Question of the week # 480

A 32-year-old man comes in regularly because his back hurts. You suspect malingering because he continually requests narcotic pain relievers and imaging studies of his spine. He has come 5 times in the last 6 months with the same problem, typically stating that the pain improves with exercise and leaning forward but is worse at night; pain also occurs at times in his buttocks and does not improve with rest. On physical examination you find no abnormalities of the spine besides inflexibility of the lower spine when he leans forward. Neurological examination is normal, including the absence of pain on a straight-leg raise test. X-ray of the spine and sacroiliac joint is normal. All blood tests including rheumatoid factor, ESR, and C-reactive protein are normal. Today, he again claims to have only minimal improvement with ibuprofen. He is requesting narcotics and a “doctor’s note to get out of work.” What is the next best step in management?

A. MRI of the sacroiliac joint
B. Anti-cyclic citrullinated peptide (anti-CCP)
C. HLA-B27 testing
D. Methotrexate
E. Report to employer for malingering

29 Responses

  1. “A”

  2. A

  3. HLA27

  4. Mri
    A

  5. HLA 27

  6. C hla B27

  7. Anticcp

  8. HLA B27

  9. C.

  10. A- ankylosing spondlytis

  11. Hla b27

  12. Mri

  13. E

  14. MRI

  15. E

  16. C

  17. C

  18. Anti ccp

  19. C suspecting of ankylosing spondylitis

  20. Mri

  21. A

  22. C. HLA-B27

  23. C

  24. C suspecting of ankylosing spondylitis

  25. Ankylosing spondylitis (AS) is characterized by involvement of the spine and sacroiliac (SI) joints;
    ●Age of onset <40 years
    ●Insidious onset
    ●Improvement with exercise
    ●No improvement with rest
    ●Pain at night (with improvement upon arising)
    ●Buttock pain, especially alternating between the two sides, may be indicative of SI involvement

    There are no laboratory tests that are by themselves diagnostic of axSpA, although two types of tests can contribute to making the diagnosis. These include
    ●HLA-B27 testing
    ●Acute phase reactants –The erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) are useful for monitoring disease activity, if they are elevated at baseline of treatment
    —Imaging studies are extremely important in the diagnosis of axSpA.

    ● All patients with AS show significant changes in the plain radiographs of the sacroiliac joints in the form of erosions or fusion. Because disease progression is slow, unless changes are suspected, it is not necessary to repeat radiographs of the vertebrae more than once every two years.
    ●In patients with sacroiliitis documented by plain radiography, additional imaging, such as an MRI, is not necessary for diagnosis; however, in patients in whom plain radiographs do not reveal sacroiliitis or findings are uncertain, and when there is a high index of clinical suspicion of SpA, abnormal findings on MRI are an important part of making the diagnosis of nr-axSpA This is because MRI, unlike plain radiographs, can reveal inflammatory changes, fatty changes, and subtle structural abnormalities.
    2013 Assessment of SpondyloArthritis International Society (ASAS) modified Berlin algorithm
    ●STEP ONE ● (AP) plain radiograph of the pelvis

    ● STEP TWO: In patients who are not positive for sacroiliitis by plain radiography of the pelvis , ascertained; a patient with at least 4 of the 11 SpA features
    •Inflammatory back pain (IBP)
    •Heel pain (enthesitis)
    •Dactylitis
    •Uveitis
    •Positive family history for SpA
    •Inflammatory bowel disease
    •Alternating buttock pain
    •Psoriasis
    •Asymmetric arthritis
    •Positive response to nonsteroidal antiinflammatory drugs (NSAIDs)
    •Elevated acute phase reactants (ESR or CRP)

    ●STEP THREE: Patients with fewer than four SpA features and without radiographic sacroiliitis should undergo HLA-B27 testing.

  26. ●STEP THREE: Patients with fewer than four SpA features and without radiographic sacroiliitis should undergo HLA-B27 testing.

  27. C

  28. a

  29. C. HLA-B27 testing

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