Case report: Tuberculosis as a cause unilateral of sacroiliitis in lupus patients

doi:10.15406/mojor.2022.14.00602

MOJ

eISSN: 2374-6939

Orthopedics & Rheumatology

Case Report Volume 14 Issue 6

Case report: Tuberculosis as a cause unilateral of sacroiliitis in lupus patients

Cláudia Holanda Ribeiro,

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Cristina Lauren Carpinetti, Márcio Felipe de Freitas, Angélica Ferreira de Sá Roris, Fernanda MS Bezerra, Bárbara Seabra Carneiro, Sandra Lúcia Euzébio Ribeiro

Federal University of Amazonas (UFAM), Faculty of Medicine, Manaus, Amazonas. Getúlio Vargas University Hospital (HUGV), Rheumatology Service, Brazil

Correspondence: Cláudia Holanda Ribeiro, Federal University of Amazonas (UFAM), Faculty of Medicine, Manaus, Amazonas. Getúlio Vargas University Hospital (HUGV), Rheumatology Service, Brazil

Received: November 01, 2023 | Published: November 16, 2022

Citation: Ribeiro CH, Carpinetti CL, de Freitas MF, et al. Case report: Tuberculosis as a cause unilateral of sacroiliitis in lupus patients. MOJ Orthop Rheumatol. 2022;14(6):173-174. DOI: 10.15406/mojor.2022.14.00602

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Abstract

Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease, with variable manifestations, which is frequently exacerbated, requiring differential diagnosis with infectious conditions. In the case report, the patient satisfied the following criteria as per ACR/EULAR (2019): FAN 1:640 homogeneous nuclear, fever, alopecia, hypocomplementemia, antidsDNA 1:80 and lymphopenia. She was on: prednisone 20mg/day, hydroxychloroquine 400mg/day and calcium+vitamin D3. She was pale (3/4+), dehydrated and tachycardic. Osteoarticular examination: Patrick-Fabere positive for left sacroiliac; pain in external and internal rotation in left hip and painful palpation in the metacarpal, proximal interphalangeal, wrists, knees, ankles, hip and thigh joints, especially in the left and right.

Radiography showed extensive sclerosis (grades 3 and 4) in left sacroiliac and rectified lumbar lordosis. Later, magnetic resonance imaging revealed extensive subcortical bone marrow edema at the left sacroiliac associated with capsulitis. In addition to positive BAAR TRM-TB, Lupus patients present a high incidence of TB, which is an important hypothesis in febrile cases with inflammatory lombalgy, since its osteoarticular form mainly affects the spine. Therefore, the importance of differential diagnosis for effective management is evident.

Keywords: sacroiliitis, infection, osteoarticular, tuberculosis, systemic lupus erythematosus

Introduction

Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease, with variable manifestations, which is frequently exacerbated, and it is necessary to differentiate it from infectious conditions. In this context, tuberculosis (TB) appears as a possible infectious etiology, whose osteoarticular form represents only 1% to 3% of cases. This presentation in lupus patients is often recurrent, of non-specific findings, which make diagnosis difficult, and of sometimes devastating consequences. However, its damage is potentially preventable if the infection is treated early and correctly.

Case report

Patient K.C.O.S, 27 years old, female, diagnosed with SLE in 2018, also meets the new ACR/EULAR (2019) classification criteria: FAN 1:640 homogeneous nuclear, fever, alopecia, hypocomplementemia, antidsDNA 1:80 and lymphopenia. In July 2019, she presented severe back pain requiring the use of opioid, headache, measured fever, weight loss and night sweating. She was using prednisone 20mg/day, hydroxychloroquine 400mg/day and calcium + vitamin D3. On physical examination she was in regular general condition, hypocoradic, tachycardic, cardiac auscultation without changes. In the osteoarticular examination she presented Patrick-Fabere positive for left sacroiliac, pain external and internal rotation of the left coxofemoral joint, besides generalized arthralgia. Chest computerized tomography was requested to exclude active TB, because PPD showed a strong reactor (20mm), revealing alveolar opacity in the left base. The results of molecular rapid test (MRT) for TB and sputum smear were initially negative. Radiographies showed sclerosis and reduction of joint space in left sacroiliac (grade 3 by New York criteria) and lumbar lordosis rectification. Magnetic resonance imaging revealed extensive subcortical bone marrow edema in left sacroiliac associated with capsulitis. The findings showed suspicion of infectious arthritis, and the site was successfully approached. The biopsy analysis revealed a granulomatous inflammatory process, BAAR and MRT-TB positive in the material. Later, BAAR was also positive in the sputum. The patient made use of the conventional therapeutic scheme for 9 months, and showed expressive clinical improvement.^1-9

Conclusion

Tuberculosis is a high incidence disease in Amazonas. The immunosuppressed patients, which includes lupus patients, present a higher frequency of extrapulmonary forms than the general population, but the diagnosis can be complex. It is important to always think of tuberculosis as a differential diagnosis in lupus activity, if there are suggestive signs and symptoms. In the case reported, the satisfactory response resulted from the patient's early approach and appropriate and regular use of treatment.