Inflammatory Spondyloarthropathy with Extra-Articular Manifestations
This 28-year-old requires urgent rheumatology referral for suspected axial spondyloarthropathy (likely ankylosing spondylitis) with extra-articular manifestations of uveitis and peripheral arthritis. The combination of inflammatory back pain in a young adult (worse in early morning, improved with activity), acute anterior uveitis (red eyes without discharge), and peripheral joint involvement (knee swelling) represents a classic triad requiring immediate specialist evaluation and MRI imaging. 1
Key Diagnostic Features Present
This patient demonstrates multiple red flags for inflammatory spondyloarthropathy:
Age and symptom pattern: Back pain onset before age 45 with duration exceeding 3 months, worse in early morning (difficulty attending classes before 8-10 AM), and improved with exercise rather than rest—these are cardinal features of inflammatory back pain 1
Extra-articular manifestations: Red eyes without discharge strongly suggests acute anterior uveitis, occurring in 25-40% of patients with axial spondyloarthropathy 1
Peripheral arthritis: Knee pain with swelling indicates type 1 peripheral arthropathy (asymmetric, affecting weight-bearing joints), which typically parallels intestinal or axial disease activity 1
Morning stiffness duration: The inability to function before 8-10 AM implies morning stiffness lasting well over 30 minutes, a specific criterion for inflammatory back pain 1
Immediate Actions Required
Urgent Rheumatology Referral
Refer immediately to rheumatology without waiting for imaging results. The presence of acute uveitis constitutes a medical urgency requiring ophthalmology evaluation within 24-48 hours to prevent vision-threatening complications. 1
Diagnostic Imaging Protocol
Order MRI of the complete spine (cervicothoracic and thoracolumbar regions with T1 and STIR sequences) plus coronal/oblique sacroiliac joints with T1 and STIR sequences without contrast. Plain radiographs will miss early disease in the majority of cases, and this patient's age and symptom duration make early axial spondyloarthropathy highly likely. 1
- MRI demonstrates high sensitivity and specificity for detecting sacroiliitis and spinal inflammation before radiographic changes appear 1
- Do not wait 6 weeks for conservative management given the extra-articular manifestations and inflammatory pattern 1
Laboratory Testing
Order HLA-B27 testing immediately. HLA-B27 has 90% sensitivity for axial spondyloarthropathy, provides a post-test probability of 32%, and only requires testing three HLA-B27 positive patients to diagnose one case. 1
- ESR and CRP have only 50% sensitivity and are inadequate for screening, though elevated levels predict worse prognosis 1
- HLA-B27 positivity is less common in IBD-associated axial arthropathy but remains diagnostically valuable 1
Treatment Approach Pending Specialist Evaluation
Symptomatic Management
Initiate NSAIDs at therapeutic doses as first-line treatment. NSAIDs are more effective than simple analgesia for inflammatory back pain and represent the cornerstone of initial therapy. 1, 2
- Naproxen 500mg twice daily is appropriate, as it has demonstrated efficacy in ankylosing spondylitis with decreased night pain, morning stiffness, and pain at rest 2
- Short-term NSAID use is safe if inflammatory bowel disease is excluded or in remission 1
- Avoid systemic corticosteroids for axial symptoms, as they lack efficacy 1
Activity Modification
Advise the patient to remain active and engage in regular exercise, particularly extension exercises and physiotherapy. Unlike mechanical back pain, inflammatory back pain improves with movement and worsens with rest. 1
- Early physiotherapy referral can prevent long-term disability 1
- Avoid prolonged morning inactivity; encourage gentle stretching and movement upon waking 1
Peripheral Arthritis Management
For the knee swelling, consider local corticosteroid injection if symptoms don't resolve rapidly with systemic treatment. Type 1 peripheral arthropathy typically responds to treatment of underlying disease activity. 1
Critical Pitfalls to Avoid
Do not dismiss this as mechanical back pain based on age alone. While pediatric and young adult back pain is common, the specific pattern of inflammatory symptoms, extra-articular manifestations, and morning predominance distinguish this from overuse injuries. 1
Do not order plain radiographs of the spine and sacroiliac joints as initial imaging. Radiographs have only 80% sensitivity and specificity for sacroiliitis and will miss early disease, delaying diagnosis by months to years. 1
Do not wait for "failed conservative management" before imaging. The presence of inflammatory symptoms and extra-articular manifestations bypasses the usual 6-week conservative trial required for mechanical back pain. 1, 3
Do not prescribe muscle relaxants or benzodiazepines. These medications lack efficacy for inflammatory back pain and carry significant risks. 1
Prognosis and Long-Term Considerations
Axial spondyloarthropathy has a disabling long-term course if diagnosis is delayed. Early diagnosis and treatment with anti-TNF agents are often necessary, as sulfasalazine and methotrexate are ineffective for axial disease (though sulfasalazine may help peripheral arthritis). 1
The acute uveitis requires immediate ophthalmology evaluation and typically responds to topical corticosteroids, but recurrence is common and may necessitate systemic immunosuppression. 1
HLA-B27 positivity predicts worse prognosis and increased likelihood of requiring biologic therapy. 1