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A Patient With Back Pain and Morning Stiffness

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 44-year-old White man presented with a 15-year history of dull midline lower back pain associated with bilateral hip pain. He also noted bilateral hand pain along the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints and prolonged morning stiffness lasting approximately 45 minutes. Family history was notable for a brother with osteoarthritis, hypogonadism, and type 2 diabetes.

Vital signs were within normal limits (heart rate, 92/min; blood pressure, 136/84 mm Hg; respiratory rate, 16/min; oxygen saturation, 97%; temperature, 37.0 °C). Musculoskeletal examination revealed swelling of the second, third, and fifth MCP joints and second and third PIP joints bilaterally as well as decreased knee and hip range of motion with minimal knee effusions. Lower back flexion was decreased with only 4-mm excursion on the modified Schober test. Results of cardiopulmonary, abdominal, neurologic, and dermatologic examinations were unremarkable.

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Hereditary hemochromatosis

A. Check ferritin and transferrin saturation

The key to the correct diagnosis is the combination of osteoarthritis affecting atypical sites and pronounced inflammatory symptoms.1,2 The symmetric polyarthritis, prolonged morning stiffness, and effusions are consistent with inflammatory arthritis. However, imaging revealed findings consistent with osteoarthritis, such as asymmetric joint space narrowing with hook-like osteophytes in the MCP joints as well as subchondral sclerosis and osteophyte formation in the hips.

Radiographs showed sacroiliac joint sclerosis. However, rheumatoid arthritis (choice B) rarely affects the sacroiliac joints. The patient also reported back pain, which, along with the radiographic finding of sacroiliac joint sclerosis, is consistent with spondyloarthropathy. However, sacroiliac joint sclerosis is nonspecific, and spondyloarthropathy alone would not explain advanced degenerative changes elsewhere.2 Therefore, magnetic resonance imaging of the sacroiliac joint (choice C) is unlikely to be useful. Orthopedic surgery consultation (choice D), in anticipation for joint replacement, may be considered after confirming the diagnosis.

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Article Information

Corresponding Author: Sameet Sangha, MD, MPH, Division of Immunology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242 (Sameet-Sangha@UIowa.edu).

Published Online: August 27, 2020. doi:10.1001/jama.2020.6261

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share his information.

References
1.
Sahinbegovic  E , Dallos  T , Aigner  E ,  et al.  Musculoskeletal disease burden of hereditary hemochromatosis.   Arthritis Rheum. 2010;62(12):3792-3798. doi:10.1002/art.27712PubMedGoogle ScholarCrossref
2.
Chevalier  X , Dougados  M , Jammet  P , Amor  B .  Sacroiliitis in hemochromatosis  [in French].  Ann Med Interne (Paris). 1990;141(2):199-200.PubMedGoogle Scholar
3.
Bacon  BR , Adams  PC , Kowdley  KV , Powell  LW , Tavill  AS ; American Association for the Study of Liver Diseases.  Diagnosis and management of hemochromatosis: 2011 practice guideline by the American Association for the Study of Liver Diseases.   Hepatology. 2011;54(1):328-343. doi:10.1002/hep.24330PubMedGoogle ScholarCrossref
4.
Odufalu  FD , Harris  K .  Hemochromatosis? when bloodletting is not the cure: a teachable moment.   JAMA Intern Med. 2017;177(1):15-16. doi:10.1001/jamainternmed.2016.5872PubMedGoogle ScholarCrossref
5.
Carroll  GJ , Breidahl  WH , Bulsara  MK , Olynyk  JK .  Hereditary hemochromatosis is characterized by a clinically definable arthropathy that correlates with iron load.   Arthritis Rheum. 2011;63(1):286-294. doi:10.1002/art.30094PubMedGoogle ScholarCrossref
6.
Carroll  GJ , Breidahl  WH , Olynyk  JK .  Characteristics of the arthropathy described in hereditary hemochromatosis.   Arthritis Care Res (Hoboken). 2012;64(1):9-14. doi:10.1002/acr.20501PubMedGoogle ScholarCrossref
7.
Kowdley  KV , Brown  KE , Ahn  J , Sundaram  V .  ACG Clinical Guideline: hereditary hemochromatosis.   Am J Gastroenterol. 2019;114(8):1202-1218. doi:10.14309/ajg.0000000000000315PubMedGoogle ScholarCrossref
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