Rheumatol Int (2005) 25: 401–405 DOI 10.1007/s00296-004-0470-0
O R I GI N A L A R T IC L E
Reuven Mader Æ Ori Segol Æ Muhammed Adawi Philippe Trougoboff Æ Elchanan Nussinson
Arthritis or vasculitis as presenting symptoms of Crohn’s disease
Received: 20 August 2003 / Accepted: 12 March 2004 / Published online: 20 April 2004 Ó Springer-Verlag 2004
Abstract Objective: The aim of this study was to describe arthritis or vasculitis as initial manifestations of Crohn’s disease (CD). Methods: We describe three cases in which the rheumatological manifestations preceded the bowel disease and one with rheumatological manifestation and asymptomatic gut inflammation. The information on clinical manifestations, laboratory examination results, imaging procedures, and histological data were gathered from the patients’ medical charts. A MEDLINE search for the associations of extraintestinal manifestations of inflammatory bowel disease was performed. Results: Arthritis or vasculitis preceded the bowel disease by 3 to 15 months. In one case, the bowel disease remained asymptomatic throughout the follow-up period. Conclusion: Rheumatological presentations of CD such as arthritis and vasculitis are uncommon. The diagnosis of CD without evident bowel symptoms might offer explanations and treatment options for puzzling symptoms and signs. Recognition, early diagnosis, and treatment of the underlying gut disease might prove useful for both the bowel disease and the rheumatological manifestations. Keywords Arthritis Æ Crohn’s disease Æ Inflammatory bowel disease Æ Vasculitis
R. Mader (&) Æ M. Adawi Rheumatic Diseases Unit, Ha’Emek Medical Center, Afula 18101, Israel E-mail:
[email protected] Tel.: +972-4-6494354 Fax: +972-4-6494453 R. Mader The B. Rappaport Faculty of Medicine, The Technion Israel Institute of Technology, Haifa, Israel O. Segol Æ E. Nussinson Gastroenterology Institute, Ha’Emek Medical Center, Afula, Israel P. Trougoboff Pathology Institute, Ha’Emek Medical Center, Afula, Israel
Introduction Crohn’s disease (CD) is an idiopathic form of a chronic, transmural, granulomatous inflammation of the intestine of unknown etiology. Although it usually involves the terminal ileum and colon, any portion of the gut may be affected, with incidence increasing in the western world [1]. Ulcerative colitis (UC) is also an inflammatory disease of the colon. The inflammation is usually limited to the mucosal layer of the colon. Although it often affects the rectum, the extent of colonic involvement is variable. Because of similarities in the clinical presentation of these conditions and, at times, the difficulties in differentiating between them, they are often grouped under the term inflammatory bowel disease (IBD). The arthritis associated with IBD shares characteristics of the seronegative spondyloarthropathies such as oligoarthritis of medium and large joints involving mainly the lower extremities, sacroiliitis, spondylitis, and enthesopathies. Several extraintestinal manifestations may accompany IBD, including various rheumatological manifestations. The temporal relationship between the rheumatological manifestations and clinical presentation of the bowel disease has not been extensively studied. Several cases of rheumatological extraintestinal manifestations that antedated or appeared concomitantly with CD have been reported. We describe four patients in whom arthritis or vasculitis preceded the bowel disease or led to the diagnosis of asymptomatic CD. Recognition of these manifestations as the presenting symptoms of CD is important in light of the pathogenetic and treatment implications related to the diagnosis of CD and to avoid erroneous diagnosis and management.
Methods The medical charts of four patients who presented with arthritis or vasculitis that were later diagnosed as extraintestinal manifestations of CD were reviewed.
402
A MEDLINE search from 1966 to the present was performed. The initial screening used the terms ‘‘ulcerative colitis,’’ ‘‘Crohn’s disease,’’ ‘‘inflammatory bowel disease,’’ and ‘‘extraintestinal.’’ The relevant clinical manifestations were cross-referenced with the specific diseases.
Patients Case 1 A 15-year-old male was referred for evaluation of a painful and swollen left knee of 3-weeks duration. The pain also involved the right wrist and right shoulder, without evident local swelling. Systems review was unremarkable, and there was no relevant family history. General physical examination was unremarkable. Musculoskeletal examination disclosed stress tenderness in the left knee and right shoulder, with mild effusion in the left knee. Laboratory tests revealed an erythrosedimentation rate of 102 mm in the 1st h, Creactive protein (CRP) of 107 mg/dl (normal
