HSS What's the Diagnosis Case 213

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Findings The radiograph demonstrates the patient is skeletally mature at some locations and immature at others. There is subtle irregularity seen of both greater trochanters. The MRI demonstrates prominent edema pattern particularly about tendinous attachments to the greater and lesser trochanters.

Bony abnormalities are seen of the greater trochanters as well. Edema pattern is seen about a lower lumbar facet joint. The sacroiliac joints are not completely mature but with additionally areas of edema pattern of the bone and subchondral bony abnormalities. Both hip joints demonstrate joint effusions with synovitis and areas of edema pattern of both femoral heads.

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Diagnosis: Enthesitis related Arthritis Enthesitis related arthritis (ERA) is one of the seven categories of juvenile inflammatory arthritis (JIA). JIA is a heterogeneous group of arthritides. ERA is a process related to ligament and tendinous attachments. Although this can be found in the other types of JIA, in ERA it is a prominent feature. In ERA, sacroiliitis and peripheral arthritis particularly of lower extremity joints may also be found. ERA is more common in boys who frequently are HLA-B27 positive.

Uveitis is also frequently found. It is important to try and classify this arthritis as unfortunately, patients with ERA often have a higher burden of disease and overall worse outcome.

In the case presented, the subtle irregularities of the greater trochanters on the radiograph represented erosions. The edema pattern at the entheses represent ongoing inflammatory change. The findings at the sacroiliac joints in part may relate to skeletal immaturity but the subchondral edema pattern and extent of abnormality indicate there are also erosions and an active sacroiliitis.

Although not the dominant feature, inflammatory change of the facet joints as seen in this case can occur and inflammation of the hip joints (also as seen in this case) can be present. The edema pattern of the femoral heads was likely about subtle capsular attachment sites.

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References Mistry RR, Patro P, Agarwal V, Misra DP. Enthesitis-related arthritis: current perspectives. Open Access Rheumatol. 2019 Jan 25;11:19-31. doi: 10.2147/OARRR.S163677. PMID: 30774484; PMCID: PMC6354696.

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