Award: Presidential Poster Award
Pratikkumar Vekaria, MD, Johnnie Mao, MD, Ravish Patel, MD, Devin Vaishnani, MD, Tejas Raiyani, MD
Redmond Regional Medical Center, Rome, GA
Introduction: Crohn’s disease(CD) is an autoimmune IBD that can occur anywhere along GI tract. Its pathology show transmural granulomatous inflammation that can include all layers of GI lining. Extra-intestinal manifestations can be seen in multiple organ systems like skin, joints, eyes, and mouth. These symptoms are common in patient involving large intestine compare to involving only small-intestine. Nasal involvement is rare with CD and very few cases have been reported so far.
Case Description/Methods: 32-year-old female with PMH of CD, pyoderma gangrenosum and rectovaginal fistula presented with bloody diarrhea and abdominal pain for week and a half. Her abdominal pain was located in RLQ and epigastric region. She denied chest pain, dyspnea. She had fever for 2 days. Physical exam was significant for RUQ, RLQ, and epigastric tenderness. CT abdomen showed mild transverse colitis and MRI of pelvis showed anal fistula with no abscess. Her stool was positive with WBCs. Gastroenterologist put her on wide-coverage empiric antibiotics. As her abdominal pain improved, she began to complain of severe headache and developed erythematous swelling on dorsum of nose. CT head showed paranasal sinus (PNS) mucosal thickening. Multiple IV pain medications didn’t help her pain. ENT was consulted and given her history, believed she might have CD. Trial of IV steroids was given and her symptoms improved. ENT subsequently obtained nasal biopsy. Report showed chronic inflammation, edema, and fibroplasia that was consistent with CD. Gastroenterologist began Adalimumab and her symptoms improved.
Discussion: Extra-intestinal involvement can be seen in almost 36% of cases of CD. Nasal manifestation occur rarely. Common presentation can be nasal obstruction, bleeding, mucosal inflammation and septal perforation. Our patient did not have these manifestations, but she presented with severe headache that even strong pain medication didn’t help much. This is unusual presentation of CD. Furthermore, there are various treatment options available in case of nasal CD from steroids to leukocytapharesis. In our case, new biologics therapy, TNF-α Inhibitor, worked better in combination with steroids. It would be interesting to know if nasal steroid has any role to play in local remission. From our and other case reports, we suggest that patient with CD, especially large intestinal involvement, when present with headache, fever or PNS symptoms, should warrants careful evaluation to rule out nasal CD.
Citation: Pratikkumar Vekaria, MD, Johnnie Mao, MD, Ravish Patel, MD, Devin Vaishnani, MD, Tejas Raiyani, MD. P1445 - NASAL CROHN’S: RARE BUT REAL POSSIBILITY!. Program No. P1445. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.