Case 3: A 36-year-old man presented with an ischiorectal abscess that required incision and drainage in 1989. Because of diarrhea and a weight loss of 20 kg, further investigations were done. Fecal cultures and studies for parasites were negative. Colonoscopy showed superficial and deep serpentine ulcers, mucosal swelling, erythema, friability and pseudopol- yps in the transverse and descending colon, with a normal ascending colon and rectum. The ileum was erythematous but not ulcerated. Multiple ileal and colonic mucosal biopsies showed severe but patchy inflammatory changes, but no granulomas. Upper gastrointestinal endoscopy and biopsies revealed focal gastritis (without Helicobacter species) and nonspecific duodenitis; no granulomas were found. Barium radiographs of the upper gastrointestinal tract were normal, but a barium enema showed changes of Crohn’s disease.
The patient had a four-year history of right hip pain that worsened with walking and was associated with morning stiffness. Slight tenderness of the right hip was noted during his initial evaluation in 1989; his right leg was externally rotated, with a restricted range of motion in both legs, more on the right side. Radiographs of both hips in July 1989 revealed changes typical of avascular necrosis in the left hip and gross destruction of the right hip. In addition, there was radio- graphic evidence of sacroiliitis and early ankylosing spondy- litis.
Treatment in 1989 consisted of intravenous antibiotics and oral 5-aminosalicylic acid with symptomatic improvement. The patient was not treated with corticosteroids at that time or later because it was believed that they might result in worsening of the osteonecrosis. He did not seek further medical care until August 1991, when perianal pain and sepsis recurred. The patient declined to undergo further barium or endoscopic gastrointestinal studies. Incision and drainage of an abscess, and intravenous antibiotic therapy led to resolution of his perianal disease. Later hip radiographs and MRI, obtained in 1991, showed worsening osteonecrosis with destruction of both hips. Hip replacement surgery was declined.
Case 4: A 10-year-old boy was initially hospitalized in 1971 and then in 1981 for polyarthritis involving his knees, ankles and wrists. Treatment with acetylsalicylic acid both times resulted in symptomatic improvement. In 1981, radiographs of the pelvis, hips, hands and feet were normal except for poor definition of the sacroiliac joint margins. A radionuclide bone scan showed increased uptake in both sacroiliac joints. Because of some diarrhea, barium radiographs of the upper and lower gastrointestinal tracts were obtained, and showed changes characteristic of Crohn’s disease involving the distal ileum and transverse colon. Since 1981, he was treated with sulphasalazine 4 g daily and supplements of iron and folic acid. Get the medication you need. Purchase Cialis online
In September 1985, abdominal pain and diarrhea developed. Examination revealed right lower quadrant tenderness. An anal fistula was present. Sigmoidoscopy showed multiple discrete aphthous ulcers; a rectal biopsy showed active inflammation but no granulomas. Laboratory studies were normal, except for an erythrocyte sedimentation rate of 82 mm/h; tests for rheumatoid factor and antinuclear antibodies were negative. Human leukocyte antigen typing was negative for human leukocyte antigen-B27. Blood and fecal cultures, including cultures for Yersinia species, and studies for parasites were negative. Abdominal ultrasound revealed no abscess. Barium radiographic studies showed changes in the distal ileum and transverse colon similar to those recorded in 1981, as well as narrowing of the distal descending colon. The sacroiliac joint margins were poorly defined, and there was irregular demineralization of the right and left femoral heads. Some hip pain was present, particularly on the right side. Because of the patient’s gastrointestinal symptoms, he was treated with a low residue diet and metronida- zole 750 mg daily orally. Because of worsening hip pain and decreasing mobility, he underwent total replacement of the right hip in 1986 and of the left hip in 1988. The synovium of each hip joint showed villous hyperplasia with synovio- cyte hypertrophy as well as hyperplasia, fibrosis and inflammation of the subsynovium. Sections from the femoral head showed extensive degeneration of articular cartilage with osteonecrosis of the bony trebeculae; however, no wedge- shaped sclerosis or cystic degeneration of the subchondral region was evident. Granulomas were not present in synovium, joint capsule, skeletal muscle or bone.