I recently saw a 17-year-old patient whose case caused a lot of people in our local healthcare community to scratch their heads. NJ is a high school senior, a sprinter who holds numerous school records. He had been a perfectly healthy kid until last year, when he began to battle painful plantar fasciitis. He spent a year trying various exercises and ice, bought several pairs of new shoes, and even tried prescription orthotics looking for something that relieved the pain.
Everything seemed futile, as his midfoot and plantar pain progressed to heel pain, which then led to swelling in his heel and Achilles. NJ and his mother assumed that between track, football, and year-round training that he must have injured his foot somewhere.
Frustrated with the lack of improvement, NJ tried physical therapy (no help) and went to see a podiatrist (nothing) before finally ending up in the office of an orthopedic surgeon.
The orthopedic surgeon first tried a series of cortisone injections (no relief) before coming to the conclusion that NJ’s problems were most likely related to heel spurs. And so NJ was scheduled for surgery, where the surgeon moved his inflamed Achilles tendon and scraped the spurs off his heel.
Unfortunately, the surgery was unsuccessful in relieving NJ’s pain, but with school sports season about to begin, NJ felt that he had no choice but to try to live with the pain. He regularly iced his foot after practices and games, and continued to search for that “perfect shoe” that would solve his problems.
A few weeks into his senior year, NJ started having knee and low back pain. NJ, his mother, and his school’s athletic trainer felt that NJ’s knee and low back pain must be due to his favoring his bad foot, and so the trainer tried to realign NJ’s back on a number of occasions to no avail.
Despite all this, NJ managed to play in every football game during his senior season. His mother was convinced that his pain was mostly due to being pushed too hard by his coach and overdoing it on the field. Finally, though, when the pain and swelling had not subsided weeks after the football season ended, NJ went to a different orthopedic surgeon. This surgeon did not feel that an MRI was needed and suggested exploratory arthroscopic surgery to fix what he was convinced would be a torn ligament in the knee.
During the surgery, however, the surgeon saw that something was not quite right. There were no tears in NJ’s knee, but there was a thickened pannus and chronic synovitis. A subsequent biopsy revealed increased plasma cells consistent with inflammatory arthritis.
NJ got lucky. Although the approximate time for new patients in Michigan to see a rheumatology provider can be 6-to-9 months, we were able to get NJ into our office immediately after a desperate call from his surgeon’s physician assistant.
We faced several challenges. NJ was adopted as a newborn, so his family history is limited. We were told that NJ’s biologic mother had a likely family history of RA and possibly psoriasis or eczema.
I asked NJ about any history of rash, and was told that he shaved his head due to a dry flaking scalp. NJ denied any history of uveitis or inflammatory back pain at night. He also denied any regular diarrhea, constipation, inflammatory bowel symptoms, and gastrointestinal infection. He did tell me that he had regular morning stiffness in his foot and knee of at least 45 minutes, and that he constantly battled joint discomfort.
Armed with this information, his history of Achilles enthesitis, and his biopsy results, we diagnosed NJ with undifferentiated spondyloarthropathy. Labs were drawn, and I put NJ on prednisone 10 mg. I asked him and his mother to come back in a week.
At home, I told my teenaged daughters about this handsome young man I had seen in clinic and how worried I was that he had some type of inflammatory arthritis when it dawned on me that I missed an important question. I never thought to ask NJ about his sexual history, which was a huge oversight, a slap-yourself-in-the-forehead type of mistake. It is well documented that reactive arthritis can be caused by common sexually transmitted disease such as chlamydia or gonorrhea,1 and I had missed asking NJ important questions to complete my differential diagnosis.
I called NJ’s mom the next day. I told her that I was concerned about NJ, and that I realized that I forgot to ask if he was sexually active, explaining that that too can cause reactive arthritis. I informed her that most sexually transmitted diseases that lead to reactive arthritis would cause unusual penile discharge.1 She did not seem shocked or offended, telling me she was pretty sure that her son was sexually active but that she would ask. We agreed to meet in a few days to review NJ’s lab results and hopefully put the pieces together.
We got incredibly lucky!
While NJ’s sexual activity turned out not to be linked with his pain, his labs revealed that he carried the HLA-B27 antibody, meaning that he is genetically predisposed to the spondyloarthropathies. While our eventual diagnosis of ankylosing spondylitis could have been made without this genetic clue, it certainly helped to make us more confident in our diagnosis. The flaking of his scalp, at least for now, is being attributed to either psoriasis or simply dry skin.
After we made our diagnosis, we started NJ on sulfasalazine 500 mg delayed release tablets and asked him to slowly taper the prednisone over the next 10 weeks. As there is limited evidence that methotrexate is effective in patients with ankylosing spondylitis2—and I remain concerned about the possibility of NJ getting someone pregnant or drinking excessively—our next option is a biologic.
The fact that we diagnosed NJ early in the disease process is a big plus. Many patients with ankylosing spondylitis remain undiagnosed for years and suffer while searching for answers. Our hope is that we can get NJ into remission and keep him there.
My lesson in this case involves education—both for myself and my fellow healthcare providers. NJ had two senseless knee surgeries, but we are fortunate that his second orthopedic surgeon was aware that there was nothing for him to “fix” when he recognized that the cause of NJ’s swelling was Achilles enthesitis and not an injury or ligament damage.
Iris Zink, MSN, NP, RN-BC is a nurse practitioner at Lansing Rheumatology in Lansing, Michigan, and President of the Rheumatology Nurses Society.
1. Braun J, Kingsley G, van der Heijde D, Sieper J. On the difficulties of establishing a consensus on the definition of and diagnostic investigations for reactive arthritis. Results and discussion of a questionnaire prepared for the 4th International Workshop on Reactive Arthritis, Berlin, Germany, July 3-6, 1999. J Rheumatol. 2000;27(9):2185-92.
2. Chen J, Veras MM, Liu C, Lin J. Methotrexate for ankylosing spondylitis. Cochrane Database Syst Rev. 2013;(2):CD004524.