A Rare Coexistence of Crohnʼs Disease and Sarcoidosis

Crohn's disease (CD) and sarcoidosis are granulomatous diseases with very rare simultaneous coexistence, and less than ten reported cases in the English literature. While their underlying etiology is yet to be identified, they are characterized by multi-organ involvement and pathognomonic non-caseating granulomas. We describe two patients with concomitant diagnosis of sarcoidosis and CD. A 56 year old female presented with cough, dyspnea, abdominal bloating, diarrhea and weight loss but otherwise negative review of systems. Patient's son had Crohn's disease. Chest CT scan revealed small nodules and adenopathy. Patient underwent bronchoscopy and pathology was consistent with non-caseating granulomas consistent with sarcoidosis. TB Quantiferon, respiratory cultures and AFB staining were all negative. Patient was treated with Plaquenil for sarcoidosis. Abdominal CT scan revealed distal small bowel wall thickening and mesenteric adenopathy. Colonoscopy with biopsies performed showed extensive ulcerations in terminal ileum. Pathology was consistent with acute on chronic inflammation with granulomas supporting diagnosis of CD. Patient was treated with budesonide and responded well to therapy. A 62 year old male with history of mycosis fungoides and sarcoidosis presented with recurrent episodes of abdominal pain. A few years ago, patient was found to have palpable lymph nodes in the neck warranting biopsy. Histopathology of paratracheal lymph nodes revealed non-necrotizing granulomas consistent with sarcoidosis. Chest CT scan showed perihilar adenopathy. Tuberculosis was excluded. Patient was not treated for sarcoidosis. Abdominal CT scan showed wall thickening of distal small bowel suggestive of CD. Patient denied any extra-intestinal manifestations of CD. Double-balloon enteroscopy was performed and showed multiple erosions and small bowel strictures. Pathology of terminal ileum revealed granulomas. Patient was given Pentasa and budesonide. Patient responded well to therapy, refusing biologics. Diagnosis of Crohn's disease in patients with sarcoidosis may be challenging because both are associated with granulomas seen on pathologic specimen. In case of suspected sarcoidosis with gastrointestinal involvement proper therapy for sarcoidosis should be initiated. Future serologic and genetic studies are warranted to further investigate underlying basis for pathophysiologic coexistence and their relevance regarding medical management.