Pulmonary Necrobiotic Nodules at Time of Diagnosis in a Patient with Ulcerative Colitis.

Inflammatory bowel disease (IBD) is an umbrella term encompassing intestinal conditions Crohn's disease and ulcerative colitis (UC), characterized by inflammation of intestinal wall, differing in location, depth, pathophysiology, and sequela. Extraintestinal manifestations (EIM) of IBD commonly affect the skin, joints, eyes, and in rare instances, the lungs. Pulmonary involvement affects the large and small airways, serosal surface, and vasculature leading to a range of pathology, including bronchiectasis, pleural effusions, and necrobiotic nodules. The presence of EIM is uncommon at the diagnosis, particularly in regard to pulmonary EIM, most commonly seen years later. We present the case of a 22-year-old African American female who was discovered to have pulmonary involvement of her UC at the time of her diagnosis complicating management of her appendicitis. A 22-year-old female with a history of UC was transferred from an outside hospital for the management of her appendicitis after imaging revealed numerous pulmonary nodules. The presence of multiple cavitary pulmonary nodules delayed surgical intervention leading to a ruptured appendix. The patient had no cardiopulmonary complaints, and review of prior imaging studies showed these nodules to be present six weeks prior, the time of her diagnosis with UC. After antibiotic management failed, the patient required a laparotomy appendectomy with omentectomy due to resulting appendiceal abscess and phlegmon. The nodules were determined to be EIM of UC after sarcoidosis, infectious, and malignant etiologies were ruled out. For the pulmonary nodules, she is following at an outside hospital for the management of her UC as treatment of her underlying UC will result in a decrease or resolution of the EIM. EIM of IBD may present in patients at any time, even before their initial diagnosis of an IBD. While pulmonary manifestations are rare EIM, the presence of pulmonary nodules at the time of initial diagnosis is exceedingly uncommon. Evaluation and management of these nodules, even if asymptomatic in nature, requires diligence and thorough documentation regarding their onset and etiology. In the event of a medical emergency, such as in the case of our patient with appendicitis, a lack of thorough documentation and evaluation of the nodules may result in unnecessary medical testing, invasive procedures, and delay in treatment of their current medical illness.

A Rare Case of Atrial Metastasis From a Rectal Adenocarcinoma.

Colorectal cancers typically metastasize to the lymph nodes, liver or lungs. Metastasis to the heart is rare and although a few cases of cardiac metastases from colon cancer are described in the literature, cases of metastatic rectal cancer to the heart are far fewer. A 69-year-old woman with a history of rectal adenocarcinoma treated with neo-adjuvant chemotherapy and radiation, followed by resection and adjuvant chemotherapy, presented with increasing dyspnea on exertion and lower extremity edema 5 years after oncology follow-up. Echocardiography revealed a mass within the right atrium, which was biopsied and found to be consistent with metastatic rectal adenocarcinoma and a thrombus. The patient was deemed to be a poor surgical candidate given her co-morbidities and overall prognosis. Chemotherapy was offered and refused by the patient. The medical literature has a paucity of similar cases of rectal adenocarcinoma metastasizing to the right atrium. Further studies are needed to help guide standardized treatment options.