Akira Hokama; Taiga Miyagi; Yukiko Takeichi; Eriko Uema; Sayuri Takehara; Tetsuya Ohira; Atsushi Iraha; Tetsu Kinjo; Jiro Fujita

doi:10.5217/ir.2020.00036

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Image of the issue Sausage-like fingers in Crohn’s disease: Akira Hokama^1,, Taiga Miyagi², Yukiko Takeichi², Eriko Uema², Sayuri Takehara¹, Tetsuya Ohira¹, Atsushi Iraha², Tetsu Kinjo¹, Jiro Fujita²; Intestinal Research 2020;18(3):341-342.
DOI: https://doi.org/10.5217/ir.2020.00036
Published online: May 25, 2020

¹Department of Endoscopy, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan

²Department of Infectious Diseases, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan

Correspondence to Akira Hokama, Department of Endoscopy, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara 903-0215, Japan. Tel: +81-98-895-1144, Fax: +81-98-895-1414, E-mail: hokama-a@med.u-ryukyu.ac.jp

• Received: March 2, 2020 • Accepted: March 6, 2020

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Answer to the Images: CD Complicated by Dactylitis and Pelvic Enthesitis
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REFERENCES

Question: A 65-year-old man presented with pain and swelling of both hands, fever, fatigue, and right hip joint pain for 2 weeks. He had had a 30-year history of ileocolonic CD with four times of bowel surgery. His medication included maintenance infliximab for 10 years, and mesalazine for over 20 years. Physical examination showed a body temperature of 38.6°C. Fingers were swollen like sausage and there was tenderness on the flexor tendons (Fig. A). Paralysis and neurological deficit were not noted. Laboratory tests showed elevated levels of white blood cells (10.9 × 10³/μL), CRP (10.46 mg/dL; reference range, < 0.14 mg/dL), ESR (103 mm/hr; reference range, 2–10 mm/hr), IgG (2,089 mg/dL; reference range, 861–1,747 mg/dL), IgA (644 mg/dL; reference range, 93–393 mg/dL), and IgM (277 mg/dL; reference range, 33–183 mg/dL). Tests for antinuclear antibody, anti-neutrophil cytoplasmic antibody, and anti-cyclic citrullinated peptide antibody were negative. Blood culture was negative. Written informed consent was obtained. What is the most likely diagnosis?

Answer to the Images: CD Complicated by Dactylitis and Pelvic Enthesitis

Physical examination showed dactylitis involving the fingers of both hands (Fig. A). CD complicated by dactylitis and pelvic enthesitis around the right hip joint was diagnosed and treatment with 60 mg/day of prednisolone was initiated. Symptoms and inflammatory parameters improved in several days and then prednisolone was tapered. He has been asymptomatic during 2 years of follow-up with infliximab. Musculoskeletal complication is a common extraintestinal manifestation of CD, classified into axial spondyloarthritis (SpA) and peripheral SpA. Axial SpA includes ankylosing spondylitis and non-radiographic axial SpA, whereas peripheral SpA consists of peripheral arthritis, enthesitis, and dactylitis [1]. Although the immunological mechanisms of “gut-joint” axis have not become clear, it is speculated that both bacterial antigens and reactive T-cell clones, activated into the gut home the joint in association with certain human leukocyte antigen alleles [1]. Dactylitis is caused by flexor tenosynovitis and clinical examination is a sufficient method for its diagnosis [2]. The prevalence of dactylitis is very low with a range under 5% in CD patients [3]. There is a clinical dilemma presented by CD patients with musculoskeletal symptoms is whether the symptoms are caused by CD-associated SpA, unrelated musculoskeletal conditions, or TNF-α inhibitors induced adverse effects [4], as in this case which the clinical course suggested CD-associated SpA. In conclusion, we should consider SpA carefully in the era of biologic treatments for CD.

NOTES

FINANCIAL SUPPORT

The authors received no financial support for the research, authorship, and/or publication of this article.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTION

Collecting materials: Hokama A, Miyagi T, Takeichi Y, Uema E, Takehara S, Ohira T, Iraha A, Kinjo T. Drafting the manuscript: Hokama A. Supervising the study: Fujita J. All authors reviewed the final version of the manuscript.

REFERENCES

1. Fragoulis GE, Liava C, Daoussis D, Akriviadis E, Garyfallos A, Dimitroulas T. Inflammatory bowel diseases and spondyloarthropathies: from pathogenesis to treatment. World J Gastroenterol 2019;25:2162–2176.Article PubMed PMC
2. Olivieri I, Padula A, Scarano E, Scarpa R. Dactylitis or “sausageshaped” digit. J Rheumatol 2007;34:1217–1222.PubMed
3. Karreman MC, Luime JJ, Hazes JMW, Weel AEAM. The prevalence and incidence of axial and peripheral spondyloarthritis in inflammatory bowel disease: a systematic review and meta-analysis. J Crohns Colitis 2017;11:631–642.Article PubMed PDF
4. Subramaniam K, Tymms K, Shadbolt B, Pavli P. Spondyloarthropathy in inflammatory bowel disease patients on TNF inhibitors. Intern Med J 2015;45:1154–1160.Article PubMed

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