A 55 year old woman presents with a swollen left knee that started seven months ago and seems to be getting worse. Over the last month she has developed left lower back pain at night and also in the morning that improves with activity. In fact she has no back pain during the day, but her left lower back pain does come back when she sits for a period of time or when she stands long time washing dishes. She does have dry skin but no history of psoriasis. She does admitted to having bowel issues mostly diarrhea and she was told that she may have Irritable bowel syndrome. She also recalls a history of iritis 12 years ago and was told by her ophthalmologist that she should see a rheumatologist but she never did.
She works in a supermarket and is on her feet and active most of the day. She recalls no previous trauma. She has no history of Psoriasis but her father has had psoriasis over the years. Her sister was diagnosed with Crohn’s disease two years ago.
Joint examination is remarkable for moderate left knee swelling with limited range of motion but no evidence of instability. She has tenderness over the left Achilles tendon with mild swelling and minimal tenderness and swelling on the right Achilles tendon as well. She has tenderness over the medial and lateral epicondyles with good range of motion around the elbows. Her Sacroiliac joint on the left side is also tender on examination.
Her serology showed an elevated ESR of 40, CRP elevation of 15. Her ANA was slightly elevated at 1:80 with speckled pattern. Her rheumatoid factor was borderline at 17 but her anti-CCP, and HLA-B27 were both negative.
This patient most likely has all of the following except:
- Spondyloarthritis
- Sacroiliac joint inflammation
- Enthesopathy
- Achilles Tendonitis