Rheuma Case: 26-year-old Woman with Persistent Low Back Pain

00:00 A 26 year old guitar player reluctantly presents to your office for persistent low back pain. Now she reports slowly progressive back troubles over the past several years which has now begun to interfere with her touring schedule.

00:15 It takes over an hour for her to get moving each morning.

00:18 She frequently wakes up from sleep with back pain that compelled her to get up and walk around.

00:24 It always feels better over the course of the day.

00:27 She's sometimes afraid to go to sleep knowing what the night will bring. Pain began on the right side but now it's bilateral radiating down into her buttocks.

00:36 Social History, she's a non-smoker. She drinks “A few beers nightly”.

00:42 She's had several male sexual partners in various cities over the past 12 months. Family history; is non-contributory review systems she has noticed also some redness in her right eye over the past few weeks. She also reports some pain and swelling to the back of her left heel but reports no rashes.

01:02 So let's highlight some key features of this case thus far.

01:06 First in terms of time course, this has been going on for several years.

01:10 This certainly falls into the chronic indolent category.

01:14 Next, the pattern of joint involvement.

01:16 It started off as somewhat asymmetric but now we've got bilateral symptoms but we've also got something going on with the left heel.

01:23 I'd call this asymmetric and because we have more than one joint involved but not quite five or six, we'd use the term oligoarticular.

01:33 Is there evidence of joint inflammation? Well, anytime a patient tells you it takes over an hour for the stiffness to resolve, that's usually a good indication that there's some inflammatory process going on.

01:43 We can say yes, there is joint inflammation.

01:47 Next up systemic involvement. Well, we clearly have some other systems involved. There's something going on with our left heel.

01:54 There's something going on with her right eye.

01:56 But it's a little early for us to say whether or not she has systemic involvement because otherwise the review of systems wasn't too revealing. More on that later.

02:06 Which of the following is the most likely diagnosis? Rheumatoid arthritis, a spondyloarthritis, not otherwise specified.

02:17 Osteoarthritis, a Crystalline arthropathy or lupus? Well, let's look back at the case. So 26 years old, Rheumatoid arthritis, she's got the right gender; it is more common in women.

02:30 It's a little unusual to start at age 26, but absolutely reasonable.

02:35 And the fact that she has morning stiffness, well, that's a classic feature of any of this autoimmune inflammatory arthrophatis, her age, like I said, a bit young.

02:45 Normally with rheumatoid arthritis, you're going to have more upper extremity symptoms, particularly involving the hands, the wrists, the PIPs, etc. That's a little unusual. We're not seeing any of that.

02:57 In terms of rheumatoid arthritis in the back you don't typically rheumatoid arthritis having anything to do with the low back.

03:03 Next up on our differential is spondyloarthritis the topic of this lecture.

03:08 Her back does seem to be the primary problem.

03:12 I'll remind you that the word spondylosis comes from the ancient Greek word for vertebrae. So anytime we're talking about the spondyloarthritides, we’re thinking about involvement of the axial skeleton, particularly the low back.

03:24 Moreover, she's having morning stiffness which again, supports an inflammatory arthropathy. Her age is actually spot on for something like ankylosing spondylitis, for example.

03:35 And the fact that she has some extra articular manifestations, maybe something going on with her left heel may also fit with one of those diagnoses.

03:44 I will mention however, it is more common in males, maybe a 2 to 3 to 1 ratio but that's certainly not a deal breaker.

03:53 Next up osteoarthritis or some sort of degenerative joint disease I mean, low back pain is extremely common as a degenerate joint disease.

04:02 That being said, all the extra articular stuff that we're talking about and particularly that taking an hour to get going in the morning.

04:09 Those things are not typical of osteoarthritis or degenerative disease of the spine.

04:14 Her age, that's the biggest ding against Osteoarthritis.

04:17 She's 26 you don't get osteoarthritis 26 years old, so I think that one's really going to fall off of our list.

04:23 Next up a Crystalline athropathy like gout or CPPD.

04:28 That would be a fantastically rare cause of lower back pain.

04:32 I have once seen it involve the cervical spine, but those are very rare birds. Moreover, 26 year old woman will be almost unheard of for her to get gout or CPPD.

04:44 Next up is lupus. Well, in favor of lupus. She is 26 and she is a woman.

04:50 Remember the gender ratio for lupus is about 9 to 1 in favor of women she meets the demographic. the extra articular stuff maybe suggest a systemic illness of which lupus is a classic systemic illness.

05:02 The arthritis though tends to be more peripheral with lupus rather than involving the lumbar spine. That's counting against lupus.

05:11 Alright, so going back to our list here, we can definitely take off osteoarthritis and crystalline athropathy. But we're still kind of left with rheumatoid arthritis, lupus and spondyloathropathy even though spondyloarthritis is the most likely diagnosis.

05:27 Let's do a physical exam, get some blood work and see if that'll help us out.

05:30 She's a febrile, heart rate 76, blood pressures okay.

05:36 She does have some evidence of right eye conjunctival injection.

05:41 More on that later. No Lymphadenopathy cardiopulmonary exams is pretty benign abdomens benign, neurologic exam is benign.

05:49 Then moving on to her musculoskeletal exam.

05:51 She has decreased range of motion of her lumbar spine with lateral flexion and forward flexion.

05:59 She's tended to palpation over her bilaterals sacral iliac joints and she has slightly warm, tender swollen left heel at the insertion of the achilles tendon, skin and nail exam Oh, she's got a bunch of tattoos but otherwise it's normal.

06:14 Then looking at her blood work, mild anemia with hemoglobin of 10.4 white counts okay.

06:20 Rheumatoid factor is negative. Her NTCCP antibody is also negative.

06:25 ESR 51. CRP is mildly elevated and her ANA is completely negative.

06:31 You might ask at this point, whether it be reasonable to check an HLA b 27 haplotype. Knowing that we're considering the spondyloarthropathy. Of note, HLA b 27 is present in about 7% of North American Caucasians compared with 90% of patients who are diagnosed with ankylosing spondylitis.

06:52 So it can definitely be a helpful piece of information.

06:55 While ankylosing spondylitis is the disease most associated with HLA b 27.

07:00 About 50% of patients with the other axial spondyloarthritides will also have that haplotype.

07:07 Alright, going through a few key features of this exam, so the right eye conjuctival injection, something like ankylosing spondylitis or any of the other spondyloarthritides you'll commonly see eye involvement shown in the top here is conjunctivitis, which would be the most common manifestation but you can have much more significant pathology like anterior uveitis as shown in this picture. This is going to increase our likelihood of having a spondyloarthritis.

07:34 Next up the fact that the bowels are normal that's going to steer us away from an enteropathic arthritis which is one of the subtypes of spondyloarthritides. The decreased range of motion of the lumbar spine.

07:45 Well remember, Ankylosing from the word ankylosing spondylitis literally means disease of bending. So we're going to do some tests to try and see how well she can bend her spine and there's a classic test called the schober’s test. So here's the Schober test.

08:03 The way it's performed is you're taping a tape measure to the back of somebody's spine, and then you're drawing two lines on the patient's lumbar spine. By having the patient lean forward you expect those two lines to move farther apart.

08:15 But in somebody who has trouble bending forward that is someone with ankylosing spondylitis.

08:19 The excursion of those two lines may be less than 10 centimeters and contrast for a normal spine it should be more than 15 centimeters.

08:27 So that's a quick overview of the schober test.

08:29 The fact that our patient has decreased range of motion of the lumbar spine as well as tenderness to palpation on those bilateral Sacroiliac joints, that is definitely steering us towards an axial spondyloarthritides.

08:43 Next up the swollen left heel, now you might start thinking about rheumatoid arthritis because that can have rheumatoid nodules.

08:52 But the rheumatoid nodule should be painless and it really should just be a firm integrated area rather than swelling and tenderness the way she's describing it. So this sounds more like enthesitis which is inflammation at the insertion of a tendon or ligament into bone which again is suggestive of a spondyloarthritides.

09:13 Finally, really putting the nail on the coffin for rheumatoid arthritis or lupus, our serologic testing is completely negative rheumatoid factors negative the ANA is negative. And if you needed more evidence the NTCCP antibody is also negative ESR being 51 is just a nonspecific inflammatory marker. And same thing goes with the CRP.

09:33 And just to highlight a little bit further about enthesitis and fasciitis, both things that we oftentimes see with the spondyloarthritides.

09:40 Enthesitis is inflammation at the insertion of a ligament into bone.

09:45 And shown here in this picture on the bottom left is a picture of the adductor muscles inserting into the femur and you can see that whitish area there is basically edema in the tendon insertion. Likewise on the right side images there we have MRI evidence of fasciitis in this case the plantar fascia.

10:04 On the top left image, there is a picture of the calcaneus which is where the plantar fascia will insert into the calcaneus tubercle.

10:12 There's thickening and some edema in the plantar fascia at that site.

10:18 Okay, so which of the following is the most likely diagnosis? Well, for ankylosing spondylitis, I mentioned there is a two to three to one male predominance, but again not a deal breaker. She has progressive back pain, which is typical, possibly with some evidence of a peripheral arthritis and this concern about the achilles ethesitis would certainly be suggested, or stiffness absolutely supports this diagnosis. And the fact that she has evidence of some conjunctivitis or worse is definitely supportive as well.

10:50 So we're going to leave this one on our list.

10:53 Next up is psoriatic arthritis. Well, this can definitely involve the back though more commonly, you're also going to have wrist involvement, with DIPs which she was not reporting the stiffness goes along with it. But most importantly 80% of patients who have developed psoriatic arthritis already have some evidence of plaque psoriasis some cutaneous manifestations well before they developed arthritis.

11:17 So I think we can safely take that went off the table as well.

11:21 Reactive arthritis This is most common in young men but can also occur in women, particularly in the setting of sexual promiscuity. And Oligoarthritis is typical would may be accompanied by conjunctivitis it seems like it's going to have to stay on our list for now as well.

11:40 Now for the last one enteropathic arthritis the last of those four types of spondyloarthritis you need to have inflammatory bowel disease type symptoms she reports no gastrointestinal symptoms, so that one is immediately X out.

11:55 Alright, so let's take a look at some imaging which will hopefully make the final diagnosis for us. First up, we've got some plane radiographs of the lumbar spine first a AP film and then a lateral film on the far right by looking at these films and we can see a loss of the normal lumbar lordosis. We have active inflammatory osteatis particularly of L4 and L5 vertebrae with some early squaring of the vertebral bodies in particular and that film on the far right, you can see these bridging syndesmophytes between the individual vertebrae sometimes called bamboo spine. Then on our MRI of the Sacroiliac joints. We're seeing contrast enhancement particularly in the right SI joint, shown on this film with these two arrows with some early erosions as well. Okay, at this point the diagnosis is clear. Our girl rocker has ankylosing spondylitis