Abstract A 14 year old boy with history of uncontrolled Crohn’s Disease presented to the ED with 4 weeks of night sweats and 2 weeks of productive cough and pleuritic chest/back pain. The cough was productive of yellow, malodorous sputum. Chest x-ray obtained in the Emergency Department demonstrated bilateral nodular densities, which were further characterized on CT. The patient had initially been diagnosed with Crohn’s disease in January of 2024. He had been on several months of infliximab without significant improvement of symptoms, and was ultimately started on prednisone and Ustekinumab in the weeks leading up to presentation. Prednisone was being tapered at the time of symptom onset. He was ultimately admitted to the hospital medicine service, where testing for fungal antigens, TB, and respiratory pathogens was performed and notable only for rhino or enterovirus. ACE was obtained to evaluate for sarcoidosis and was 10. Sinus CT was notable for complete opacification of the left maxillary sinus, which was felt to be the most likely etiology of productive cough. Flexible bronchoscopy was performed and was unremarkable, with negative cultures and minimal bronchitis. He was treated for sinusitis but ultimately had worsening of symptoms and presented to the ED again. Chest CT performed 1 week after the initial imaging was notable for significant interval growth of the nodules. As infectious studies were negative, ACE was negative, and ANCA was negative, the most likely diagnosis was felt to be necrobiotic nodules; an extraintestinal manifestation of Crohn’s. He ultimately underwent tissue biopsy with interventional radiology, which demonstrated mixed lymphoplasmacytic and neutrophilic inflammation, ruling out the remaining diagnostic considerations: malignancy and thromboembolic disease. Repeat CT was performed approximately two months following the second CT in January 2025 and demonstrated near complete resolution of lesions. Additionally, chest pain, activity tolerance, and GI symptoms had significantly improved. The patient continues to have mild obstruction on spirometry, for which he is on fluticasone 110mcg 2 puffs BID. Our case is notable as it is only the second reported pediatric case of necrobiotic nodules in the literature. Additionally, it demonstrates the finding of ongoing obstruction in the setting of IBD, despite improvement of symptoms. Although necrobiotic nodules are uncommon, pulmonary manifestations of Crohn’s are not, particularly in the setting of increased use of more targeted biologic agents. Pulmonologists should be vigilant for these complications when evaluating patients with history of IBD. This abstract is funded by: None
Agnihotri et al. (Fri,) studied this question.