Chronic cough associated with Crohn's disease
© Faruqi et al; licensee BioMed Central Ltd. 2010
Received: 1 March 2010
Accepted: 8 August 2010
Published: 8 August 2010
A 62-year-old man presented with chronic dry cough. He was known to have Crohn's disease which was in remission. A plain chest radiograph demonstrated bilateral apical infiltrates. A HRCT of the chest showed normal proximal airways. Stenosis of medium size airways was present with post-stenotic dilation. These dilated peripheral bronchi appeared fluid filled. Patchy areas of consolidation were seen as well. These changes were thought to be due to Crohn's disease involving the lungs and responded well to treatment with cortico-steroids. We report this uncommon radiological association with Crohn's disease.
Clinically relevant respiratory manifestations of inflammatory bowel disease are very uncommon. They are reported more commonly in association with Ulcerative Colitis and less often with Crohn's disease. The most frequent respiratory manifestation of inflammatory bowel disease is bronchiectasis. We report a case of chronic dry cough in association with Crohn's disease with interesting associated radiology and good response to treatment with steroids.
Discussion and conclusion
The Inflammatory Bowel Diseases (IBD), Ulcerative Colitis (UC) and Crohn's disease (CD), are known to have multiple extra intestinal manifestations with as many as 36% of cases having at least one . Although association between respiratory disease and IBD has been observed more than three decades ago, clinically significant respiratory manifestations of IBD are uncommon [2, 3]. Any part of the lung and its vasculature may be involved in association with IBD. Large airways disease is the commonest site of lung involvement in IBD. In a recent review these accounted for 39% of the cases of which two thirds comprise bronchiectasis. Bronchiectasis is most commonly observed in UC, predominates in women and more common in non-smokers. Interestingly flare up of bronchiectasis has been observed within a year following colectomy [4, 5]. This transfer of the inflammatory process from the gastro intestinal tract to the lungs has been suggested as evidence for causal link between the two . The common origin of the lung and the gastro intestinal tract from the primitive foregut and similarities in tissue structure suggest a patho-physiologic reason for lung involvement in IBD.
Clinically smaller airways disease in IBD is rare and involvement is both at a younger age and at an early point in the disease course. Pathologically, bronchiolitis is most commonly reported. Bronchiolitis obliterans organizing pneumonia (BOOP) is the most common parenchymal lung manifestation reported in association with IBD. In the majority of cases the association is with UC. As with idiopathic BOOP, it responds well to corticosteroid therapy. Several other parenchymal lung diseases such as other interstitial pneumonias and eosinophilic pneumonias as well as pulmonary nodules have been reported. Pulmonary nodules are rare and can be necrobiotic or granulomatous [4, 5, 7, 8].
Although the lung manifestations of IBD have been well described in literature, our patient was unique in the indolent presentation as well as the distinctive radiological features. Large airways involvement in the form of severe tracheo-bronchial stenosis with marked inflammation has been observed in CD . In our patient stenosis was seen in medium size airways. Bronchial biopsy showed evidence of inflammation which is the most prevalent involvement in IBD . The location of stenosis in the medium size bronchi lead to the unique radiological picture of dilated, fluid filled peripheral airways seen on the CT scan. Patchy areas of consolidation seen could represent BOOP. In the context of IBD, associated lung diseases respond well to corticosteroid treatment. The dosage, duration and route of administration are empirical and based on clinical experiences. As the symptoms of our patient were mild in nature we started treatment with a relatively low dose of prednisolone to which he responded very well. However stopping prednisolone resulted in a relapse of his symptoms necessitating a small maintenance dose along with inhaled budesonide. He remains well on the above treatment.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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