A Tale of Two Systems

A 43-year-old man, employed in food-industry, presents (in a primary care unit) with complaints of diffuse abdominal pain, involuntary loss of 7kg in 6 weeks (11% of his weight) and black stool. The abdominal pain has an intensity of 7 in 10 (and began six weeks earlier), initially being restricted to the epigastric region and worsening after meals; with time became more constant and diffuse.  Besides the black stool, he also describes intermittent episodes of mucous diarrhoea associated with tenesmus. Denies fever, night-sweats, chest pain, cough, shortness of breath, nausea, vomiting, dysuria, oral ulcerations or rashes. Simultaneously, he also complains about a recent cervical pain that sometimes wakes him up at night, and morning stiffness (around 1 hour). He has a personal history of insulin treated/dependent Diabetes Mellitus type 2 and chronic low back pain (of approximately 20 years). Refers, as well, a single episode of auto-limited acute anterior uveitis three years ago.

His current medication consists of isophane insulin 10U – 2x/day metformin 500mg 2x/day and ibuprofen 400mg, in SOS.

In what concerns his social history, this man is a former smoker (30 packs-year), but quitted 5 years ago. He denies alcohol or illicit drugs intake. He lives with his dog (vaccinated) in an urban area and denies recent visits to the countryside, although he travelled to Brazil 10 months ago (denying any relevant epidemiologic history since then). His family history is irrelevant.

During his physical examination, his blood pressure was 135/80mmHg and his heart rate was 87bpm with no signs of haemodynamic instability. In his chest exam, no abnormalities were found neither in heart nor lung examination. In his abdomen, there was a diffuse tenderness, especially in the left flanks. No peritoneal signs. No palpable masses or organomegalies. He had also a limitation of chest expansion (1cm) and anterior lumbar flexion (1,5cm – Shober test) with no other relevant findings.

Considering the patient anamnesis and physical examination which of the following hypothesis would more probably explain the patient’s articular symptoms?
  1. Reactive arthritis due to a primary acute uveitis;
  2. Bone metastasis due to a primary GI neoplasm;
  3. Spondiloarthritis;
  4. Polymyalgia rheumatica;
  5. Vasculitis with lung, gastrointestinal and musculoskeletal manifestations.

Correct answer: C. The patient has a chronic inflammatory back pain (≥3 months) with an onset before 45 years, with recent extension to the cervical spine. He also has a history of acute anterior uveitis. In addition, there is a possibility of an IBD taking into account the weight loss and mucous diarrhoea associated with tenesmus, although we still need more data to infer such supposition. All of these could point to a/are compatible with a hypothesis of spondyloarthritis. However, we still need more data in order to meet (or not) the criteria, such as sacro-iliac imaging, HLA-B27 status and further investigation of the abdominal complaints.

Reactive arthritis usually occurs within 1 month of a primary infection, typically a genitourinary (urethritis) or gastrointestinal infection. (and not a uveitis) However, we cannot rule it out specially in the context of a possible gastrointestinal infection in the beginning of symptoms.

The unexplained weight loss and black stool could also be caused by a GI neoplasm. Nevertheless, the onset of the osteoskeletal symptoms (since 20 years ago) does not favour the metastasis ’theory’.

The cervical pain that wakes him up at night, the back pain and morning stiffness (around 1 hour) could be features related to polymyalgia rheumatica (PMR). However, this disease is usually present in patients over the age of 50 and shoulder pain is reported in 75-99% of patients. He does not meet the ACR/EURLAR 2012 classification criteria for PMR.

Vasculitis comes in a broad/wide range of diseases that may have very heterogeneous presentations. Even though this could be a suitable diagnosis, it is not the most likely one.

You asked for a blood analysis, that gave you the following results:

  • Blood-cells count: Hb: 11g/dl (normocytic normochromic anaemia); WCC: 7.400/L with 56% Polymorphonuclear cells (normal range); Platelets: 300.000/L (normal range);
  • C-reactive protein: 93mg/L; ESR: 57mm/h (both elevated);
  • Creatinin:0.87mg/dL (0.50; 1.00); Urea: 30mg/dL (20-40); AST: 40 U/L (<32); ALT: 30 U/L (<33); GGT: 37U/L (6-42).
  • Stool sample’s culture (repeated 2 times) and parasitological exams where negative;
  • To strengthen these findings, it was also required the following immunologic tests: ATA IgA (anti-transglutaminase antibodies IgA); ASCA – (anti-saccharomyces cerevisiae antibodies); p-ANCA + (perinuclear anti-neutrophil cytoplasm antibodies); HLA-B27 + (Human leucocyte antigen B27).

What could be the best explanation for the lab findings?
  1. A malabsorption syndrome. Ask for an immunologic panel in order to detect causes such as pancreatic insufficiency or celiac disease.
  2. A GI tract infection/haemorrhagic gastroenteritis causing anaemia and elevated inflammatory patterns;
  3. Anaemia due to chronic inflammation and blood loss (early iron-deficiency pattern). Perform a colonoscopy.
  4. Acute GI viral infection due to a virus with negative cultures. Perform a stool polymerase chain reaction (PCR).
  5. An irritable bowel syndrome in a patient with a chronic mechanical back pain.

Coming soon…

You decide to request pelvic and spinal x rays. Below are the actual findings:


What can be observed in these radiographies?
  1. Radiographic sacroileitis and syndesmophytes all along the vertebrae;
  2. Multiple disc hernias and pelvic fractures;
  3. Multiple metastases along the vertebrae and iliac bone;
  4. Lumbar osteophytes with pelvic fracture;
  5. Diffuse osteomyelitis.

Coming soon…

You decide to further investigate the cause of the black stools and anaemia.

Which one is the best next step to proceed with the investigation?
  1. Faecal occult blood testing (FOBT)
  2. Colonoscopy (whole colon);
  3. Barium enema;
  4. Capsule endoscopy;
  5. Virtual colonoscopy with CT scanning.

Coming soon…

The report of the exam you requested shows lesions compatible with an active ulcerative colitis. In order to target both conditions you decide to start an anti-TNFα biological therapy. Which of the following is NOT part of the recommended screening?
  1. Chest X-ray examination;
  2. Exclude infections;
  3. Exclude congestive heart failure (NYHA class III/IV and ejection fraction ≤50%);
  4. Exclude inflammatory bowel disease;
  5. Serology for HIV, HBV and HVC (for some countries only if risk factors).

Coming soon…