A 46-Year-Old Man With Spine Pain and a Rash

Herbert S. Diamond, MD, MACP

Disclosures

February 26, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 46-year-old white man presents with diffuse musculoskeletal pain and morning stiffness lasting about one hour. Six months ago, he developed a painful, diffusely swollen right fourth toe. The pain was improved with over-the-counter naproxen, but the swelling never completely resolved.

Over the next six months, pain spread to involve his cervical and lumbar spine; he also developed swelling and pain affecting his right wrist and forearm, the left fourth distal interphalangeal (DIP) joint, and the right ankle. In addition, tenderness was reported in the area of the greater trochanter.

His past medical history was positive only for nasal pollen allergies, acne as a teenager, and dandruff for the past five years. His family history is positive for myocardial infarction in his father (at age 49 years), psoriasis, (also in his father), and stage 1 breast cancer in his mother, who was treated with radiation and a lumpectomy, with good outcome to date.

Physical Examination and Workup

A physical examination confirmed swelling in the joints, as well as tenderness in the areas that the patient had described as painful. Erythema and warmth were found over the involved peripheral joints. The remainder of the physical examination was within normal limits except for a nonpruritic, erythematous rash in the intragluteal cleft and multiple patches of a scaly rash on his scalp that had been diagnosed as seborrhea. He had no rashes on the extensor surfaces and no nail abnormalities.

Workup revealed a hemoglobin level of 11.8 g/dL and an otherwise normal complete blood count (CBC). Hepatic and renal chemistry, urine analysis, rheumatoid factor (RF), and antinuclear antibody (ANA) findings were normal. His serum uric acid level was 6.7 mg/dL (normal range ≤7 mg/dL).

Radiographs of the hands revealed soft tissue swelling of the right wrist and forearm without erosions or juxta-articular osteoporosis, and soft tissue swelling and an erosion at the left fourth DIP joint.

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