A 53-year-old female patient consulted physical medicine, rehabilitation and rheumatology department due to the pain radiating from the right inguinal region and the right hip to knee while she was being followed by general surgery clinic because of solid mass in the liver. During the assessment, patient complained of having an intermittent backache for a long time; she described a constant pain in her right hip and groin spreading to right knee that started 1 week ago and was increasing with rest. Patient also reported there was pain and slight swelling in the right ankle 10 days before that lasted for 3 days. In her background no previous illness is noted. Patient had an abdominal pain lasting for the last 6 months and abdominal ultrasound was performed; a solid mass was detected in the liver. We learned that the patient had no history of arthritis, gastroenteritis, urinary tract infection, psoriasis, or previous operation. She has not been using any medication except for analgesic. The patient had no relatives with history of inflammatory disease or malignancy in her family history. In the physical examination loss of lumbar lordosis was detected. Waist movement was slightly restricted to all directions due to pain, hand fingertip-to-floor distance was 10 cm, sacroiliac compression test was positive on the right, FABERE test was positive on the right, her right knee was warm and tender, there was no rash on the skin, local sensitivity was detected in the right upper quadrant with palpation, and other system evaluations were normal. Sacroiliac MRI was seen because of the suspicion of sacroiliitis. The sacroiliac MRI, which was assessed independently by radiology department, showed a signal enhancement consistent with the right iliac focal bone marrow edema adjacent to the right sacroiliac junction (Figure 1) and there were 2 cystic lesions at iliac front adjacent to the right hip joint. Abdomen tomography of our patient, which was requested by general surgery department, showed a well-defined 55 x 48 mm hypodense lesion with a superior calcification (lily symptom) in segment 3 (Figure 2). Hydatid cyst hemagglutination titer test was 1/320 and the patient was diagnosed as hydatid cyst disease. The patient was taken to our clinic because of development of right ankle arthritis and right knee arthritis.
In our clinic, the laboratory tests required for sacroiliitis and arthritis etiology were done. The results of these tests showed that RF was negative, anti-CCP was negative, anti-cardiolipin antibodies were negative, ds DNA was negative, ANA was negative, c-ANCA and p-ANCA were negative, sedimentation was 38 m/h, CRP was 23 mg/L, WBC was 7,31 (103/12.7 g/dL), PLT was 364 (103/muL), tumor markers were negative. In addition, Brucella Wright and Coombs agglutination tests were negative. EBV VCA Ig M, EBV VCA Ig G, and Anti-CMV Ig G were detected as positive; EBV EA, Anti-CMV IG m were detected as negative. The right knee joint was punctured and 60 cc yellow clear liquid aspirated. At the examination of knee joint fluid Tbc DNA, tbc real time PCR, mycobacterial culture were detected as negative and there was no reproduction in cell culture; 8000 leucocytes (30% MNL, 70% PMNL) and 20 erythrocytes were detected in the cell analysis of aspiration fluid. Microscopic examination of the joint fluid showed no protoscolex and hook structures of the Echinococcus parasite. There was no reproduction in the blood culture. Anti-HCV, HBsAg, and Anti-HIV tests were negative. There was no evidence in the ECO for infective endocarditis. The patient consulted pulmonary medicine department. In the assessment PPD test was 5 mm and sputum culture and microscopic examination showed no Tbc Bacillus. HLA-B27 genetic assay was negative for spondyloarthropathy. The patient is diagnosed as reactive arthritis secondary to echinococcal infestation after all tests and no history of other diseases which can cause sacroiliitis and peripheral arthritis like SPA (spondyloarthropathy), familial Mediterranean fever, Behcet's disease, sarcoidosis, inflammatory bowel disease, and malignancy. Symptomatic treatment as 4 x 1 cold pack and TENS treatment were applied to the right knee of the patient. Acemetacin 60 mg capsule 2 x 1 was given as medical treatment. On the 5th day of treatment, right knee and ankle arthritis were clinically regressed and then patient was directed to the general surgery department for surgical treatment of hydatid cysts.