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Periostitis in a patient with ulcerative colitis.

CLINICAL HISTORY A 25-year-old woman, suffering from ulcerative colitis confirmed by colonoscopy and histological examination of colon biopsy specimens performed 3 years before, was referred to our outpatient clinic in February of 2000 because of pain in both forearms, especially overnight. These symptoms started mid-January, a few days after a gastroenteritis-like syndrome, nonbloody stools, and diffuse muscle and joint aches and fatigue. Ulcerative colitis was still active and needed therapy with mesalazine (1.5 g/day), prednisone (5 mg/ day), and azathioprine (100 mg/ day). General examination revealed a moon-like facies related to prolonged steroid therapy and a tender red nodule over the right pretibial region suggesting a diagnosis of erythema nodosum. Examinations of peripheral joints, spine, and sacroiliac joints were normal. Palpation of the proximal third of both forearms was sensitive without any inflammatory signs. The fingers were not clubbed. Laboratory tests showed an increased erythrocyte sedimentation rate (ESR; 69 mm/hr) and C-reactive protein (CRP; 77 mg/L). The rheumatoid factor was absent, and the patient was HLA B27 negative. Plain x-rays were normal. A Tc-MDP scintigraphy disclosed an increased isotope uptake of the right and left radial (Fig. 1), left cubital, left humeral, and right tibial diaphyses. Magnetic resonance images (MRI) of the forearms showed abnormal bone marrow and periosteal signals of the radius, hypointense on T1-weighted images (Fig. 2), hyperintense on fat saturation sequences, with strong enhancement after IV Gd-Ominscan administration (Fig. 3). On the adjacent soft tissues there was also an hyperintense signal on proton density fat saturation sequences (Fig. 4) and a contrast enhancement indicating local edema. Despite the fact that no histological examination was performed, a diagnosis was made of diffuse periostitis in this patient suffering from ulcerative colitis. Pain improved after 10 days of therapy with 15 mg/day of prednisone (which could progressively be reduced). Follow-up was marked by an ulcerative colitis flare 6 months later with recurrence of the forearm pain. Pain and colonic symptoms improved with an increased dose of prednisone (20 mg/day) and azathioprine (125 mg/day). There were no follow-up x-rays made, and the patient is presently free of any skeletal symptom.