SAGES Magazine

THE SOUTH AFRICAN GASTROENTEROLOGY REVIEW 2022 | VOLUME 20 | ISSUE 1 | 33 CASE REPORT imaging abnormalities do not have symptoms. Despite advanced pulmonary disease on chest imaging our patient reported minimal symptoms. Her respiratory symptoms were assessed repeatedly by different doctors. Where symptoms exist, cough and dyspnoea are the most common. The clinical approach to IBD patients with respiratory disease is well established. Infections are the commonest cause of respiratory disease and must be excluded particularly in patients on immunosuppression treatment. Medication related pulmonary disease is an important entity to consider in patients already on treatment for IBD. In one case series of 31 patients with IBD (UC = 22) and interstitial lung disease (ILD), drug-related ILD was diagnosed in 64% of the patients. 9 Medication induced lung disease is therefore relatively common although it can be difficult in some cases to separate medication related disease from actual IBD related EIM or other pulmonary complication of IBD. Medication associated lung disease is strictly not an EIM in IBD but will be briefly discussed here. Medications that are more associated with parenchymal lung disease are mesalamine (including the sulfapyridine component of salazopyrine), infliximab and methotrexate. Other medications that have also been implicated are adalimumab, golimumab, vedolizumab and the thiopurines. In the highlighted case series, 9 infliximab accounted for 8 out of 20 (40%) cases of drug-induced interstitial lung disease with the diagnosis occurring after a mean of 5.4 doses (range 2-8 doses) of infliximab; while aminosalicylate accounted for 9 out of 20 (45%) cases and occurred after mean IBD duration of 6.6 years (range 0.8-14 years). Methotrexate was implicated in 1 out of 20 patients after 2 years of treatment at 15mg/week. Despite these observations, clinical features can occur at any time because drug induced lung disease can be dose dependent or idiosyncratic. The work up of a patient with suspected IBD related pulmonary disease is similar to that for any patient with acute or chronic respiratory disease and includes HIV testing, autoimmune tests, sputum tests for routine culture and tuberculosis testing, chest imaging, spirometry, blood gas analysis, broncho-alveolar lavage and lung biopsy. There are no patterns of abnormality that are specific for IBD related pulmonary disease. In the appropriate clinical context, the diagnosis of IBD-related lung disease is one of exclusion. The treatment of IBD-related respiratory disorders depends on the specific pattern of involvement, and in most patients, corticosteroids are required in the initial management. Corticosteroids, both systemic and aerosolized, are the mainstay therapeutic approach and patients typically respond to this treatment, underscoring the inflammatory basis of the disease process. Antibiotics must also be administered in the case of infectious and suppurative processes. In a case series of 17 patients with IBD (14 with UC and 3 with CD) and respiratory symptoms, 11 patients exhibited a clinical and/or physiological response to corticosteroids administered either orally, in the case of alveolar disease, or inhaled or orally or both, in airway disease. 10 Occasionally second line immunosuppressive agents may be required in the case of corticosteroid dependence or suboptimal response. Although drug-induced pulmonary disease may respond to drug withdrawal alone, corticosteroids are commonly prescribed in this context depending on the nature of disease and severity of symptoms. 9,11 Response to corticosteroids in the case of drug-induced pulmonary disease is more variable. 9 In conclusion, this case report seeks to alert physicians managing IBD patients to the increasingly prevalent pulmonary manifestations. In addition, a brief literature review of the subject has been provided. Although most inflammatory lung disease can be expected to respond well to treatment, more advanced disease such as pulmonary fibrosis (which our patient had) is associated with less response to treatment and greater lung-specific morbidity and mortality. References 1. Bernstein, Charles N; Blanchard, James F MD; Rawsthorne, Patricia RN; Yu, Nancy. The Prevalence of Extraintestinal Diseases in Inflammatory Bowel Disease: A Population-Based Study, American Journal of Gastroenterology: April 2001 - Volume 96 - Issue 4 - p 1116-1122 2. Songür, Necla; Songür, Yldran; Tüzün, Meriç; Doan, Ibrahim; Tüzün, Dilek; Ensari, Arzu; et al. Pulmonary Function Tests and High-Resolution CT in the Detection of Pulmonary Involvement in Inflammatory Bowel Disease, Journal of Clinical Gastroenterology: October 2003 - Volume 37 - Issue 4 - p 292-298 3. Amra B, Ataabadi G, Emami MH, Hassanzadeh A, Golshan M, Soltaninejad F. Pulmonary function tests in ulcerative colitis. J Res Med Sci 2014; 19:605-9. 4. Devendra Desai, Samir Patil, Zarir Udwadia, Shailendra Maheshwari, Philip Abraham, Anand Joshi. Pulmonary manifestations in inflammatory bowel disease: a prospective study. Indian J Gastroenterol 30, 225 (2011) 5. Black H, Mendoza M, Murin S. Thoracic manifestations of inflammatory bowel disease. Chest. 2007 Feb;131(2):524-32. 6. Kim J, Chun J, Lee C, Han K, Choi S, Lee J, et al. Increased risk of idiopathic pulmonary fibrosis in inflammatory bowel disease: A nationwide study. J Gastroenterol Hepatol. 2020 Feb;35(2):249-255. 7. Rogler G, Singh A, Kavanaugh A, Rubin DT. Extraintestinal Manifestations of Inflammatory Bowel Disease: Current Concepts, Treatment, and Implications for Disease Management. Gastroenterology. 2021 Oct;161(4):1118-1132. 8. Godet PG, Cowie R, Woodman RC, Sutherland LR. Pulmonary function abnormalities in patients with ulcerative colitis. Am J Gastroenterol. 1997 Jul;92(7):1154-6. 9. Eliadou E, Moleiro J, Ribaldone DG, Astegiano M, Rothfuss K, Taxonera C, et al; ECCO CONFER COMMITTEE. Interstitial and Granulomatous Lung Disease in Inflammatory Bowel Disease Patients. J Crohns Colitis. 2020 May 21;14(4):480-489. 10.Mahadeva R, Walsh G, Flower CD, Shneerson JM. Clinical and radiological characteristics of lung disease in inflammatory bowel disease. Eur Respir J. 2000 Jan;15(1):41-8. 11.Basseri B, Enayati P, Marchevsky A, Papadakis KA. Pulmonary manifestations of inflammatory bowel disease: case presentations and review. J Crohns Colitis. 2010 Oct;4(4):390-7.