Download PDF
Z Gastroenterol 2014; 52(3): 285-289
DOI: 10.1055/s-0034-1365933
Kasuistik
© Georg Thieme Verlag KG Stuttgart · New York

A Rare Cause of Peripheral Arthralgia in Inflammatory Bowel Disease: Multifocal Osteonecrosis

Seltene Ursache peripherer Arthralgien bei CED: Multifokale Osteonekrosen
P. C. Grunert
1   Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie (einschl. Arbeitsbereich Stoffwechselerkrankungen) CCM / CVK, Charité-Universitätsmedizin Berlin, Berlin, Germany
,
F. Collettini
2   Klinik für Strahlenheilkunde, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
,
C. Perka
3   Centrum für Muskuloskeletale Chirurgie, Klinik für Orthopädie, Charité-Universitätsmedizin Berlin, Berlin, Germany
,
M. Zeitz†
1   Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie (einschl. Arbeitsbereich Stoffwechselerkrankungen) CCM / CVK, Charité-Universitätsmedizin Berlin, Berlin, Germany
,
B. Wiedenmann
1   Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie (einschl. Arbeitsbereich Stoffwechselerkrankungen) CCM / CVK, Charité-Universitätsmedizin Berlin, Berlin, Germany
,
C. Büning
1   Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie (einschl. Arbeitsbereich Stoffwechselerkrankungen) CCM / CVK, Charité-Universitätsmedizin Berlin, Berlin, Germany
› Author Affiliations
Further Information

Publication History

02 December 2013

03 January 2014

Publication Date:
12 March 2014 (online)

Also available at
    Permissions and Reprints

Abstract

Osteonecrosis (ON) is characterized by an infarction of osseous tissue in the subchondral regions of the bone. We report the case of a young male patient with ulcerative colitis (UC) developing severe and multifocal, large joint ON resulting in severe disability. Since typical symptoms of ON, like joint pain, might be misinterpreted as common extraintestinal manifestations, ON might easily be overlooked in patients with inflammatory bowel disease (IBD). Plain radiographs detect only advanced cases, MRI is the diagnostic method of choice with a specificity and sensitivity of > 90 %. We discuss the incidence of ON specifically in IBD and provide an update on risk factors like treatment with corticosteroids (CS), although ON has been reported in IBD patients without previous CS treatment. Apart from that, underlying inflammation, thromboembolic events and genetic risk factors might be involved in ON development supporting the hypothesis of a complex cascade. Causative therapies for ON are not available, and surgical interventions like trepanning, core decompression and prosthetic replacement are often necessary. Our intention is to direct attention to this severe complication in the differential work-up of joint pain in IBD patients.

Zusammenfassung

Wir berichten über einen jungen Patienten mit Colitis ulcerosa und Ausbildung multifokaler Osteonekrosen (ON). ON sind charakterisiert durch Infarkte des subchondral gelegenen Knochengewebes. Kardinalsymptom sind in erster Linie Gelenkschmerzen, die bei Patienten mit chronisch entzündlichen Darmerkrankungen (CED) leicht als extraintestinale Manifestationen im Sinne von peripheren Arthralgien fehlinterpretiert werden können. Da konventionelle Röntgenaufnahmen nur fortgeschrittene Stadien zeigen, stellt die Magnetresonanztomografie (MRT) mit einer Spezifität und Sensitivität von > 90 % den Goldstandard in der Diagnostik dar. Wir stellen die aktuelle Literatur zur Inzidenz von ON besonders im Hinblick auf CED sowie zu Risikofaktoren zusammen. Kortikosteroide sind ein bekannter Risikofaktor, obgleich ON bei CED-Patienten auch ohne Kortikosteroidtherapie berichtet wurden. Weitere Risikofaktoren wie hohe Entzündungsaktivität, thrombembolische Ereignisse und genetische Varianten können zur Ausbildung von ON beitragen und unterstreichen das Bild einer komplexen Entstehungskaskade. Kausale Therapien der ON existieren nicht und chirurgische Interventionen wie medulläre Dekompression und Endoprothesenimplantation sind oft notwendig. Unser Anliegen ist es, auf ON als schwerwiegende Komplikation in der Differenzialdiagnose von Gelenkschmerzen bei CED-Patienten aufmerksam zu machen.

Key words

chronic inflammatory bowel disease - extraintestinal manifestation - ulcerative colitis - Crohn's disease - osteonecrosis - peripheral arthralgia - corticosteroids

Schlüsselwörter

chronisch entzündliche Darmerkrankung - extraintestinale Manifestation - Colitis ulcerosa - Morbus Crohn - Osteonekrosen - periphere Arthralgien - Kortikosteroide
 

  • References

  • 1 Salvarani C, Vlachonikolis IG, van der Heijde DM et al. Musculoskeletal manifestations in a population-based cohort of inflammatory bowel disease patients. Scand J Gastroenterol 2001; 36: 1307-1313
    CrossrefPubMedGoogle Scholar
  • 2 Hauzeur JP, Malaise M, Gangji V. Osteonecrosis in inflammatory bowel diseases: a review of the literature. Acta Gastroenterol Belg 2009; 72: 327-334
    PubMedGoogle Scholar
  • 3 Pivec R, Johnson AJ, Mont MA. Differentiation, diagnosis, and treatment of osteoarthritis, osteonecrosis, and rapidly progressive osteoarthritis. Orthopedics 2013; 36: 118-125
    CrossrefPubMedGoogle Scholar
  • 4 Flouzat-Lachaniette CH, Younes C, Delblond W et al. The natural progression of adult elbow osteonecrosis related to corticosteroid treatment. Clin Orthop Relat Res 2012; 470: 3478-3482
    CrossrefPubMedGoogle Scholar
  • 5 Lykissas MG, Gelalis ID, Kostas-Agnantis IP et al. The role of hypercoagulability in the development of osteonecrosis of the femoral head. Orthop Rev (Pavia) 2012; 4: e17
    PubMedGoogle Scholar
  • 6 Hirota Y, Hirohata T, Fukuda K et al. Association of alcohol intake, cigarette smoking, and occupational status with the risk of idiopathic osteonecrosis of the femoral head. Am J Epidemiol 1993; 137: 530-538
    CrossrefPubMedGoogle Scholar
  • 7 Shim K, MacKenzie MJ, Winquist E. Chemotherapy-associated osteonecrosis in cancer patients with solid tumours: a systematic review. Drug Saf 2008; 31: 359-371
    CrossrefPubMedGoogle Scholar
  • 8 Akinyoola AL, Adediran IA, Asaleye CM et al. Risk factors for osteonecrosis of the femoral head in patients with sickle cell disease. Int Orthop 2009; 33: 923-926
    CrossrefPubMedGoogle Scholar
  • 9 Freeman HJ, Freeman KJ. Prevalence rates and an evaluation of reported risk factors for osteonecrosis (avascular necrosis) in Crohn's disease. Can J Gastroenterol 2000; 14: 138-143
    PubMedGoogle Scholar
  • 10 Zibis AH, Karantanas AH, Roidis NT et al. The role of MR imaging in staging femoral head osteonecrosis. Eur J Radiol 2007; 63: 3-9
    CrossrefPubMedGoogle Scholar
  • 11 Jawad MU, Haleem AA, Scully SP. In brief: Ficat classification: avascular necrosis of the femoral head. Clin Orthop Relat Res 2012; 470: 2636-2639
    CrossrefPubMedGoogle Scholar
  • 12 Kamata N, Oshitani N, Sogawa M et al. Usefulness of magnetic resonance imaging for detection of asymptomatic osteonecrosis of the femoral head in patients with inflammatory bowel disease on long-term corticosteroid treatment. Scand J Gastroenterol 2008; 43: 308-313
    CrossrefPubMedGoogle Scholar
  • 13 Assouline-Dayan Y, Chang C, Greenspan A et al. Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum 2002; 32: 94-124
    CrossrefPubMedGoogle Scholar
  • 14 Khan A, Illiffe G, Houston DS et al. Osteonecrosis in a patient with Crohn's disease unrelated to corticosteroid use. Can J Gastroenterol 2001; 15: 765-768
    PubMedGoogle Scholar
  • 15 Freeman HJ, Kwan WC. Brief report: non-corticosteroid-associated osteonecrosis of the femoral heads in two patients with inflammatory bowel disease. N Engl J Med 1993; 329: 1314-1316
    CrossrefPubMedGoogle Scholar
  • 16 Freeman HJ. Osteomyelitis and osteonecrosis in inflammatory bowel disease. Can J Gastroenterol 1997; 11: 601-606
    PubMedGoogle Scholar
  • 17 Jaffe WL, Epstein M, Heyman N et al. The effect of cortisone on femoral and humeral heads in rabbits. An experimental study. Clin Orthop Relat Res 1972; 82: 221-228
    PubMedGoogle Scholar
  • 18 Fast A, Alon M, Weiss S et al. Avascular necrosis of bone following short-term dexamethasone therapy for brain edema. Case report. J Neurosurg 1984; 61: 983-985
    CrossrefPubMedGoogle Scholar
  • 19 McCluskey J, Gutteridge DH. Avascular necrosis of bone after high doses of dexamethasone during neurosurgery. Br Med J (Clin Res Ed) 1982; 284: 333-334
    CrossrefPubMedGoogle Scholar
  • 20 Sambrook PN, Hassall JE, York JR. Osteonecrosis after high dosage, short term corticosteroid therapy. J Rheumatol 1984; 11: 514-516
    PubMedGoogle Scholar
  • 21 Mattano LA, Devidas M, Nachman JB et al. Effect of alternate-week versus continuous dexamethasone scheduling on the risk of osteonecrosis in paediatric patients with acute lymphoblastic leukaemia: results from the CCG-1961 randomised cohort trial. Lancet Oncol 2012; 13: 906-915
    CrossrefPubMedGoogle Scholar
  • 22 Seamon J, Keller T, Saleh J et al. The pathogenesis of nontraumatic osteonecrosis. Arthritis 2012; Article ID 601763
    PubMedGoogle Scholar
  • 23 Weinstein RS. Glucocorticoid-induced osteonecrosis. Endocrine 2012; 41: 183-190
    CrossrefPubMedGoogle Scholar
  • 24 Zizic TM, Marcoux C, Hungerford DS et al. Corticosteroid therapy associated with ischemic necrosis of bone in systemic lupus erythematosus. Am J Med 1985; 79: 596-604
    CrossrefPubMedGoogle Scholar
  • 25 Gladman DD, Chaudhry-Ahluwalia V, Ibañez D et al. Outcomes of symptomatic osteonecrosis in 95 patients with systemic lupus erythematosus. J Rheumatol 2001; 28: 2226-2229
    PubMedGoogle Scholar
  • 26 Mok CC, Lau CS, Wong RW. Risk factors for avascular bone necrosis in systemic lupus erythematosus. Br J Rheumatol 1998; 37: 895-900
    CrossrefPubMedGoogle Scholar
  • 27 Massardo L, Jacobelli S, Leissner M et al. High-dose intravenous methylprednisolone therapy associated with osteonecrosis in patients with systemic lupus erythematosus. Lupus 1992; 1: 401-405
    CrossrefPubMedGoogle Scholar
  • 28 Klingenstein G, Levy RN, Kornbluth A et al. Inflammatory bowel disease related osteonecrosis: report of a large series with a review of the literature. Aliment Pharmacol Ther 2005; 21: 243-249
    CrossrefPubMedGoogle Scholar
  • 29 Migliaresi S, Picillo U, Ambrosone L et al. Avascular osteonecrosis in patients with SLE: relation to corticosteroid therapy and anticardiolipin antibodies. Lupus 1994; 3: 37-41
    CrossrefPubMedGoogle Scholar
  • 30 Rascu A, Manger K, Kraetsch HG et al. Osteonecrosis in systemic lupus erythematosus, steroid-induced or a lupus-dependent manifestation?. Lupus 1996; 5: 323-327
    CrossrefPubMedGoogle Scholar
  • 31 Tang S, Chan TM, Lui SL et al. Risk factors for avascular bone necrosis after renal transplantation. Transplant Proc 2000; 32: 1873-1875
    CrossrefPubMedGoogle Scholar
  • 32 Shibatani M, Fujioka M, Arai Y et al. Degree of corticosteroid treatment within the first 2 months of renal transplantation has a strong influence on the incidence of osteonecrosis of the femoral head. Acta Orthop 2008; 79: 631-636
    CrossrefPubMedGoogle Scholar
  • 33 Asano T, Takahashi KA, Fujioka M et al. ABCB1 C3435T and G2677T/A polymorphism decreased the risk for steroid-induced osteonecrosis of the femoral head after kidney transplantation. Pharmacogenetics 2003; 13: 675-682
    CrossrefPubMedGoogle Scholar
  • 34 Asano T, Takahashi KA, Fujioka M et al. Genetic analysis of steroid-induced osteonecrosis of the femoral head. J Orthop Sci 2003; 8: 329-333
    CrossrefPubMedGoogle Scholar
  • 35 Fiedler T, Büning C, Reuter W et al. Possible role of MDR1 two-locus genotypes for young-age onset ulcerative colitis but not Crohn's disease. Eur J Clin Pharmacol 2007; 63: 917-925
    CrossrefPubMedGoogle Scholar
  • 36 Zintzaras E. Is there evidence to claim or deny association between variants of the multidrug resistance gene (MDR1 or ABCB1) and inflammatory bowel disease?. Inflamm Bowel Dis 2012; 18: 562-572
    CrossrefPubMedGoogle Scholar
  • 37 Etzel JP, Larson MF, Anawalt BD et al. Assessment and management of low bone density in inflammatory bowel disease and performance of professional society guidelines. Inflamm Bowel Dis 2011; 17: 2122-2129
    CrossrefPubMedGoogle Scholar
  • 38 Moschen AR, Kaser A, Enrich B et al. The RANKL/OPG system is activated in inflammatory bowel disease and relates to the state of bone loss. Gut 2005; 54: 479-487
    CrossrefPubMedGoogle Scholar
  • 39 Grainge MJ, West J, Card TR. Venous thromboembolism during active disease and remission in inflammatory bowel disease: a cohort study. Lancet 2010; 375: 657-663
    CrossrefPubMedGoogle Scholar
  • 40 Massari L, Fini M, Cadossi R et al. Biophysical stimulation with pulsed electromagnetic fields in osteonecrosis of the femoral head. J Bone Joint Surg Am 2006; 88 (Suppl. 03) 56-60
    CrossrefPubMedGoogle Scholar
  • 41 Wang CJ, Wang FS, Huang CC et al. Treatment for osteonecrosis of the femoral head: comparison of extracorporeal shock waves with core decompression and bone-grafting. J Bone Joint Surg Am 2005; 87: 2380-2387
    CrossrefPubMedGoogle Scholar
  • 42 Disch AC, Matziolis G, Perka C. The management of necrosis-associated and idiopathic bone-marrow oedema of the proximal femur by intravenous iloprost. J Bone Joint Surg Br 2005; 87: 560-564
    CrossrefPubMedGoogle Scholar
  • 43 Jäger M, Zilkens C, Westhoff B et al. Efficiency of iloprost treatment for chemotherapy-associated osteonecrosis after childhood cancer. Anticancer Res 2009; 29: 3433-3440
    PubMedGoogle Scholar