When sacroiliitis is the onset of Crohn's disease: A case report

A 10-year-old boy affected by symptomatic epilepsy was admitted to Rimini's Paediatric Ward for legs pain with morning-stifness, evening fever, and decreased appetite. Clinical examination showed anserine gait without stenic deficit, hyperreflexic deep tendon reflexes, and unsustained clonus. Blood test showed increased CRP; normal CPK and LDH. In anamnesis, maternal psoriasis. As we suspected a spondyloarthropathy, we decided to perform a pelvis MRN which reported the presence of spondylitis. According to the radiological findings we started Ibuprofen theraphy. During hospital admission, bloody and mucous stools appeared. Considering the strong association between rheumatologic disorders and Inflammatory Bowel Disease (IBD) we decided to detect fecal calprotectin which was increased. HLA B27, ASCA, ANCA, were normal. Infective diarrhea was excluded by stool culture. Abdominal ultrasound was negative. The colonoscopy showed multiple aphthous ulcers throughout the colon and the histology confirmed Crohn's Colitis. Without any clinical improvement, after 7 days of oral steroid therapy, we decided to add Adalimumab to his medications (Top Down). There is a strong association between IBD and extraintestinal manifestations, like spondyloarthropathy, but arthritis rarely appears before the intestinal symptoms. In our case, the poor general conditions and bowel's changes acted like “red flags”, leading to a correct diagnosis while the disease's severity and the chance of a negative outcome lead us to choose an alfa-TNF Inhibitor as medication. In conclusion, a careful evaluation of the clinical objectivity is the key to make the correct diagnosis (even if not expected) and to choose the appropriate therapy.