A 30-year-old man comes to the office due to low back pain and stiffness for 2 months. The pain is worse in the morning and improves with activity. The patient has also had intermittent diarrhea and lower abdominal pain for the past 3 months. He has taken ibuprofen, which helped the back pain but made the diarrhea worse. He has not traveled outside the United States. The patient has been sexually active with the same female partner for 2 years and uses condoms regularly. He has no other medical conditions and does not use tobacco, alcohol, or recreational drugs. Vital signs are normal. Physical examination shows limited spine flexion and tenderness in the lower back. Laboratory studies demonstrate elevated C-reactive protein. Plain radiographs reveal sacroiliac joint inflammation. Which of the following best explains this patient's symptoms?
Extraintestinal manifestations of inflammatory bowel disease | |
Dermatologic |
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Hepatobiliary |
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Musculoskeletal |
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Ophthalmic |
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Vascular |
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*More commonly seen with Crohn disease. **More commonly seen with ulcerative colitis. | |
This patient likely has inflammatory bowel disease (IBD) with associated inflammatory arthritis. IBD, which includes Crohn disease and ulcerative colitis, can demonstrate multiple extraintestinal manifestations, including arthritic, ocular, dermatologic, and hepatobiliary. Arthritis associated with IBD can involve the axial (eg, spine) or peripheral (eg, knee) joints, and affected patients frequently have an HLA B27 genotype. Patients with axial involvement (ie, spondyloarthritis) frequently have sacroiliitis that manifests with lower back and buttock pain and prolonged stiffness that improves with activity.
There are no specific tests to confirm the diagnosis of IBD-associated arthritis, but typical laboratory abnormalities include elevated inflammatory markers (eg, C-reactive protein), anemia of chronic disease, and a positive fecal calprotectin. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve arthritis symptoms but may exacerbate bowel inflammation (possibly due to disruption of COX-mediated immunomodulation or intestinal microcirculatory blood flow). Consequently, NSAIDs are often avoided, and the medications used to treat the gastrointestinal manifestations of IBD (eg, azathioprine, infliximab) are commonly used to treat associated joint disease as well.
(Choice A) Gluten-sensitive enteropathy (ie, celiac disease) causes malabsorptive diarrhea, which is frequently greasy. It is not worsened by NSAID administration, and an elevated C-reactive protein is not seen. The characteristic cutaneous finding is dermatitis herpetiformis.
(Choice C) Gastrointestinal paraneoplastic syndromes include secretory, watery diarrhea due to vasoactive intestinal peptide-secreting tumors, carcinoid syndrome (eg, cutaneous flushing, watery diarrhea, respiratory difficulties), and gastroparesis due to autoimmune destruction of parasympathetic neurons. None of these syndromes would explain this patient's arthritis or worsening diarrhea with ibuprofen use.
(Choice D) Reactive arthritis is an inflammatory arthritis that may occur several weeks following infectious diarrhea (eg, Shigella, Salmonella, Yersinia, Campylobacter, Clostridioides difficile) or sexually transmitted genitourinary infection (eg, Chlamydia trachomatis). The axial skeleton can sometimes be affected, but arthritis affecting one or several peripheral joints is more typical. It is less likely in this patient as NSAIDs are not expected to worsen infectious diarrhea, and he has not had recent high-risk sexual behavior.
(Choice E) Rheumatoid arthritis usually involves peripheral arthritis (eg, metacarpophalangeal joints) with the lumbar or sacral spine rarely involved. Moreover, although rheumatoid arthritis can involve multiple organ systems, gastrointestinal manifestations are rare.
(Choice F) Spinal osteomyelitis can present with subacute worsening of back pain, but the pain is typically worse with activity and fever is commonly present.
Educational objective:
Inflammatory bowel disease is frequently associated with inflammatory arthritis, which can involve the axial or peripheral joints. Treatment with nonsteroidal anti-inflammatory drugs may exacerbate the underlying bowel inflammation.