CASE 1

A 25 year old male has a 6 months history of progressive lower back pain.  It began slowly without prior trauma and it is associated with stiffness and pain, particularly in the second portion of the night.  He will awaken and need to get up and move around for a period of time before he can return to bed.  In the morning, he has prolonged morning stiffness of his back, particularly in the buttock region.  The pain will sometimes radiate down towards the posterior knee but never below it and sometimes alternate from one side to the other.  He prefers to walk around at work rather than sit at his desk.

1) Which of the following is likely the source of his pain?

CASE 2

A 30 year old female has new onset joint pain and swelling in her right index finger, left wrist, and left ankle of 3 weeks duration.  There was no antecedent trauma.  She is in good health without any other medical problems.  She travelled to Central America for an extended period of time and just returned 2 months ago.  She developed an episode of what she presumed was traveler’s diarrhea that was associated with fevers, chills, crampy abdominal pain and loose stools.  Her symptoms resolved after a week.  Other companions on the same trip also developed similar symptoms.  She has tried naproxen 220mg BID with some improvement. 

On exam, she is afebrile with normal vital signs.  General exam is normal.  Joint exam reveals dactylitis of her right index finger, swelling in her left wrist, and medial left ankle which is   painful on inversion against resistance. 

Laboratories:  ESR of 45mm/hr; CRP of 30mg/L (normal <10mg/L); WBC of 13,000 cells/mm3; hgb of 14 gm/dL and hct of 40%. Creatinine, LFTs and urinalysis are normal.

2) What is the most appropriate next step in management of this patient?

CASE 3

A 22 year old previously healthy male developed unilateral uveitis that was treated with topical steroids successfully. 3 months later, he develops onset of left knee pain and swelling that is associated with prolonged morning stiffness that gradually improves by noon. He also notes chest wall pain with inspiration and bilateral heel pain. He denies any rashes, diarrhea or mouth ulcers. There is family history of an uncle with Crohn’s disease.

Physical exam reveals normal vital signs.  The general exam is normal.   The chest wall is tender at the costochondral junctions. Musculoskeletal exam reveals moderate size left knee effusion that is warm and limited range of motion. The ankles are normal but there is point tenderness and swelling of bilateral Achilles insertion at the retrocalcaneal region.

3) The most likely diagnosis is:

4) Psoriatic arthritis has a wide range of clinical features that are clinically present in other spondyloarthropathies. The one feature that is unique and characteristic in psoriatic arthritis is:

Tumor necrosis factor alpha inhibitors (TNFi) are the predominant class of biologic medications used to treat ankylosing spondylitis, psoriatic arthritis, and inflammatory bowel disease when more traditional medications are ineffective.  The decision to use these medications includes assessing risk factors.

5) Which of the following would be a contraindication to starting a TNFi?