Description
A 27-year-old Sudanese woman presented to the emergency department with a 1-week history of lumbar back pain radiating to the buttocks. There was no history of trauma, fever or weight loss. Medical history included ulcerative colitis, maintained in remission with oral mesalazine. On examination, there was midline tenderness over the upper lumbar spine. Neurological examination was normal.
MRI of the lumbar spine (figure 1) demonstrated oedema in the subcutaneous tissue adjacent to the first lumbar (L1) vertebra and bone marrow oedema of the corresponding spinous process. These changes were reported as being consistent with contusion secondary to trauma. This was incompatible with the clinical history.
Figure 1.
T2-weighted MRI of the lumbar spine demonstrating oedema in the subcutaneous tissue adjacent to the first lumbar (L1) vertebra and bone marrow oedema of the L1 spinous process.
While undergoing further evaluation, the patient developed acute bloody diarrhoea. Stool microscopy, culture and Clostridium difficile toxin were negative. Flexible sigmoidoscopy showed severely active ulcerative colitis with spontaneous bleeding and ulceration.
In the context of active ulcerative colitis, the MRI was reviewed again. The appearances are consistent with enthesitis of the supraspinous ligament, maximal at the point of insertion at the L1 spinous process, with a differential diagnosis not initially considered.
Treatment was initiated with intravenous hydrocortisone. Symptoms of enthesitis and ulcerative colitis both responded rapidly. Azathioprine was given alongside a reducing course of corticosteroids to maintain long-term remission.
Enthesitis is a component of seronegative spondyloarthropathy associated with inflammatory bowel disease (IBD).1 The prevalence of spondyloarthropathy was reported to be 22% in a population study of IBD patients.2 Disease activity of the two entities is not always related.3
Learning points.
If a clinically unexplained finding is reported on the diagnostic imaging, revisit the history and explore the differential diagnosis.
Remember to consider known disease associations.
Seronegative arthropathy is commonly associated with inflammatory bowel disease (IBD) and should be considered in IBD patients presenting with rheumatological symptoms.
Footnotes
Competing interests: None.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
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- 2.Palm O, Moum B, Ongre A, et al. Prevalence of ankylosing spondylitis and other spondyloarthropathies among patients with inflammatory bowel disease: a population study (the IBSEN study). J Rheumatol 2002;29:511–15 [PubMed] [Google Scholar]
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