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?
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Filed under: Uncategorized, USMLE STEP III QUESTION BANK, USMLE Test Prep | Tagged: Archer Rheumatology, USMLE step 3 Rheumatology |
Archer USMLE Step 3 Blog 
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HLA27
Mri
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HLA 27
C hla B27
Anticcp
HLA B27
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A- ankylosing spondlytis
Hla b27
Mri
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MRI
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Anti ccp
C suspecting of ankylosing spondylitis
Mri
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C. HLA-B27
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C suspecting of ankylosing spondylitis
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.
●STEP THREE: Patients with fewer than four SpA features and without radiographic sacroiliitis should undergo HLA-B27 testing.
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C. HLA-B27 testing