The Clinical Respiratory Journal LETTER TO THE EDITOR
Asymptomatic pulmonary embolism in patient with fistulizing mild Crohn’s disease A 32-year-old man was admitted to our clinic complaining of diarrhea and mild abdominal pain. He had a history of extra-abdominal fistulizing ileocolonic Crohn’s disease (CD) occurred after appendectomy and he had received azathioprine and adalimumab treatment for 3 months owing to activation of CD. The active fistula of the disease has not responded to treatment. His vital signs were within normal limits. Physical examination revealed extra-abdominal fistula with moderate output (between 200 and 400 mL per day) on the right lower abdomen. Blood tests showed a white cell count of 5000 per mm3, erythrocyte sedimentation rate 45 mm/h, C-reactive protein 13.7 mg/L, total protein 5.1 g/dL, albumin 3.0 g/dL, creatinine 0.5 mg/dL and CD activity index was 165. During routine inspections for infliximab treatment, consolidation was found on the lateral side of the right middle lobe on the chest Xray (Fig. 1A). Thoracic computed tomography was taken for preliminary investigation of peripheral pulmonary lesions and nonmassive pulmonary embolism was detected on examination (Fig. 1B). Anticoagulant treatment was started with low-molecular-weight heparin. Because, from his mild clinical presentation and low-flow fistula, surgical procedure was not considered and adalimumab treatment was switched Infliximab treatment with azathioprine. Pulmonary thromboembolism (PTE) is a common cardiovascular disease, complication of underlying venous thrombosis (1). The classic presentation of PTE is the abrupt onset of pleuritic chest pain, dyspnea and hypoxia. But patients with nonmassive PTE may have
(A)
no obvious symptoms at presentation. Patients with inflammatory bowel disease are at increased risk of venous thromboembolism (2). Endothelial injury, stasis or turbulence of blood flow and blood hypercoagulability are three common predisposing factor for thrombus formation. CD, especially fistulizing form, may cause PTE with these three steps. Because of nonspecific clinical presentation, physician should be vigilant in patient with active or inactive CD for PTE. Fatih Karaahmet1, Ayse Munevver Demirtas2, Hakan Akinci1, Yusuf Coskun1 and Ilhami Yuksel1,3 1 Department of Gastroenterology, Diskapi Yildirim Beyazit Educational and Research Hospital, Ankara, Turkey 2 Department of Internal Medicine, Diskapi Yildirim Beyazit Educational and Research Hospital, Ankara, Turkey 3 Department of Gastroenterology, Yildirim Beyazit University School of Medicine, Ankara, Turkey
References 1. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29: 2276–315. 2. Papay P, Miehsler W, Tilg H, et al. Clinical presentation of venous thromboembolism in inflammatory bowel disease. J Crohns Colitis. 2013;7: 723–9.
(B)
Figure 1. Radiologic images. (A) Consolidation on the lateral side of the right middle lobe on the chest X-ray. (B) A clot in the segmental artery of the right middle lobe.
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
1
Asymptomatic pulmonary embolism in patient with fistulizing mild Crohn’s disease A 32-year-old man was admitted to our clinic complaining of diarrhea and mild abdominal pain. He had a history of extra-abdominal fistulizing ileocolonic Crohn’s disease (CD) occurred after appendectomy and he had received azathioprine and adalimumab treatment for 3 months owing to activation of CD. The active fistula of the disease has not responded to treatment. His vital signs were within normal limits. Physical examination revealed extra-abdominal fistula with moderate output (between 200 and 400 mL per day) on the right lower abdomen. Blood tests showed a white cell count of 5000 per mm3, erythrocyte sedimentation rate 45 mm/h, C-reactive protein 13.7 mg/L, total protein 5.1 g/dL, albumin 3.0 g/dL, creatinine 0.5 mg/dL and CD activity index was 165. During routine inspections for infliximab treatment, consolidation was found on the lateral side of the right middle lobe on the chest Xray (Fig. 1A). Thoracic computed tomography was taken for preliminary investigation of peripheral pulmonary lesions and nonmassive pulmonary embolism was detected on examination (Fig. 1B). Anticoagulant treatment was started with low-molecular-weight heparin. Because, from his mild clinical presentation and low-flow fistula, surgical procedure was not considered and adalimumab treatment was switched Infliximab treatment with azathioprine. Pulmonary thromboembolism (PTE) is a common cardiovascular disease, complication of underlying venous thrombosis (1). The classic presentation of PTE is the abrupt onset of pleuritic chest pain, dyspnea and hypoxia. But patients with nonmassive PTE may have
(A)
no obvious symptoms at presentation. Patients with inflammatory bowel disease are at increased risk of venous thromboembolism (2). Endothelial injury, stasis or turbulence of blood flow and blood hypercoagulability are three common predisposing factor for thrombus formation. CD, especially fistulizing form, may cause PTE with these three steps. Because of nonspecific clinical presentation, physician should be vigilant in patient with active or inactive CD for PTE. Fatih Karaahmet1, Ayse Munevver Demirtas2, Hakan Akinci1, Yusuf Coskun1 and Ilhami Yuksel1,3 1 Department of Gastroenterology, Diskapi Yildirim Beyazit Educational and Research Hospital, Ankara, Turkey 2 Department of Internal Medicine, Diskapi Yildirim Beyazit Educational and Research Hospital, Ankara, Turkey 3 Department of Gastroenterology, Yildirim Beyazit University School of Medicine, Ankara, Turkey
References 1. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29: 2276–315. 2. Papay P, Miehsler W, Tilg H, et al. Clinical presentation of venous thromboembolism in inflammatory bowel disease. J Crohns Colitis. 2013;7: 723–9.
(B)
Figure 1. Radiologic images. (A) Consolidation on the lateral side of the right middle lobe on the chest X-ray. (B) A clot in the segmental artery of the right middle lobe.
The Clinical Respiratory Journal (2015) • ISSN 1752-6981 © 2015 John Wiley & Sons Ltd
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