A Rare Cause of Peripheral Arthralgia in Inflammatory Bowel Disease: Multifocal Osteonecrosis

Abstract

Osteonecrosis (ON) is characterized by an infarction of osseous tissue in the subchondral regions of the bone. We report the case of a young male patient with ulcerative colitis (UC) developing severe and multifocal, large joint ON resulting in severe disability. Since typical symptoms of ON, like joint pain, might be misinterpreted as common extraintestinal manifestations, ON might easily be overlooked in patients with inflammatory bowel disease (IBD). Plain radiographs detect only advanced cases, MRI is the diagnostic method of choice with a specificity and sensitivity of > 90 %. We discuss the incidence of ON specifically in IBD and provide an update on risk factors like treatment with corticosteroids (CS), although ON has been reported in IBD patients without previous CS treatment. Apart from that, underlying inflammation, thromboembolic events and genetic risk factors might be involved in ON development supporting the hypothesis of a complex cascade. Causative therapies for ON are not available, and surgical interventions like trepanning, core decompression and prosthetic replacement are often necessary. Our intention is to direct attention to this severe complication in the differential work-up of joint pain in IBD patients.

Zusammenfassung

Wir berichten über einen jungen Patienten mit Colitis ulcerosa und Ausbildung multifokaler Osteonekrosen (ON). ON sind charakterisiert durch Infarkte des subchondral gelegenen Knochengewebes. Kardinalsymptom sind in erster Linie Gelenkschmerzen, die bei Patienten mit chronisch entzündlichen Darmerkrankungen (CED) leicht als extraintestinale Manifestationen im Sinne von peripheren Arthralgien fehlinterpretiert werden können. Da konventionelle Röntgenaufnahmen nur fortgeschrittene Stadien zeigen, stellt die Magnetresonanztomografie (MRT) mit einer Spezifität und Sensitivität von > 90 % den Goldstandard in der Diagnostik dar. Wir stellen die aktuelle Literatur zur Inzidenz von ON besonders im Hinblick auf CED sowie zu Risikofaktoren zusammen. Kortikosteroide sind ein bekannter Risikofaktor, obgleich ON bei CED-Patienten auch ohne Kortikosteroidtherapie berichtet wurden. Weitere Risikofaktoren wie hohe Entzündungsaktivität, thrombembolische Ereignisse und genetische Varianten können zur Ausbildung von ON beitragen und unterstreichen das Bild einer komplexen Entstehungskaskade. Kausale Therapien der ON existieren nicht und chirurgische Interventionen wie medulläre Dekompression und Endoprothesenimplantation sind oft notwendig. Unser Anliegen ist es, auf ON als schwerwiegende Komplikation in der Differenzialdiagnose von Gelenkschmerzen bei CED-Patienten aufmerksam zu machen.

Key words

chronic inflammatory bowel disease - extraintestinal manifestation - ulcerative colitis - Crohn's disease - osteonecrosis - peripheral arthralgia - corticosteroids

Schlüsselwörter

chronisch entzündliche Darmerkrankung - extraintestinale Manifestation - Colitis ulcerosa - Morbus Crohn - Osteonekrosen - periphere Arthralgien - Kortikosteroide

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