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In a recent issue of the Annals of Rheumatic Diseases, Hoballah et al reported high false-positive results on sacroiliac MRI based on the Assessment of SpondyloArthritis international Society (ASAS) criteria in the early postpartum period.1 Similarly, Renson et al reported a markedly high prevalence of postpartum sacroiliac bone marrow oedema on sacroiliac MRI and recommended waiting at least 6 months after delivery to perform sacroiliac MRI.2 Both studies excluded patients with inflammatory bowel disease. We would like to share below a case of new onset axial spondyloarthritis in an early postpartum patient with ulcerative colitis.
A Japanese female patient in her 30s with ulcerative colitis in clinical remission without treatment was evaluated for a 2-month history of progressive right buttock pain which began 6 months after childbirth. Naproxen was ineffective in relieving the pain.
Physical examination showed tenderness in the right sacroiliac joint and was positive for Patrick’s test and Gaenslen test. Laboratory analysis showed serum C reactive protein 1.7 mg/dL and was negative for human leucocyte antigen-B27. A plain radiograph of the sacroiliac joint was normal. MRI revealed bone marrow oedema without erosion or ankylosis in the right sacroiliac joint, thus satisfying the ASAS criteria for active sacroiliitis (figure 1A). The pain dramatically improved 4 days after adalimumab treatment was begun, and the MRI findings improved by week 8 (figure 1B).
In patients with inflammatory bowel disease, mechanical stress on the sacroiliac joint during labour may induce persistent inflammation leading to axial spondyloarthritis. Although the MRI findings are indistinguishable from non-specific bone marrow oedema, response to treatment can confirm the diagnosis of postpartum axial spondyloarthritis. In cases with a high index of suspicion, clinical diagnosis and prompt treatment can improve the patient’s quality of life.
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Contributors KF and NY contributed to the conception and drafting of the article. KF, NH, YM and NY provided critical revision for important intellectual content and final approval.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; internally peer reviewed.