Working Diagnosis:
Seropositive Spondyloarthritis

Treatment:
Over a course of 4 months trials of medications including sulfasalazine, prednisone, and methotrexate were stopped due to significant side effects. The patient did tolerate hydroxychloroquine with appropriate response. Her joint pain and inflammation improved, and repeat ESR and CRP levels were within normal limits.

Outcome:
The disease-modifying antirheumatic drugs caused significant fatigue, but she was able to gradually incorporate physical activity as her joint pain and swelling improved. She returned to play 2 months after initiating hydroxychloroquine therapy. After her symptoms improved she returned to her previous level of activity after 4 months.

Author's Comments:
The patient is a young female who presented with asymmetric oligoarthritis, dactylitis, and enthesitis following a suspected viral URI during a tennis tournament. As a collegiate-level athlete participating in rigorous training, she was thought to initially have overuse injuries, which lead to a delay in diagnosis. This case highlights the challenges and provider biases in diagnosing a systemic inflammatory disease in a healthy collegiate level athlete, in whom the provider would normally suspect acute and chronic musculoskeletal complaints secondary to injury or overuse. This case also emphasizes the importance of further investigating acute complaints of joint pain and swelling, in order to consider other underlying conditions and to broaden the differential diagnosis.

Editor's Comments:
While there is correlation between the HLA-B27 gene and inflammatory arthropathies, most notably ankylosing spondylitis, it cannot be relied upon for a diagnosis as it is positive in 7% of the general population and can be negative in up to 50% of non-AS inflammatory arthropathies. Spondyloarthritis is considered an umbrella diagnosis for inflammatory arthritis of the spine, the most common of which is ankylosing spondylitis and often is first diagnosed in patients in their teens and twenties. There is often a genetic component, so a careful family history is key. Clues such as "sausage digit" or dactylitis can be a red flag in cases such as this. Unfortunately this case was lost to follow-up during the COVID19 pandemic, and further clarification of the diagnosis is missing. Early diagnosis and treatment of inflammatory arthropathies is critical to limiting disease progression.

While this case lists the diagnosis as Seropositive Spondyloarthritis, seropositive arthritis is typically associated with peripheral inflammatory arthritis, notably rheumatoid arthritis. Spondyloarthritis, or inflammatory arthritis of the spine, is most often seronegative. Unfortunately, most patients with spondyloarthritis present under the age of 30, so consideration of this diagnosis is important in collegiate athletes presenting with unexplainable joint or back pain which is not responsive to typical treatment.

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