Another Vacation, Another Bout of Back Pain: A Case

Stephen Paget, MD


July 20, 2016

Diagnosis and Treatment

I concurred with the diagnosis of a recurrence of reactive arthritis and spondyloarthritis, this time probably triggered by a microorganism acquired in Mexico.

Given the intensity of the patient's fatigue and peripheral joint and axial inflammation, he was placed on prednisone 10 mg twice daily and received one intravenous pulse of methylprednisolone sodium succinate (Solu-Medrol®) 250 mg. The sulfasalazine dosage was increased to 1500 mg twice daily; methylprednisolone acetate (Depo-Medrol®) 40 mg was injected into the patient's right knee and left shoulder; and his nonsteroidal anti-inflammatory drug was switched to sustained-release indomethacin 75 mg twice daily. This led to only moderate improvement in his symptoms, and he continued to be limited in his activities of daily life and could not work. He continued to have an elevated erythrocyte sedimentation rate of 65 mm/h and a CRP level of 50 mg/L. Given the refractory nature of this flare, the patient was placed on methotrexate 25 mg subcutaneously weekly, plus folic acid 1 mg daily.

The inflammatory burden continued despite an increasingly aggressive therapeutic approach over 12 weeks. Therefore, sulfasalazine was stopped and the anti-tumor necrosis factor (TNF) alpha monoclonal antibody adalimumab was started at 40 mg subcutaneously every other week. Within 2 weeks, all of the patient's peripheral, axial, and systemic problems improved and steroids were tapered.

Key Points

The diagnosis of reactive arthritis/spondyloarthritis was based on the following:

  1. Severe, acute, asymmetrical peripheral and axial/sacroiliac joint inflammation after bowel infection in Eastern Europe and a trip to Mexico. An alternative infectious trigger can be via genital transmission of chlamydia (which was not present in this patient).

  2. A family and personal history of HLA-B27–related reactive arthritis and a prior, self-limited episode 2 years before in the setting of an intestinal infection. Episodes of reactive arthritis can be self-limited or evolve from an acute into a chronic episode, in which joint damage and chronic uveitis can occur.

  3. Enthesitis in the form of heel inflammation.

  4. Oftentimes, these episodes are highly inflammatory and refractory, and reflect the innate immune system run amok. Anti-TNF medications have made a huge difference in the outcome of the profoundly phlogistic reactive arthritis.

From a therapeutic point of view, once you have ruled out an active infection or underlying inflammatory bowel disease, you need to up the anti-inflammatory ante as guided by the global inflammatory burden, which is defined by erythrocyte sedimentation rate, CRP level, anemia, thrombocytosis, overt joint inflammation, MRI definition of sacroiliitis, and fatigue/weight loss.

Patients have differing levels of inflammation, and the treatment should befit that fact. One size does not fit all. Some will respond quickly to steroids and nonsteroidal anti-inflammatory drugs, whereas others need to be treated with sulfasalazine, methotrexate, or anti-TNF agents. Disease activity needs to be measured closely to ensure disease control and maintenance of remission.


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