Case-Based Approach for the Management of Rheumatic Diseases - Episode 1
Transcript: Sergio Schwartzman, MD: Hello and welcome to HCPLive®. Today, we will be discussing a case presentation of nonradiographic axial spondyloarthritis, a relatively new term defined in 2009, which addresses a group of patients who have inflammatory back pain and fulfill criteria for nonradiographic axial spondyloarthritis.
The patient is a 21-year-old woman who presents to a primary care physician with a 3- to 4-year history of back pain, which is worse at night and in the early morning, associated with significant morning stiffness. She had been attributing the pain to being a very active athlete and mentioned that the pain subsided once she started moving around.
She had no significant past medical history or surgical history. On physical exam by the primary care physician, she was noted to have decreased range of motion in her lumbosacral spine, and actually a Schober’s test measurement was 3.5 centimeters. There was some equivocal thickening of her Achilles’ tendon and when asked by the primary care physician, the patient stated that she may have either injured it or had tendonitis in that area in the past, but that it was not bothering her at that time.
The primary care physician recommended ibuprofen to be given, 400 milligrams 3 times a day and also recommended physical therapy. After approximately 4 weeks, the patient stated that she had mild improvement but that the back pain persisted. She noted decreased ability to move her back, and it was beginning to have an impact on her activities of normal daily living. Importantly, she developed abdominal pain, nausea, and vomiting and had to stop taking the ibuprofen. At that point, the primary care physician referred her to a rheumatologist.
The rheumatologist evaluated the patient and likewise confirmed the issue of the Schober’s test measurement being limited—otherwise, noted no other abnormalities. The clinical workup included laboratory test results that were remarkable for 3 abnormalities. The patient had an elevated CRP [C-reactive protein level] of 4.7, normal is less than 3.0, an elevated sedimentation rate of 38, normal is less than 20), and her blood was noted to be HLA-B27 positive. Imaging performed via x-rays of the sacroiliac joints and the spine showed essentially normal results; however, an MRI of the sacroiliac joints did reveal evidence of inflammation without fusion, but there was a possible erosion.
In terms of my initial impression of this patient, it was clear that she had inflammatory back pain, that she developed this at a young age, and that, indeed, the laboratory test results, including the sedimentation rate, the CRP, and, importantly, the HLA-B27 positivity, were very supportive of axial spondyloarthritis. The fact that her x-ray results were normal but the MRI test result was positive, was further support for the diagnosis of axial spondyloarthritis. But since the x-ray results were normal, this is what is now classified as nonradiographic axial spondyloarthritis.
In terms of therapeutic goals for this patient, number 1, patients come to us for relief of pain. So, my first goal would be to relieve her pain. Number 2, patients come to us, also, for improvement in their function. She had begun to have some symptoms that were having an impact on her day-to-day activities. Therefore, my second goal would be a functional goal and have her reach whatever type of function was appropriate for her. And ideally my third goal, which is difficult to achieve, would be to prevent further progression of this disease.
Transcript Edited for Clarity