This is a 30-year-old and he's coming in because he's got some pain in his back. None of us can read that top slide very well because of the zoom options. I apologize but basically no radiation into his legs he's just got pain in his back. It's worse in the morning and gets stiff and sore but within a couple of hours it goes away. It can come back at the end of the day and during the night but he gets good relief from ibuprofen. He's healthy otherwise. He's performing and able to play professional soccer and doesn't really have any other issues currently in his GI, GU, skin or joints. Exam vital signs are fine. His eye exam is normal. Some pain with his range of motion but just mild and a little tender over the buttock area. No joint swelling, no tenderness in his extremities, no rashes. Wouldn't we all love to know what his SED rate and HLA-B27 are but they're pending. He's got normal x-rays. Lumbar, spine and pelvis were included. So what's the most likely diagnosis here? First option is ankylosing spondylitis. Second option is lumbar disc degeneration. Third option is psoriatic arthritis. Fourth option is reactive arthritis. And everyone really thought, well most people thought ankylosing spondylitis was the right answer. So the picture here is Darren Fletcher. Darren Fletcher was a professional soccer player and recently retired and played for almost 10 years with inflammatory bowel disease. That's all in the public domain. I don't think he had ankylosing spondylitis but a lot of my patients that I see with concern for spondyloarthropathy these days are not necessarily the classic ankylosing spondylitis that we see depicted here but are people that have either psoriatic arthropathy or have inflammatory bowel disease related muscle or joint pain. And I think we have to remember that the spondyloarthropathies have a whole spectrum of disease beyond the classic that we all read about in medical school, ankylosing spondylitis, where you get better once you start moving around and exercising and you're stiff and sore the first couple of hours in the morning. So young males with that history, that's a classic. But you can see this with psoriatic arthropathy and you don't need to have skin disease to have psoriatic arthropathy. There's plenty of people out there that have psoriasis, that their joint disease is the first manifestation of the disease. And I think that can also go for inflammatory bowel disease, although it's obviously more common that you've got some sort of history of bloody stools or colitis to some extent. Some people have the non-GI manifestations before they have the GI manifestation. So you've just got to keep that information in your back pocket and think outside the box once in a while for young patients like this. Let's see what else I said. Ankylosing spondylitis is the correct answer and back pain, stiffness in the spine, worse with immobility and better with exercise is classic. Symptoms first thing in the morning, buttock pain. The change in the American College of Rheumatology's approach to this is that whereas when I was a resident, we were kind of poo-pooed from getting HLA-B27, now it's pretty established. Yeah, go ahead and get that. We can kind of hang our hats on that a little bit. Although it might not be positive for everybody, it is helpful if it is positive. The other thing that you should do is not stop with x-rays. You should probably go ahead and get an MRI because early findings will be apparent on MRI. You'll see some degree of sacroiliitis that you might not see on x-ray. So I've developed a much lower threshold for getting a pelvis MRI for patients that I suspect might have some sort of spondyloarthropathy and particularly younger patients.

2nd Edition, CASE 46

2nd Edition

Rheumatology

ankylosing spondylitis

back pain

HLA-B27 testing

spondyloarthropathies

MRI