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

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


November 10, 2022


The history of the present illness and the physical examination show that the patient has bilaterally tender sternoclavicular joints, along with bony hypertrophy, which is obvious to the naked eye. At the first office visit, 6 months earlier, she also had mild bilateral acromioclavicular joint tenderness. An initial trial of NSAIDs resulted in complete resolution of the sternoclavicular joint swelling. However, the patient developed worsening symptoms of shoulder pain and restriction of range of motion, and MRI findings suggested sacroiliitis. She also had involvement of the peripheral joints, including the left shoulder. The elevated CRP and ESR levels indicate the presence of an inflammatory disease.

The dramatic improvement in this patient's symptoms and joint swelling with the use of NSAIDs makes ankylosing spondylitis the most probable diagnosis. In addition, the MRI of the sacroiliac joints revealed findings suggestive of sacroiliitis, which support this diagnosis. However, this patient's presentation was atypical from the standpoint of the usual progression of ankylosing spondylitis. Typically, the progression takes 4-9 years from the onset of inflammatory back pain until the development of definite radiographic sacroiliitis.

Axial spondyloarthropathy is a chronic, systemic inflammatory disease that affects the sacroiliac joints, spine, and occasionally peripheral joints. Sacroiliitis that is evident on plain radiographs is characteristic of ankylosing spondylitis, which is the more advanced presentation of the disease. Patients who have axial spondyloarthropathy without clear sacroiliitis on plain radiography usually have inflammation detected on MRI. These patients are said to have a "nonradiographic" axial spondyloarthropathy, which may or may not progress over time to definite radiographic sacroiliitis. The Assessment of SpondyloArthritis International Society (ASAS) classification criteria were developed for patients with back pain for more than 3 months and age of onset younger than 45 years in order to identify early disease (ie, no clear sacroiliitis on radiographs). These criteria have a sensitivity of 83% and a specificity of 84% for a patient with axial spondyloarthropathy.

The clinical manifestations of axial spondyloarthropathy usually begin in late adolescence or early adulthood; onset after age 45 years is highly uncommon. It occurs slightly more often in men than in women (2:1). Patients with axial spondyloarthropathy usually present with low back pain and prolonged morning (and often nocturnal) stiffness, which improves with movement and exercise. Buttock pain may initially alternate from side to side before becoming persistent. Physical examination reveals decreased spinal mobility and sometimes enthesitis, scleral injection/photophobia (uveitis/iritis) and, in advanced disease, loss of lordosis, exaggerated kyphosis, and reduced chest expansion due to costovertebral joint involvement. Axial spondyloarthropathy is often more difficult to diagnose early in women as a result of less pronounced clinical features, atypical presentations (peripheral arthritis, cervical spine disease), and possibly slower development of radiographic changes.

Approximately 30% of patients with axial spondyloarthropathy develop a peripheral arthritis. The hips and shoulders (girdle joints) are involved most commonly. Of note, hip involvement in axial spondyloarthropathy is associated with a poor prognosis. Rarely, arthritis of the sternoclavicular, temporomandibular, cricoarytenoid joints, or the symphysis pubis occurs. Involvement of the thoracic costovertebral, sternocostal, and manubriosternal joints may cause chest pain that is worsened by coughing or sneezing.


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