A151 MEDICATION INDUCED INTERSTITIAL LUNG DISEASE IN A PATIENT WITH ULCERATIVE COLITIS

Non-infectious pulmonary complications in ulcerative colitis (UC) are rare and can be an extra-intestinal manifestation or a consequence of medications. Medications known to cause pulmonary complications include mesalamine, sulfasalazine, methotrexate, azathioprine, and tumor necrosis factor alpha (TNF-α) inhibitors. We present a case of interstitial lung disease development in a patient with UC who was treated with mesalamine and infliximab. A 43 year old previously healthy male was diagnosed with UC in February. He was started on mesalamine at a dose of 4 grams a day as well as infliximab 5 mg/kg induction and maintenance every 8 weeks. In April, he reported abdominal symptoms and was found to have low infliximab levels. He was given another 5 mg/kg induction dose and his maintenance interval changed to every 4 weeks. He then presented to hospital in August with increasing shortness of breath and pleuritic chest pain. CT scan revealed ground-glass opacities in both lungs, particularly in the upper lobes. Infectious workup including a bronchoscopy was negative. However, he was treated empirically with a 5 day course of levofloxacin but did not return to baseline. At the time of discharge, pulmonary function testing (PFT) revealed a TLC of 44% and a DLCO of 50%. This patient was diagnosed with interstitial lung process. Mesalamine and infliximab were stopped as possible causative agents. A few weeks later this patient presented with a UC flare requiring IV steroids and prednisone taper. His bowel symptoms improved as did his respiratory symptoms. Follow up PFT at the end of September showed an improved TLC of 73% and DLCO of 83%. UC has various extra-intestinal manifestations including uveitis, arthritis, and rarely pulmonary disease. Besides complications of the disease itself, mesalamine and infliximab can both induce interstitial lung disease. Literature review has revealed mesalamine-induced lung toxicity to be rare, presenting as interstitial lung disease, alveolitis, eosinophilic pneumonia, or bronchiolitis obliterans with organizing pneumonia usually 2–6 months after medication start. Cases of infliximab-induced lung disease have also been reported mainly in the rheumatoid arthritis population presenting as an interstitial lung disease. The onset of toxicity is quite variable, usually after the 2nd and 5th infusions. Possible mechanisms include increased pro-inflammatory cytokines with inhibition of TNF-α and release of proteolytic enzymes upon interaction of infliximab with T-cells and macrophages. In both mesalamine and infliximab-induced pulmonary toxicity, steroid therapy results in clinical improvement. In our patient, pulmonary toxicity can be due to mesalamine, infliximab, or a combination of both. This is the first case of interstitial lung disease as a drug-induced toxicity in a UC patient on both mesalamine and infliximab. Ground-glass opacities in the upper lobes of both lungs None

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