Background/Purpose:   Extra intestinal manifestations occur in 40-50% of patients with inflammatory bowel disease (IBD), with musculoskeletal involvement in 25%. Data regarding musculoskeletal manifestations in the pediatric population are scarce. The purpose of this study was to compare pediatric IBD patients initially presenting with arthritis, to patients presenting with arthritis of other etiologies, in order to identify clinical and laboratory red flags that may arouse suspicion of IBD.

Methods:  This retrospective cohort study included patients followed up at “Schneider Children’s Medical Center of Israel” between 1985-2016. We identified 23 children with IBD who presented with arthritis and matched them to a control group of 46 children. The latter included 21 patients with Juvenile Idiopathic Arthritis, 7 patients with Familial Mediterranean Fever and 18 patients with postinfectious arthritis. Clinical and laboratory data were collected and compared between the two groups. Fisher’s exact test, χ ²and analysis of variance were used for statistical processing.

Results:  The most statistically significant clinical factor at presentation which predicted IBD was sacroiliitis (30.4% in IBD group vs. 2.2% in control group, P<0.001), and was more common in females (46.15% vs. 20% respectively). Additive arthritis was exclusive to the IBD group (21.7%). Twenty five percent of the IBD group reported a positive family history for IBD (mostly Crohn’s Disease).The IBD group showed decreased hemoglobin and MCV levels as well as elevated RDW as compared to control (10.5, 69.1, 14.9 vs 12.0, 79.1, 13.2 respectively, P<0.001). Albumin mean values were lower in the IBD group compared to control (3.5 vs. 4.3 respectively, P<0.001). Upon direct questioning of the IBD group at presentation, the following abdominal symptoms were reported: diarrhea (43.5%), abdominal pain (39.1%), weight loss (34.8%), fever (21.7%), aphthous ulcers (17.4%), bloody stools (13%) and vomiting (8.7%). Despite these signs and symptoms 8.7% of children were diagnosed with IBD at presentation, whilst 26% were diagnosed at a delay of >1 year. The overall mean time from arthritis presentation to IBD diagnosis was 1.17±1.89 years. Three patients (13.04%) from the IBD group developed residual joint damage.

Conclusion:   Arthritis, specifically sacroiliitis, associated with microcytic anemia and/or hypoalbuminemia in children without specific signs of IBD should be considered red flags, and arouse suspicion for this disease, thus mandating thorough enquiry.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/musculoskeletal-manifestations-as-presenting-symptoms-of-inflammatory-bowel-disease-in-children-and-adolescents/