relevant relationships by Horiana Grosu No relevant relationships by Bilal Zafar