Rheumatology

Case Report
By Balamurali Krishna Muralee Dharan Veena
Group 4
Case Report
A 36-year-old man presents with polyarthritis.
On admission, he suered from arthralgia in
both knees, arthritis in both wrists, and PIP and
MCP in both hands and ankles.

PMH: Ulcerative Colitis

Laboratory data were as follows:

ESR: 18 mm/h, WBC: 10,500/mL (neutrophils:
70%, lymphocytes: 25%, monocytes: 1%), Hb:
13.6 g/dL, PLT: 34.4×104 /m L, and C-reactive
protein (CRP): 1.16 mg/dL. Urinalysis did not
demonstrate any protein on a dipstick test.
Renal and liver functions were normal.
Immunological tests demonstrated that
immunoglobulin (Ig) G, IgA, and IgM were, 1,662,
277, and 128 mg/dL, respectively. RF was < 3.
Anti-nuclear antibody and anti-CCP antibody
were negative.
The diagnosis is
Enteropathic
Arthritis
Overview
Enteropathic arthritis, a spondyloarthritis associated with
inflammatory bowel disease and other gastrointestinal diseases,
is an immune-driven inflammatory disease process.
Joint involvement is the most frequent and impactful
extraintestinal manifestation of inflammatory bowel disease.

Enteropathic arthritis may predate the onset of the intestinal

manifestations of inflammatory bowel disease.
Etiology
5. Dysbiosis of the local gut
1. Complex Etiology
microbiota
2. Genetic Factors:
- HLA-B27
- ERAP1 and ERAP2
- Epistatic Interaction
6. Disruption of the gut
3. Environmental Triggers mucosal barrier

4. Immune Dysregulation: 7.Dysregulated sensing of

- Aberrant Immune Response microbial products
- Autoimmunity
Epidemiology
● Enteropathic arthritis is the most frequent extraintestinal
manifestation of inflammatory bowel disease.
● A 2017 meta-analysis reported spondyloarthritis occurring in up
to 13% of patients with inflammatory bowel disease.
● The incidence of IBD is higher in Whites, especially those of
Ashkenazi Jewish descent, than in other racial groups.
Spondyloarthropathy aects both sexes with equal frequency,
but axial involvement is more frequent in men.
● IBD is most common in persons aged 15-35 years. Axial
involvement in IBD can occur at any age.
Presentation and History
● The peripheral arthropathies associated with IBD occur in between 5%
and 20% of patients.
● Synovial histology usually reveals nonspecific inflammatory changes
including villous hypertrophy, edema, and lymphohistiocytic infiltrates,
although granulomatous synovitis has also been described.
● Enteropathic arthritis mostly aects the lower limbs, although other
paerns of articular involvement have been described, including
monoarthropathy and small joint symmetrical polyarthropathy.
● The peripheral arthritis associated with IBD is seronegative and is
typically non-deforming and non-erosive, although erosive disease
aecting the hip, elbows, metacarpophalangeal joints,
metatarsophalangeal joints, and an erosive polyarthritis have been
described.
Types
● Axial arthritis (sacroiliitis and spondylitis) associated with inflammatory
bowel disease (IBD) has the following characteristics:
○ Insidious onset of low back pain, especially in younger
persons(<45yrs)
○ Morning stiness
○ Exacerbated by prolonged siing or standing
○ Improved by moderate activity
○ Independent of GI symptoms

● Enthesitis aects the following parts of the body:

○ Heel - Insertion of the Achilles tendon and plantar fascia
○ Knee - Tibial tuberosity, patella

● Dactylitis
● Uveitis
● Erythema nodosum
● Pyoderma gangrenosum
Diagnosis
● The diagnosis is clinically suspected when a patient with inflammatory
bowel disease develops joint pain and stiness or inflammatory back pain
● Complete blood count (CBC) - May reveal iron deficiency anemia,
leukocytosis, and thrombocytosis
● Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
concentration - Usually elevated
● Rheumatoid factor (RF) - Absent usually
● Synovial fluid analysis - Shows mild to moderate inflammatory fluid,
mononuclear cell predominance (often), negative cultures, and no crystals

CRP levels are higher in enteropathic arthritis patients with axial involvement.
HLA-B27 positivity is more commonly associated with axial involvement;
however, the prevalence remains low at about 16%.
● Imaging studies of joints are not required for diagnosis

● Can be obtained to evaluate joint damage and assess for disease

progression:
○ Radiography of the spine and sacroiliac joints.
■ Lumbar spine radiography can reveal signs of enthesitis at the
annulus fibrosus appearing as squaring of vertebral bodies,
sclerosis of superior and inferior margins, and formation of
marginal calcified bridges called syndesmophytes.
■ Sacroiliac joint radiographs may reveal sclerosis, erosions, and
ankylosis.
● Arthrocentesis

● Musculoskeletal ultrasound can assist in evaluating peripheral joint

involvement through findings of eusions and color-power Doppler
signal consistent with active inflammation.

● Sacroiliac and lumbar MRI with STIR (Short Tau Inversion Recovery) is
the gold standard for assessing axial spondyloarthritis and sacroiliitis
and can identify active inflammation not assessable by plain
radiography

● PHQ-2 and PHQ-9

Case courtesy of Andrew Dixon, Radiopaedia.org, rID: 28563 Case courtesy of Francis Deng, Radiopaedia.org, rID: 88901
Case courtesy of Domenico Nicoletti, Radiopaedia.org, rID: 41282
Management
● NSAID’S
○ COX-2 inhibitors - 3 months
● Glucocorticoids - lowest eective dosage + intra articular injections
● sDMARD’S
○ Methotrexate
○ Sulfasalazine
○ 5’-ASA
● Tumor necrosis factor (TNF) inhibitors
○ infliximab and adalimumab
○ Not Etanercept
● Interleukin-17 (IL-17) inhibitors
○ secukinumab and ixekizumab
● Interleukins 12 and 23 (IL-12/23) inhibitors
○ Ustekinumab

● Janus kinase (JAK) inhibitors

○ tofacitinib and upadacitinib

● Monoclonal antibodies against integrin α4β7

Differentials
● Fibromyalgia
● Irritable bowel syndrome (IBS)
● Whipple disease
● Brucellosis
● Poncet disease
● Reactive arthritis
● Celiac disease
● Bechet disease
● Hypertrophic osteoarthropathy
● SAPHO syndrome
Prognosis
● Inflammatory bowel disease (IBD), encompassing both Crohn’s disease
and ulcerative colitis, presents significant morbidity to patients due to
its intestinal and extraintestinal manifestations.
● Complications, particularly in the first two years of the disease, pose a
substantial risk, with a high likelihood of colectomy early in the disease
course.
● Intestinal surgery, required in about 80% of Crohn’s disease patients,
and permanent stomas in over 10% significantly impact patients'
quality of life.
● The prognosis of IBD is influenced by factors such as age at diagnosis,
disease severity, and inflammatory process control, with children and
adolescents often experiencing more severe disease.
● Additionally, the increased risk of colorectal cancer adds to the
mortality and morbidity associated with IBD, with Crohn’s disease
carrying a higher mortality rate than ulcerative colitis, particularly in
females diagnosed before age 50.
● Enteropathic arthritis symptoms further exacerbate morbidity in IBD
patients.
● Introduction of targeted biological therapies has revolutionized the
management of both enteropathic arthritis and IBD, significantly
improving patient outcomes and health-related quality of life.
Complications
● Intestinal complications include obstruction, strictures, fistulas, and
abscesses.
○ Intestinal strictures and fistulas are more common in patients with
ileal Crohn disease.
○ Primary sclerosing cholangitis and colorectal cancer are commonly
seen with ulcerative colitis. Crohn disease can also cause small
bowel malignancies.
● Articular disease can lead to chronic pain and disability. Axial disease
can cause loss of lumbar lordosis and spinal mobility, spinal deformities,
and an increased risk of vertebral fractures and subluxation.
● Additional extra articular complications include uveitis, aortic
insuiciency, and cardiac conduction abnormalities. These are seen
more frequently with HLA-B27 positivity, axial involvement, and
increased disease duration.
● Skin lesions occur in 10% to 25% of patients with inflammatory bowel
disease.
○ Erythema nodosum is associated with active synovitis and
inflammatory bowel disease.
○ Pyoderma gangrenosum occurs more frequently in females and is
unrelated to gut inflammation. Pyoderma gangrenosum is the
most severe skin manifestation of inflammatory bowel disease and
can lead to chronic non healing wounds, scarring, and pain.
● Increased risk of osteoporosis and fragility fractures.
○ Fractures can directly result from inflammation, malnutrition,
malabsorption, and the use of glucocorticoids in inflammatory
bowel disease and enteropathic arthritis.

● Patients with inflammatory bowel disease associated with peripheral

polyarticular joint involvement show an increased prevalence of
autoimmune thyroiditis.
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