Age: 33.0
Sex: M
Vaccine: ANTH, TYP, ANTH, TYP
Symptoms: Arthralgia, Back pain, HLA marker study positive, Musculoskeletal pain, Pain in extremity
Clinical narrative: This is a follow-up to a previously submitted VAERS report 447165-1. Patient developed right lateral ankle pain, as well as intermittent episodes of increased warmth and swelling. At the time, patient was a jogger and thought he might have sprained his ankle while jogging, but does not recall a specific injury or incident. He was deployed at the time and did not seek evaluation, but self treated with Ibuprofen and ALEVE. He denies any preceding GI infections, bites or trauma. By June 2010, patient had returned. He sought evaluation for his right ankle pain and swelling at an Urgent Care Clinic. He had an x-ray taken, which was negative. By July 2010, patient's intermittent episodes of right ankle pain and swelling had resolved, but he was then experiencing similar episodes with his right great toe. He sought evaluation at Urgent Care at a time when his toe was painful, warm, swollen and dark red. He was treated with Indomethacin for presumed gout, but he returned when there was no improvement. He was then prescribed colchicines, still with no improvement. Serum uric acid levels were within normal limits. Patient was referred to an Orthopedic Surgeon. During his two visits with the Orthopedic Surgeon, fluid was aspirated from his joint which had calcium crystals, consistent with pseudogout. After patient's colchicines was increased without symptom improvement, oral steroids were initiated, without significant symptom improvement. By early AUG 2010, patient began experiencing left shoulder pain that increased with movement. Shoulder X-rays and MRI were completed and reported to be negative. During the summer of 2010, patient was also evaluated by a Podiatrist. During his visits, his right great toe metatarsal phalangeal joint was injected with steroids twice, with marked improvement of symptoms, but pain and swelling returned within about 1 week post injections. In SEP 2010, he wore a "boot" and Meloxicam was initiated. In the fall of 2010, patient sought further evaluation with a Rheumatologist. The evaluation included extensive labwork, with HLA-B27 being the only positive serology. The Rheumatologist diagnosed "inflammatory oligoarthritis" and recommended he get a second opinion. Patient sought a second opinion at hospital, with initial visit in FEB 2011. At that time, he was taking Meloxicam 7.5 mg every few days which seemed to improve his symptoms, and the areas that had been affected included his right first metatarsal phalangeal joint, the right first interphalangeal joint and his right ankle, mainly on the lateral aspect. He also had recent involvement of his left first metatarsal phalangeal joint. His pain was ranging between 2-6/10 using pain scale of 0 (=no pain) to 10 (=worst pain ever experienced). After his first visit, the Rheumatologist, Dr. assessed: ..recurrent episodes of mono and oligoarthritis affecting the metatarsal phalangeal, interphalangeal joint of the toe and ankle. His diagnostic history could be consistent with gout. However, he has not had a clinical response to colchicines and an aspiration performed previously did not show evidence of monosodium urate crystals. Another aspiration was done today, which again did not show evidence of monosodium urate crystals. Thus, at the time, we feel that the diagnosis of gout is highly unlikely. Rather we would favor the diagnosis being considered by his rheumatologist which is an oligoarthritis suggestive of something in the spondyloarthropathy family. He is HLA-B27 positive. We agree that use of immunosuppressive medications should be considered at this time. We would be in favor of either sulfasalazine or methotrexate (MTX) to manage this condition long term. We have also recommended regular use of an NSAID, because clearly he is eliciting benefit from this medication. Since his initial evaluation at hospital, patient was followed up monthly since SEP 2011 through APR 2012 (except DEC 2011). In SEP 2011, his Meloxicam 7.5 mg was increased to twice daily and in OCT 2011, MTX 15 mg/week was initiated with folic acid. In NOV 2011, patient was placed on 21-day course of prednisone for increased symptoms affecting great toes, with synovitis and fluid around tendons noted on ultrasound. Late in 2011, patient began complaining of lower back and left hip pain, as well as left posterior shoulder pain. In JAN 2012, patient was complaining of persistent stiffness and pain of his lower back, left hip and right great toe. HUMIRA 40 mg subcutaneously every other week was initiated, with marked symptom improvement. In MAR 2012, patient's residual symptoms included lower back stiffness in the morning, lasting 15 to 20 minutes and left hip stiffness after sitting for prolonged periods. He also recently noted bilaterally wrist pain and swelling and MRI showed ganglion cysts. His diagnosis has been changed to HLA-B27-associated, undifferentiated spondyloarthropathy.