A Rare Association of Rheumatoid Arthritis with Crohn’s Disease

Abstract

Crohn’s disease (CD) is an chronic autoimmune inflammatory bowel disease (IBD) which may involve any part of the gastrointestinal system (GIS) (1). Although the rellationships among autoimmune diseases are known, association of rheumatoid arthritis (RA) and CD is an extremely rare condition (2,3). A 50-year-old male patient who had the diagnosis of seropositive RA for 5 years, presented with the complaints of bloody diarrhea and abdominal pain. The RA treatment had been regulated as a combination of methotrexate, sulfasalazine and hydroxychloroquine, and the patient reported that he was regularly taking the medical therapy. In joint examination, metacarpophalangeal joint arthritis were found bilateral. No hand deformity was observed. In physical examination, there were no findings except tenderness in the lower abdominal quadrants. There was not any bacterial growth in the stool culture. The results of the colonoscopy, found inflammation in the ileum (Figure 1a, 1b). Histopathologic examination was compatible with CD. Anteroposterior hand radiography revealed narrowing in 3rd and 4th proximal interphalengeal joints (Figure 1c). Genu varum deformity was found in the knee and magnetic resonance imaging (MRI) revealed synovial hypertrophy. Biochemical analysis yielded sedimentation rate as 22 mm/h (Reference range: 0-20 mm/h), C-reactive protein 1.21 mg/dL (reference range: 0-0.5 mg/dL), rheumatoid factor (+) and anti cyclic citrullinated peptide (CCP) (+). Mesalazine and azathioprine were added to his treatment protocol. At follow-up, complaints of the patiens gradually regressed within 4 months. Articular system involvement is commonly seen in IBD such as ulcerative colitis (UC) and CD. Axial and peripheral articular findings may commence before, concurrently or after the diagnosis of IBD. Peripheral arthritis is generally in form the oligoarticular involvement of the large joints. However, in a small portion of IBDs, an arthritis form may be seen, resembling rheumatoid arthritis and often affecting the small joints of the hand symmetrically and polyarticularly (4). Peripheral arthritis is reported in CD by 10-20% which is more frequent compared to UC (5). Our patient was diagnosed with CD, suggesting us the joint findings may be occured due to this condition. However, IBD arthritis is seronegative and never or rarely causes joint destruction compared to RA (5). In our patient, arthritis had begun about 5 years before GIS symptoms. According to 2010 American College of Rheumatology/European League Against Rheumatism criteria, positivity of anti CCP, RF antibodies, marked synovial hypertrophy in the knees on MRI and narrowing of the joint spacing found in our patient confirmed the diagnosis of RA. Our patient who could not describe an association between the exacerbation of CD and arthritis gave positive response to RA treatment. Hatice Resorlu, Erdem Akbal*, Ferhat Gokmen, Yilmaz Savas