Case for Discussion

Case for Discussion: December, 2013

Mr MJ, a 24-year-old male presented to the OPD with a history of severe pain in the heels and Achilles from past 6 months. The pain, lasting for more than 30 min, was worse in the morning. Resting and prolonged standing caused severe pain. No history of injury and sedentary work was reported. Around 2 years back, the patient had transient knee pain.  However, it relieved on NSAID treatment after 6 months. He was moderately built with normal vital parameters. The result of joint examination was normal. Both the heels were tender with mild swelling. Back examination was normal. Results of clinical and lab investigations are given in table 1.

 

Table 1: Results of clinical and lab investigations

Parameters evaluated

Findings

Hemoglobin

13.7 

Total WBC count

5570 

Neutrophils

49.4 

Basophils

0.2 

Lymphocytes

36.4 

Eosinophils

8.4 

Monocytes

5.6 

ESR (Westergren's method)

9

Platelet count

2.14 

RBC count

4.2 

Random blood sugar

89 

S.G.O.T [A.S.T ]

21 

S.G.P.T [A.L.T ]

22 

Creatinine (kinetic Jaffe)

0.9

C-reactive protein (quantative immunoturbidimetric method)

1.49

ANA immunofluorescence (1:40 dilution)

Negative

Haematocrit (PCV)

38.9 

M.C.V

92.2 

MCH

32.5 

MCHC

35.2 

RDW

12.2 

Total bilirubin (modified Jendrassik)

0.7

Direct bilirubin (modified Jendrassik)

0.2

Indirect bilirubin

0.5 

Alkaline phosphatase (kinetic)

62

Gamma GT

15 

Total protein

6.9 

Serum albumin

4.4 

Globulin

2.5 

AG ratio

1.8 

Colour

Pale yellow 

Appearance

Clear 

Hepatitis'C'virus antibody (rapid)

Non reactive

Human immunodeficiency virus 1and 2 (rapid)

Non reactive

Rheumatoid factor assay (quantitative immunoturbidimetry)

<6.7

Reaction

6.5 (acidic) 

Specific gravity

1.010 

Protein

Negative 

Sugar

Negative 

Ketone bodies

Negative 

Urobilinogen

Normal 

Bile pigment

Negative 

NIT

Negative 

Leucocytes

2-3/hpf 

RBCs

Absent 

Epithelial cells

Occasional 

Casts

Absent 

Crystals

Absent 

Hepatitis b surface antigen-HBSAG (rapid)

Non reactive

 

Discussion

Enthesitis of heel could be suspected in the current case due to the presence of disabling heel pain with substantial rest stiffness. This is one of the common conditions in active young patients and poses a diagnostic and management dilemma. It is significant to differentiate whether the condition is non-inflammatory (enthesopathy) or inflammatory (enthesitis). The presence of clinical features of inflammation like rest pain, improvement of pain after movement, and the presence of tenderness and/or swelling indicated the possibility of inflammatory enthesitis.

Enthesitis, defined as the inflammatory changes of an enthesis, is a characteristic finding in spondyloarthropathies (SpAs). Enthesis refers to the insertion of a tendon, ligament, capsule, or fascia into bone and it encompasses the inserted structure and the bone. The importance of enthesitis relative to synovitis, subchondral marrow inflammation, and osteitis in ankylosing spondylitis (AS) is debated. The different conditions that can cause pain in entesis include rheumatic disorders,  spondyloarthropathies,  rheumatoid arthritis,  chondrocalcinosis osteoarthritis, diffuse idiopathic skeletal hyperostosis, metabolic and endocrine disorders, hyperparathyroidism, hypothyroidism, hypoparathyroidism, X-linked hypophosphatemia, acromegaly, hemochromatosis, ochronosis, familial hypercholesterolemia, diabetes mellitus, chronic renal failure, and entesitis caused by drugs (fluoride, fluoroquinolones glucocorticosteroids, and retinoids). 1

Enthesitis is the primary clinical feature of spondyloarthritis. Pelvic enthesitis has a high specificity for confirming SpA and it can be diagnosed by MRI of sacroiliac joints.2 The hallmarks of peripheral SpA are the development of enthesitis, most typically of the Achilles tendon and plantar fascia, and new bone formation.3 Enthesopathy is more common in subjects with  untreated celiac disease and positive anti-tissue transglutaminase antibodies titre when compared to those on gluten-free diet and absence of serum anti-tissue transglutaminase antibodies titre.4 The anterior chest wall (ACW) pain was seen in 45% of patients with complaints of inflammatory back pain (IBP). In patients with IBP suggestive of SpA, presence of ACW pain is associated with enthesitis, thoracic spine involvement, radiographic sacroiliitis, diagnosis of AS, and with a more severe disease. ACW pain could be interpreted as a diagnostic feature for AS.5 It is common finding in rheumatic diseases namely AS and Behcet's disease. Musculoskeletal complaints are common in patients with familial Mediterranean fever (FMF), and these could be one of the clinical manifestations of enthesopathy.6-9 In a case series from India, 7 out of 11 patients with a typical presentation of Reiter's syndrome had enthesitis as one of their presentations.10 As per another series published from India, the most common sites of enthesitis were chondro-sternal junction (30%) and Achilles tendonitis (24.3%).11 In enthesitis of elderly gout is one of the possibility.12

 

 Thus in the presence of persisting enthesitis of heel, after excluding the possibility of post-traumatic enthesitis, it is important to rule out other differential diagnoses. . The pain may be disabling and need attention and appropriate identification X-ray of the pelvis was done in the current case to exclude sacroilitis (Fig 1.) X-ray of the heel of Achilles may indicate calcification at bony insertion suggesting enthesitis. Ultrasound examination or MRI imaging is recommended if associated tenosynovitis on neighbouring joints is suspected. Presence of conditions like hypercholesterolemia, hypothyroidism and other metabolic causes also needs be explored.

In the present case, the sacroilitis was asymptomatic. The patient was HLA B 27 negative with normal inflammatory parameters. However, the patient cannot be categorised to have seronegative SpA, since he fulfilled the criteria of ESSG criteria only partially. The radiological features of sacroilits and enthesitis may assist in diagnosing ankylosing spondylitis in those who do not have inflammatory back symptoms. Although radiological features are present according to the New York criteria, the case cannot  be categorized as AS since clinical features are absent. However, managing the patient with NSAID may help to improve the symptoms.

 

Table 2: Comparison of two criteria of seronegative SpA

ESSG Criteria

Amor Criteria*

Inflammatory spinal pain or synovitis and one of the following:

Inflammatory back pain

1 point

Alternating buttock pain

Unilateral buttock pain

1 point

Enthesitis

Alternating buttock pain

2 points

Sacroiliitis

Enthesitis

2 points

IBD

Peripheral arthritis

2 points

Positive family history of SpA

Dactylitis (sausage digit)

2 points

 

Acute anterior uveitis

2 points

 

HLA-B27 –positive or family history of SpA

2 points

 

Good response to NSAIDs

2 points

*Diagnosis of SpA with 6 or more points.

European Spondyloarthropathy Study Group (ESSG); IBD = inflammatory bowel disease; NSAID = nonsteroidal anti-inflammatory drug 

Table 3:  New York criteria for diagnosing ankylosing spondylitis

New York criteria

Radiological criterion

·         Sacroiliitis at least grade 2 bilaterally or grade 3 or 4 unilaterally.

Clinical criteria

·         Low back pain and stiffness for more than 3 months that improves with exercise but is not relieved by rest.

·         Limitation of motion of the lumbar spine in both the sagittal and frontal planes.

·         Limitation of chest expansion relative to normal values correlated for age and sex.

All reasonable measures should be taken to ensure that symptoms are due predominantly to ankylosing spondylitis and that alternative causes, including spinal fracture, disc disease and fibromyalgia, are excluded.

 

Fig 1: X- ray of pelvis indicating grade II sacroilitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References:

1.      Slobodin G, Rozenbaum M, Boulman N, Rosner I (2007) Varied presentations of enthesopathy. Semin Arthritis Rheum 37: 119-126.

2.      Jans L, van Langenhove C, Van Praet L, Carron P, Elewaut D, Van Den Bosch F, et al. Diagnostic value of pelvic enthesitis on MRI of the sacroiliac joints in spondyloarthritis. European radiology. 2014;24(4):866-71.

3.      Jacques P, Lambrecht S, Verheugen E, Pauwels E, Kollias G, Armaka M, et al. Proof of concept: enthesitis and new bone formation in spondyloarthritis are driven by mechanical strain and stromal cells. Annals of the rheumatic diseases. 2014;73(2):437-45.

4.      Atteno M, Costa L, Cozzolino A, Tortora R, Caso F, Del Puente A, et al. The enthesopathy of celiac patients: effects of gluten-free diet. Clinical rheumatology. 2014;33(4):537-41.

5.      Wendling D, Prati C, Demattei C, Loeuille D, Richette P, Dougados M. Anterior chest wall pain in recent inflammatory back pain suggestive of spondyloarthritis. data from the DESIR cohort. The Journal of rheumatology. 2013;40(7):1148-52.

6.      Tufan A, Mercan R, Tezcan ME, Kaya A, Bitik B, Ozturk MA, et al. Enthesopathy in patients with familial Mediterranean fever: increased prevalence in M694 V variant. Rheumatology international. 2013;33(8):1933-7.

7.      Sudol-Szopinska I, Cwikla JB. Current imaging techniques in rheumatology: MRI, scintigraphy and PET. Polish journal of radiology / Polish Medical Society of Radiology. 2013;78(3):48-56.

8.      Sudol-Szopinska I, Kontny E, Maslinski W, Prochorec-Sobieszek M, Warczynska A, Kwiatkowska B. Significance of bone marrow edema in pathogenesis of rheumatoid arthritis. Polish journal of radiology / Polish Medical Society of Radiology. 2013;78(1):57-63.

9.      Sudol-Szopinska I, Urbanik A. Diagnostic imaging of sacroiliac joints and the spine in the course of spondyloarthropathies. Polish journal of radiology / Polish Medical Society of Radiology. 2013;78(2):43-9.

10.  Kanwar AJ, Mahajan R. Reactive arthritis in India: a dermatologists' perspective. Journal of cutaneous medicine and surgery. 2013;17(3):180-8.

11.  Aggarwal R, Malaviya AN. Clinical characteristics of patients with ankylosing spondylitis in India. Clinical rheumatology. 2009;28(10):1199-205.

12.  Taniguchi Y, Matsumoto T, Tsugita M, Fujimoto S, Terada Y. Spondylodiscitis and Achilles tendonitis due to gout. Modern rheumatology / the Japan Rheumatism Association. 2014.