B35-29 Inflammatory Bowel Disease With Pulmonary Manifestations of Necrobiotic Nodules and Pleurisy

Introduction Extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) confer significant morbidity and mortality to affected patients, often requiring complex adjustments in evaluation and immunosuppression. We present a case of extraintestinal IBD involvement manifesting as necrobiotic pulmonary nodules and pleurisy, a rare pulmonary phenomenon. Case A 43-year-old man with past medical history of Crohn’s disease, enteropathic arthritis, and recent DVT presented to the emergency department for pleuritic pain and progressive shortness of breath. The patient’s respiratory, gastrointestinal, and arthritis symptoms had been worsening for several months since transitioning biologic therapy from Infliximab (IFX) to vedolizumab after years of adequate symptom control on IFX. When compared to previous chest imaging, computed tomography of the chest showed pleural thickening and progression of ground glass opacities into bilateral consolidations, concerning for necrobiotic pulmonary nodules (Figure1a). Non-invasive infectious workup including fungal markers and tuberculosis testing were negative. Bronchoalveolar lavage was negative for an infectious process. Infliximab antibody was negative. Given the temporal relationship between the onset of pulmonary manifestations and adjustments in biologic therapy, in collaboration with gastroenterology, the patient was re-established on his IFX therapy with improvement in respiratory, joint, and gastrointestinal symptoms. Repeat imaging 3 months later showed resolution of nodular consolidations in the upper lobes and pleural thickening (Figure1b ). Discussion Extraintestinal manifestations of inflammatory bowel disease are well-recognized and can affect nearly every organ system, with studies suggesting that up to ∼25-50% of IBD patients may develop at least one EIM. While the musculoskeletal, dermatologic, ocular, and hepatobiliary systems are most frequently involved, pulmonary and pleural involvement remain rare. The temporal association of the patient’s respiratory and joint symptoms worsening soon after transition away from infliximab—and subsequent improvement upon re-initiation of infliximab— suggest that vedolizumab (which is gut-selective by mechanism) may have allowed uncontrolled extra-intestinal inflammation. While vedolizumab has demonstrated excellent control of GI disease, its effectiveness for controlling EIMs is less well demonstrated. This case supports the consideration of systemic biologics (eg, anti-TNF) when extraintestinal manifestations are prominent. Conclusion This case highlights an uncommon but important manifestation of IBD: necrobiotic-style pulmonary nodules with pleural involvement in a patient with Crohn’s disease and enteropathic arthritis. Goal of therapy should aim to control primary pathology, recognizing that pulmonary and other EIMs often worsen in parallel to worsening GI manifestations. This abstract is funded by: None