"Seropositive Rheumatoid Arthritis With Axial Skeleton Involvement In A 17-year-old Female Athlete."

HISTORY: A 17 year old female athlete presented with a 2 year history of neck pain and stiffness radiating down the left arm with intermittent cold sensation, pallor and hyperemia. Symptoms were sporadic and worse with prolonged sitting. She initially presented to a primary care office after a neck injury described as “whiplash” during a volleyball. X-rays and MRI of the neck were negative. She underwent an ultrasound that ruled out a clot. Physical Therapy improved her pain without resolution. PHYSICAL EXAMINATION: Examination of the neck showed limited range of motion (ROM) with extension. There was no pain to palpation over the spinous processes or paraspinal muscles and shoulder. Spurling’s test was negative. Arm pain worsened with Roos' testing. On shoulder exam, there was full ROM and strength. Capillary refill, temperature and pulses were all normal. Allen's test was negative. DIFFERENTIAL DIAGNOSIS: 1. Thoracic outlet syndrome 2. Cervical radiculopathy/cervical disc herniation 3. Brachial plexopathy 4. Complex regional pain syndrome 5. Paget Schroetter syndrome TESTS AND RESULTS: She underwent workup for thoracic outlet syndrome including an MR-angiogram that had questionable low flow at the distal subclavian/axillary vein and artery. Follow up left upper extremity venogram with positional maneuvers was negative. She received OnabotulinumtoxinA injections to the pectoralis minor without improvement. She then underwent hydro-release of the superficial cervical plexus, spinal accessory and dorsal scapular nerves with D5W. This alleviated the radicular symptoms but not the neck stiffness. Due to ongoing stiffness, we repeated MRI of the neck and conducted inflammatory markers screening. The MRI showed joint effusions of the median atlantoaxial joint and left lateral atlantoaxial joint indicating underlying synovitis. Lab workup showed normal CBC with differential, TSH, ESR, CRP, CMP, iron studies, and IgG/A/M. She had positive rheumatoid factor at 19.8 and elevated anti-cyclic-citrullinated-peptide autoantibodies at 114. FINAL/WORKING DIAGNOSIS: Seropositive RA. TREATMENT AND OUTCOMES: She was referred to Rheumatology and started Methotrexate at 20 mg per week resulting in mild improvement of ROM of the neck. Adalimumab was added at 40 mg every other week for synergy.