Another Vacation, Another Bout of Back Pain: A Case

Stephen Paget, MD


July 20, 2016

Patient Profile

A 32-year-old man recently presented with acute onset of severe pain and stiffness in the right knee, hip, and lower back.

Two years earlier, while traveling in Eastern Europe, he had developed an intestinal infection, was hospitalized for 10 days, and was treated with intravenous antibodies and eventually sulfasalazine. At the time, he had acute onset of severe right hip and right knee pain that eventually responded to two injections of steroids into the right hip and one injection into the right knee. It is also of note that the patient's father has a history of human leukocyte antigen (HLA)-B27–related reactive arthritis.

The patient was well until 3 weeks ago, when, after a short business trip to Mexico, he awoke unable to move owing to severe pain in the right hip, right knee, and lower back. Frank synovitis was noted in his knee, and he had bilateral sacroiliac and heel tenderness. His condition did not improve over the next week; he experienced severe pain in both anterior groin areas and severe fatigue, and was found to have an elevated C-reactive protein (CRP) level of 32 mg/L.

He was diagnosed as having another episode of reactive arthritis and restarted treatment with sulfasalazine, which had been given for 2 months during his first episode 2 years earlier. He took two tablets twice a day, along with meloxicam 15 mg daily, with no significant improvement.

For the past 10 days, the patient had severe morning stiffness—particularly in the left shoulder, to the point where he was unable to dress himself—as well as severe right heel, right knee, and right hip pain. He also had pain and stiffness in his upper, mid-, and low back and buttock area, making sleep difficult; it was worse in the morning and improved as the day went on.

The patient was found to have an erythrocyte sedimentation rate of 27 mm/h and a markedly elevated CRP level of 65.5 mg/L. He was told that he was HLA-B27 positive. Other laboratory tests included a normal complete blood count, negative urine polymerase chain reaction probes for chlamydia and gonococcus, normal chemistry screen, normal urinalysis without pyuria, and a negative HIV test. Stool cultures were negative for Salmonella, Shigella, Yersinia, Campylobacter, and Clostridium difficile.

Sacroiliac joint radiographs were normal. The patient denied a history of uveitis; conjunctivitis; urethritis; Achilles tendinitis; or redness, warmth, or swelling of the wrists, hands, ankles, or feet. He had no history of recent diarrhea, fever, or weight loss.


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