LETTER

Uncommon arthritis aspresenting manifestationof silent Crohn’s disease

Carlos García-Porrúa1, Miguel A. González-Gay1*,Carmen González-Louzao1, Javier Castro1, MariaJ. Rivas1, Eva Santos21Rheumatology Division, Hospital Xeral-Calde, Lugo, Spain ;2Gastroenterologyy Division, Hospital Xeral-Calde, Lugo, Spain

(Submitted for publication April 27, 2000; accepted in revised formAugust 16, 2000)

arthritis / Crohn’s disease

Clinical manifestations of spondyloarthropathy areobserved in a wide and heterogeneous spectrum ofdiseases [1]. The knowledge of several clues to identifysilent inflammatory bowel disease in patients present-ing with spondyloarthropathy is of capital importance,as in these patients an ileocolonoscopy is not routinelyrecommended [2, 3]. We report a patient with arthritisin the first metatarsophalangeal joint as the presentingmanifestation of silent Crohn’s disease (CD).

A 41-year-old woman was sent to the rheumatologyoutpatient clinic because of an episode of arthritis in herleft big toe that had occurred five days earlier. Due tothis and despite having regular menses, she was clini-cally diagnosed as having gout, but no arthrocentesiswas performed at that time. Treatment with NSAIDswas given. However, no improvement of symptomswas noticed and, at the time of presenting in our clinic,physical examination disclosed the presence of pallor ofmucoses, fever (39.5° C), and arthritis in her left firstmetatarsophalangeal joint, both ankles and wrists. Therest of the examination was normal. Complete bloodcell count showed 8,100/mm3 white cells (neutrophils67%), 270,000 platelets/mm3. The hemoglobin was7.7 g/dL (MCV 63.1 fl, normal: 80–94 fl; MCH19.3 pg, normal: 27–31 pg). The erythrocyte sedimen-tation rate and fibrinogen were elevated: 99 mm/1 h

(normal < 20) and 741 mg/dL (normal: 170–400),respectively. Coombs’ test was negative, and peripheralblood smear showed a microcytic and hypochromicanemia. Other laboratory parameters, including hepaticand renal function tests, HLA B27, rheumatoid factor,ANA, anti-DNA, ANCA, antiphospholipid antibod-ies, cryoglobulins, serum C3 and C4 levels, and urinan-alysis were negative or normal. Cultures (blood, urine,and feces) were taken. Also, intracutaneous tuberculinskin test (PPD) and serologic tests for brucella (rosebengal plate agglutination test, seroagglutinations, andCoombs’ test), Q fever, mycoplasma, Chlamydia, yer-sinia, borrelia, hepatitis B, cytomegalovirus, Epstein-Barr and HIV were performed. However, all the resultswere negative and a chest radiograph was also normal.During her stay at the hospital she developed a migra-tory and additive synovitis involving the wrists, ankles,and first and second metacarpophalangeal joints ofboth hands, and second proximal interphalangeal jointof the left hand. Interestingly, dactylitis in the thirdfinger of the left hand was also observed. Due to thepresence of anemia further studies were considered. Inthis regard, a gastroscopy was normal. However, anileocolonoscopy showed an involvement of the termi-nal ileum, with aphthoid ulcers. These features weremacroscopically compatible with a moderately activeCD. Cultures of tissue biopsy for yersinia and myco-bacterium were negative. Histological features werecharacterized by chronic inflammation extendingthrough all layers of the intestinal wall that confirmedCD. Sulfasalazine has been shown to be effective in thetherapy of CD. In this case and due to the presence ofsynovitis involving the wrists, ankles, and small jointsof the hands and feet a treatment with oral prednisone(0.5 mg/kg) and sulfasalazine (2 g/d) was started withrapid and complete resolution of symptoms.

Peripheral arthritis, usually as a mono- or oligoarthri-tis, most frequently involving the knee and ankle, hasbeen found in 17% of adults with CD [4]. An acutearthropathy before diagnosis was found in 10% ofpauciarticular and in 10% of polyarticular peripheralarthritis. Furthermore, 14% of pauciarticular and 25%of polyarticular arthropathies were present at the timeof diagnosis of CD [5]. Arthritis of the first metatar-sophalangeal joint is an uncommon presenting sign of

* Correspondence and reprints: Dr. Miguel A. Gonzalez-Gay, Division ofRheumatology, Hospital Xeral-Calde, c/ Dr. Ochoa s/n, 27004 Lugo,Spain.

Joint Bone Spine 2000 ; 67 : 553-4© 2000 Éditions scientifiques et médicales Elsevier SAS. All rights reserved

CD. In our patient, despite having no symptomaticevidence of bowel inflammatory disease, severe anemiawas the clinical data leading to further studies. Inspondyloarthropathies, exogenous factors causinginflammation of the gut may lead to a disturbed per-meability of the gut wall or a deficient local immuno-logical defense mechanism permitting antigens to enterthe circulation, inducing joint and tendon inflamma-tion [3, 6]. In this regard, the importance of the disrup-tion of the ileocecal integrity in the pathogenesis of thearthritic complications of CD has been recently under-lined and, as in our case, may explain the developmentof arthritis as alarm signal of silent CD [7, 8].

REFERENCES

1 Olivieri I, Barozzi L, Padula A, De Matteis, Pavlica P. Clinicalmanifestations of seronegative spondylarthropathies. Eur JRadiol 1998 ; 27 Suppl 1 : 3-6.

2 Leirisalo-Repo M, Turunen U, Stenman S, Helenius P, Sep-pala K. High frequency of silent inflammatory bowel disease inspondyloarthropathy. Arthritis Rheum 1994 ; X : 23-31.

3 Mielants H, Veys EM, Cuvilier C, De Vos M. Ileocolonoscopicfindings in seronegative spondylarthropathies. Br J Rheumatol1988 ; 27 : 95-105.

4 Buskila D, Odes LR, Neumann L, Odes HS. Fibromyalgia ininflammatory bowel disease. J Rheumatol 1999 ; 26 : 1167-71.

5 Orchard TR, Wordsworth BP, Jewell DP. Peripheral arthropa-thies in inflammatory bowel disease: their articular distributionand natural history. Gut 1998 ; 42 : 387-91.

6 Mielants H, Veys EM, Goethals K, Van Der Straeten C, Ack-erman C. Destructive lesions of small joints in seronegativespondylarthropathies: relation to gut inflammation. Clin ExpRheumatol 1990 ; 8 : 23-7.

7 Fiocchi C. Inflammatory bowel disease: aetiology and patho-genesis. Gastroenterology 1998 ; 115 : 182-205.

8 Orchard TR, Jewell DP. The importance of ileocecal integrityin the arthritic complications of Crohn’s disease. InflammBowel Dis 1999 ; 5 : 92-7.

S1297319X00002207/CORJoint Bone Spine 2000 ; 67 : 553–4

554 C. Garcia-Porrua et al.