A 38-Year-Old Woman with Waxing and Waning Pulmonary Nodules

 This NEJM Case Records report chronicles a diagnostic challenge involving a 38-year-old woman with progressive dyspnea, waxing and waning pulmonary nodules, and years of systemic symptoms—bloody diarrhea, joint pain, dacryoadenitis, and fatigue. After exclusion of infection, malignancy, and vasculitis, the diagnosis of granulomatous lung disease and serositis emerged as extraintestinal manifestations of inflammatory bowel disease (IBD). Colonoscopy confirmed ulcerative proctitis with a periappendiceal “cecal patch.” CT-guided biopsy revealed well-formed granulomas and fibrin deposition. Ocular symptoms, sacroiliitis, and dactylitis reinforced systemic inflammation. Treatment escalated from glucocorticoids to TNF-α inhibitors (infliximab → adalimumab), followed by ustekinumab ± methotrexate, resolving pulmonary and joint symptoms.

 This NEJM Case Records report chronicles a diagnostic challenge involving a 38-year-old woman with progressive dyspnea, waxing and waning pulmonary nodules, and years of systemic symptoms—bloody diarrhea, joint pain, dacryoadenitis, and fatigue. After exclusion of infection, malignancy, and vasculitis, the diagnosis of granulomatous lung disease and serositis emerged as extraintestinal manifestations of inflammatory bowel disease (IBD). Colonoscopy confirmed ulcerative proctitis with a periappendiceal “cecal patch.” CT-guided biopsy revealed well-formed granulomas and fibrin deposition. Ocular symptoms, sacroiliitis, and dactylitis reinforced systemic inflammation. Treatment escalated from glucocorticoids to TNF-α inhibitors (infliximab → adalimumab), followed by ustekinumab ± methotrexate, resolving pulmonary and joint symptoms.