Morning Stiffness, Dry Eyes, Back Pain in a Fit 58-Year-Old

Kristine M. Lohr, MD, MS; Muhammad Sohail Khan, MD

Disclosures

November 10, 2022

Physical Examination and Workup

At the current office visit, the patient's vital signs are normal. Six months ago, bilateral tender and hypertrophied bony sternoclavicular joints were noted. The remainder of the physical examination was otherwise unremarkable. By the time of the current office visit, the bilateral sternoclavicular joint swelling has resolved. A new finding is that shoulder abduction is limited to 30-40 degrees. Results of the occiput-to-wall distance test and the chest expansion and Schober tests are normal at the current visit and were normal on the prior visit.

Laboratory tests at the first office visit revealed:

  • Antinuclear antibody (ANA) level: Positive ANA of 1:160 with a nucleolar pattern (reference range, negative)

  • Serum interferon-gamma release assay (QuantiFERON): Negative (reference range, negative)

  • Hepatitis panel: Negative (reference range, negative)

  • C-reactive protein (CRP) level: 13.9 mg/L (reference range, < 10.0 mg/L)

  • Rheumatoid factor level: Negative (reference range, negative)

  • Anti–cyclic citrullinated peptide (anti-CCP) antibody level: Negative (reference range, negative)

  • Erythrocyte sedimentation rate (ESR): 84 mm/h (reference range, 1-20 mm/h for women)

At the initial office visit, a radiograph of the sacroiliac joint was unremarkable, without any erosion (Figure 1). A radiograph of the left shoulder showed mild glenohumeral and acromioclavicular joint osteoarthrosis (Figure 2). A radiograph of the knees revealed mild patellofemoral compartment osteoarthrosis bilaterally, with small to moderate suprapatellar effusions.

Figure 1.

Figure 2.

Laboratory studies at the current office visit show:

  • Human leukocyte antigen B27 (HLA B27) level: Negative (reference range, negative)

  • Anti-DNA antibody, anti-Smith antibody immunoglobulin (Ig)–G, anti-SSA 52 and 60 IgG, and anti-SSB IgG levels: Negative (reference range, negative)

  • C3 complement level: Normal (reference range, 80-160 mg/dL)

  • C4 complement level: Normal (reference range, 15-45 mg/dL)

A synovial biopsy from the right sternoclavicular joint reveals benign cartilage with cystic degeneration but no infection or inflammation.

An MRI shows grossly symmetric periarticular edema about the bilateral sacroiliac joints, most pronounced on the inferior iliac sides (Figure 3). Associated mild erosion is noted along the iliac side. Overall, the findings are most suggestive of active sacroiliitis. No ankylosis of the sacroiliac joint is noted.

Figure 3.

An MRI of the left shoulder reveals extensive supraspinatus and infraspinatus bursal-sided fraying, with articular-sided low-grade fraying and/or tearing of the supraspinatus and infraspinatus proximal to the footprint. In addition, multifocal intrasubstance tearing of the infraspinatus footprint is noted. A moderate amount of fluid is present in the subacromial-subdeltoid bursa. The scan also shows moderate to severe acromioclavicular joint osteoarthrosis, with a laterally downsloping acromion, and mild glenohumeral osteoarthrosis. Labral degeneration, with extensive maceration and fraying of the mid-anterior to anteroinferior labrum, is present.

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