REFRACTORY ATYPICAL POLYARTHRITIS AND CRY OGLOBULINEMIA IN A PATIENT WITH COLONIC-CARCINOMA AND PALLIATIVE INTESTINAL-BYPASS DD - CARCINOMA-POLYARTHRITIS OR BYPASS-ARTHRITIS

The case of a 63 year old woman with mesenteric recurrence of a coloni c carcinoma and infiltration of the duodenum is reported. To bypass du odenal stenosis a duodenojejunostomy was performed. Three months later the patient developed severe atypical polyarthritis which led to hosp italization. The arthritis affected large and small joints in an asymm etrical pattern. Fever and Raynaud's phenomenon of both hands accompan ied the arthritis. Elevated sedimentation rate, acute phase proteins, cryoglobulinemia and immune complexes were remarkable laboratory findi ngs. Rheumatoid factor was absent. In the subsequent course the polyar thritis was refractory to steroids and nonsteroidal anti-inflammatory drugs. Only treatment with broad-spectrum antibiotics ameliorated the arthritis. Postenteric reactive arthritis, septic arthritis and metast atic arthritis could be excluded. Although the patient had a family hi story of rheumatoid arthritis and a HLA-type DR4 the diagnosis of rheu matoid arthritis was not very likely since distal interphalangeal join ts were affected, rheumatoid factor was absent and antibiotic therapy was successful. The case serves to discuss carcinoma-polyarthritis and bypass-arthritis as the main differential diagnosis.