Clinical Pearls & Morning Reports
Arthritis and arthralgias are frequent extraintestinal manifestations of inflammatory bowel disease; they occur more commonly in patients who have Crohn’s disease with colonic involvement than in patients who have ulcerative colitis, and are often associated with other extraintestinal features, such as aphthous stomatitis. Read the NEJM Case Records of the Massachusetts General Hospital here.
Q: How common are arthralgias in early Lyme disease?
A: Lyme disease is a tickborne infection caused by Borrelia burgdorferi. Symptoms of early localized Lyme disease, which develop within days after the tick bite, include fatigue, headaches, myalgias, arthralgias, and fevers. Erythema migrans occurs in approximately 80% of patients, so the absence of a rash does not rule out the infection. Arthralgias occur in 33% of patients during early disease and may be the only manifestation of the infection. Joint pain is often transient and migratory; it usually lingers at one site for hours or days.
Q: Is arthritis common in children with parvovirus B19 infection?
A: Arthritis due to parvovirus B19 occurs in less than 10% of infected children, as compared with 60% of infected adults. Children with arthritis due to parvovirus B19 initially have mild upper respiratory symptoms, followed by fever, rash, and polyarthritis. Levels of inflammatory markers may be mildly elevated but are normal in more than 50% of cases. Fevers are usually low grade.
A: Systemic juvenile idiopathic arthritis is characterized by fever with a daily spike in temperature (>38.5°C) and with normal or subnormal temperatures during the rest of the 24-hour period. Affected patients often appear ill when they are febrile and otherwise appear well. This condition is also characterized by arthritis, which can involve any joint and any number of joints but most often occurs in the lower leg. In 81% of patients, an evanescent salmon-pink rash develops, although it is sometimes difficult to see. The rash usually is triggered by heat or fever and fades when the body temperature is normal. It often involves the axillae and the area around the waist but can occur anywhere on the body. Patients with systemic juvenile idiopathic arthritis typically have leukocytosis with a white-cell count of 20,000 to 30,000 per microliter and neutrophilic predominance.
A: Most children with a new diagnosis of inflammatory bowel disease present with bloody diarrhea, abdominal pain, tenesmus, and growth failure. Approximately 6% of pediatric patients have extraintestinal symptoms at the time of initial presentation. Arthritis due to inflammatory bowel disease is self-limiting and nonerosive, and it is not associated with specific autoantibodies or HLA types. Peripheral arthritis tends to be acute, occurs early in the disease course, and involves few joints. There is often evidence of joint swelling and effusion, most commonly involving the knee.