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Patient Case: Spondyloarthritis

Patient Case: Spondyloarthritis

Discussion

A 32-year-old male presents to a rural health clinic with a five-year history of chronic lower back pain and morning stiffness lasting over an hour. The pain gradually worsens with rest and improves with physical activity. He also reports intermittent swelling and pain in his right knee and left ankle over the past year.

Additionally, he has experienced episodes of red, painful eyes with blurred vision, which resolved spontaneously. He denies recent infections or a history of trauma. There is no family history of autoimmune diseases. Physical examination reveals tenderness over the sacroiliac joints and reduced lumbar spine mobility.

Laboratory tests show mild anemia with normal inflammatory markers, and HLA-B27 testing is positive. X-rays reveal sacroiliac joint sclerosis and narrowing, suggesting sacroiliitis. A diagnosis of spondyloarthritis is made. The patient is started on nonsteroidal anti-inflammatory drugs (NSAIDs) and advised on regular physical activity to maintain spinal flexibility. A referral is made for rheumatology follow-up to assess the need for advanced therapies.

Questions
1. What is the most likely diagnosis in this patient?

a) Rheumatoid arthritis

b) Spondyloarthritis

c) Osteoarthritis

d) Gout

2. Which of the following features is most characteristic of spondyloarthritis?

a) Pain that worsens with activity and improves with rest

b) Symmetric small joint involvement

c) Chronic lower back pain with morning stiffness improving with activity

d) High fever and migratory arthritis

3. Which extra-articular manifestation is commonly associated with spondyloarthritis?

a) Skin rash with silvery scales

b) Episodic eye redness and pain (uveitis)

c) Malar rash

d) Oral ulcers

4. What is the best initial treatment for this patient?

a) Methotrexate

b) Nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy

c) High-dose corticosteroids

d) Long-term opioid therapy

Reveal answers

Answers

1. b) Spondyloarthritis

The patient's history of chronic lower back pain, morning stiffness that improves with activity, peripheral joint involvement, and HLA-B27 positivity strongly suggest spondyloarthritis. Other conditions, like rheumatoid arthritis, typically involve the small joints symmetrically.

2. c) Chronic lower back pain with morning stiffness improving with activity Inflammatory back pain in spondyloarthritis worsens with rest and improves with movement, distinguishing it from mechanical causes like osteoarthritis, where pain worsens with activity.

3. b) Episodic eye redness and pain (uveitis)

Uveitis is a common extra-articular manifestation of spondyloarthritis. Other forms of spondyloarthritis (such as psoriatic arthritis) may be associated with skin lesions, but this case does not suggest psoriasis.

4. b) Nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy

NSAIDs are the first-line treatment for symptom relief, while physical therapy helps maintain mobility and prevent stiffness. Disease-modifying drugs like methotrexate are typically not effective unless there is peripheral joint involvement.