An 11-year-old Saudi female, presented with fever, pain, and swelling in the left foot for a 6-month duration. Magnetic resonant imaging (MRI) of the left lower limb confirmed the diagnosis of multifocal, chronic osteomyelitis involving the distal left fibula, lower part of both tibiae, and metatarsal bones of both feet (Figure 1). Surgical incision and drainage in the affected lower limb was done, and the aspirated fluid and bony tissue biopsy excluded fungal and bacterial causes of chronic osteomyelitis, including mycobacterial tuberculosis. Initial management by intravenous antibiotic therapy was provided; however, it was stopped following negative bacterial culture.
Subsequently, she was referred to our service because of stunted growth, past history of chronic bloody diarrhea, abdominal pain, and multiple blood transfusions following recurrent, and severe hemoglobin drop. Family history was remarkable for Crohn's disease in a paternal aunt.
Physical examination revealed pallor and stunted growth.
Initial laboratory workup showed features of iron deficiency anemia, high erythrocyte sedimentation rate (ESR), and high C-reactive protein (CRP). Upper digestive endoscopy was unremarkable, with normal duodenal, stomach, and esophageal histology. The diagnosis of UC was established following clinical, colonoscopic, histological, and radiological findings. Hence, colonoscopy showed features of pancolitis with pseudopolyps in the entire colon; histology showed features of chronic active colitis, crypt architectural distortion, and absence of granuloma (Figure 2); terminal ileum (TI) was normal macroscopically and histologically; and magnetic resonance enterography (MRE) excluded small bowel disease. The final diagnosis of ulcerative colitis UC in association with chronic multifocal osteomyelitis was made. A remarkable remission for intestinal and bony symptoms as well was achieved following IBD therapy prednisolone, mesalamine, and azathioprine.