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Intolerable Unilateral Hip Pain: Clues from the History

      To the Editor
      A 36-year-old woman was hospitalized with acute onset of severe left-sided hip pain.
      Though she had gone to bed the night before in comfort, she awoke that Tuesday morning with pain in her left anterolateral hip. Weight-bearing and ambulation became increasingly intolerable. By evening, she could no longer stand, was in excruciating pain, and presented to the emergency department.
      On examination, she was alert and interactive but visibly uncomfortable. Temperature was 36°C (96.8°F). She was normotensive. Heart and lung sounds were unremarkable. The abdomen was soft, diffusely tender, with normal bowel sounds. Any left hip active or passive range-of-motion testing provoked unbearable pain. There was no dactylitis or rash.
      Laboratory studies identified a leukocytosis with neutrophilic predominance (white blood cell count [WBC] 16.97 K/mm3, 88% neutrophils), hemoglobin 10.7 g/dL, and platelets of 399 K/mm3. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated at 39 mm/h and 6 mg/dL, respectively.
      Orthopedic surgery and musculoskeletal radiology services were consulted. Shortly after midnight, ultrasound-guided left hip arthrocentesis yielded yellow-colored synovial fluid with 84,456 WBCs/mm3, 91% polymorphonuclear neutrophils (PMNs), and 3000 red blood cells (RBCs). No crystals were seen. Gram stain was negative.
      Due to concern for septic arthritis, she was commenced on broad-spectrum antimicrobial therapy with vancomycin and ceftriaxone. Intravenous morphine was administered for pain control. Later that Wednesday morning, left hip magnetic resonance imaging showed a moderate-sized joint effusion (Figure 1), mild synovitis, with extensive periarticular soft tissue edema. She was admitted to the medicine service. Her temperature that day peaked at 37.7°C (99.9°F).
      Figure 1
      Figure 1Left hip magnetic resonance imaging revealing a moderate-sized hip joint effusion. Synovial fluid identified by asterisks.
      Operative irrigation and debridement of the left hip joint was planned within 24 hours of admission. Anesthesia preoperative evaluation was undertaken. Yet, the orthopedic service conveyed that a diagnosis of septic arthritis was not certain in the absence of positive synovial fluid cultures.
      On Thursday morning, the rheumatology service was consulted. Further history revealed right shoulder pain 2-3 weeks prior that impaired use of that arm, only to subside then replaced several days later by left-sided shoulder pain. She further elaborated that her left-sided hip pain had first commenced 9 days earlier, of sharp stabbing quality. She took ibuprofen, rested, and the pain steadily resolved over 3 days, enabling her to resume regular activities, including jogging the weekend preceding the current hospitalization.
      Review of systems was notable for a 3-month history of intermittent diffuse abdominal cramping associated with periodic bloody stools.
      The differential diagnosis for a painful, swollen joint with elevated synovial fluid leukocytosis includes septic arthritis, crystal-induced monoarthritis, rheumatoid arthritis, and spondyloarthropathy.
      • Baker DG
      • Schumacher Jr., HR
      Acute monoarthritis.
      ,
      • Siva C
      • Velazquez C
      • Mody A
      • Brasington R
      Diagnosing acute monoarthritis in adults: a practical approach for the family physician.
      Although a joint fluid WBC count >50,000 WBCs/mm3, with neutrophil predominance, raises clear concern for septic arthritis, alternative diagnoses should be considered.
      Given the informative history of a migratory oligoarthritis, intermittent abdominal pain with bloody stools in a young adult, a presumptive diagnosis of inflammatory bowel disease-associated arthritis was suspected.
      • Abraham C
      • Cho JH
      Inflammatory bowel disease.
      Surgery was deferred. She was prescribed 400 mg of ibuprofen every 6-8 hours. Fecal calprotectin level was markedly elevated.
      Her hip pain improved dramatically over the course of that day, and on Friday, she was able to walk unassisted. Colonoscopy that Friday revealed numerous superficial ulcers, inflamed mucosa, and erythema affecting the sigmoid colon and rectum. She was discharged home on Saturday.
      Histologic evidence of crypt distortion, basal plasmacytosis, ulceration, cryptitis, prominent lymphoid aggregates, and marked reactive epithelial changes were identified (Figure 2A and B). Cytomegalovirus immunostain was negative.
      Figure 2
      Figure 2Hematoxylin and eosin staining of the left colon (A) revealing mild crypt distortion and basal plasmacytosis, with rectal specimen (B) similarly identifying basal plasmacytosis, identified by bracket.
      She was diagnosed with inflammatory bowel disease. Thereafter, a course of tumor necrosis factor alpha antagonist therapy, with infliximab infusions, was implemented above and beyond mesalamine and budesonide, with improvement. Celecoxib was employed for intermittent arthritis symptoms.
      • Nielsen OH
      • Ainsworth MA
      Tumor necrosis factor inhibitors for inflammatory bowel disease.

      References

        • Baker DG
        • Schumacher Jr., HR
        Acute monoarthritis.
        N Engl J Med. 1993; 329: 1013-1020
        • Siva C
        • Velazquez C
        • Mody A
        • Brasington R
        Diagnosing acute monoarthritis in adults: a practical approach for the family physician.
        Am Fam Physician. 2003; 68: 83-90
        • Nielsen OH
        • Ainsworth MA
        Tumor necrosis factor inhibitors for inflammatory bowel disease.
        N Engl J Med. 2013; 369: 754-762
        • Abraham C
        • Cho JH
        Inflammatory bowel disease.
        N Engl J Med. 2009; 361: 2066-2078