Rheumatological Manifestations
of Gastrointestinal Disease
69
Nayan K. Kothari and Srilatha Kothandaraman
Questions and Answers
1. A 65-year-old male is diagnosed to have ulcerative colitis
involving the entire colon. He also has sacroiliitis with
low back pain. He failed to respond with prednisone,
sulfasalazine, and infliximab therapy. Total colectomy
was performed as the disease duration was prolonged. What
is the likely course of spondyloarthritis in this patient?
A. Complete resolution
B. Progression
C. Development of peripheral arthropathy
D. Cannot be determined
Answer: B
The two complications spondyloarthritis and ankylosing
spondylitis do not respond to total colectomy, while other
complications resolve. Unlike peripheral arthritis in colitis, sacroiliitis and ankylosing spondylitis (AS) do not
depend on the duration, extent, or severity of bowel
involvement and remain progressive irrespective of gut
disease. Treatment involves NSAIDs or COX-2 inhibitors, infliximab and adalimumab. Methotrexate and sulfasalazine have not been proven useful.
2. A 68-year-old female presents with bilateral pain in the
hands, feet, ankles, and knees and a rash over both legs.
She also gives history of her hand turning blue in cold
weather. On examination, there is tenderness of the proximal inter-phalangeal and metacarpophalangeal joints,
ankles, and knees; there are also erythematous macules
and purpuric papules with ulceration in some lesions,
located in the shin of both legs. Her past medical history
includes migraine, and there is a history of intravenous
drug abuse. Liver enzymes are elevated. What would be
the next appropriate test to order?
A. Hepatitis B surface antigen
B. Hepatitis C antibody
C. Rheumatoid factor
D. Cryoglobulins
Answer: B
Mixed Cryoglobulinemia (Raynaud’s phenomenon, arthralgias, peripheral neuropathy, vasculitis, diffuse glomerulonephritis, and hepatosplenomegaly) with emphasis on
lymphoproliferation and rheumatoid factor positivity is a
noted extrahepatic manifestation of Hepatitis C. The risk
factors include increased age, female gender, and longer
duration of disease. Types II and III cryoglobulinemia,
also known as the mixed cryoglobulinemias, are associated with systemic lupus erythematosus (SLE), Sjögren
syndrome, and viral infections particularly Hepatitis C.
3. A 70-year-old male presents to the clinic with complaints
of chronic diarrhea for 5 months, polyarthralgias, fever,
and 20 lb weight loss. He also notices difficulty maintaining balance and feels unsteady while walking. His friends
have noticed that he walks with feet apart. On examination, arthralgias of both ankles and wrists are noted, along
with a wide-based gait, no muscle weakness with intact
proprioception. Lab work shows random blood glucose of
140. What would be the most appropriate next step in
making the diagnosis?
A. B12 and folate levels
B. HbA1C
C. Upper gastrointestinal endoscopy and biopsy
D. CT scan of the abdomen
Answer: C
Whipple disease, caused by a bacterium Tropheryma
whipplei, is a malabsorption syndrome involving the
small intestine, also affecting the joints, CNS, and cardiovascular system. Rheumatological manifestations include
nondeforming, migratory, symmetrical polyarthritis
involving knees, ankles, and wrists. Sacroiliitis can also
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_69, © Springer Science+Business Media, LLC 2012
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occur. Arthralgia can precede intestinal and neurological
manifestations. Biopsies of tissue samples from the small
bowel through endoscopy show macrophages staining
positive with periodic acid-Schiff stain in the villi. A sensitive PCR assay may detect T. whipplei DNA in patients
N.K. Kothari and S. Kothandaraman
with classic symptoms but negative PAS staining on duodenal biopsies. Patients with joint disease must be
screened for Whipple’s, as it is a fatal condition and the
patient should not receive immunosuppressive agents.