A typical presentation of ankylosing spondylitis with acute anterior uveitis and cutaneous rash: a case report

Ankylosing spondylitis (AS) is a chronic inflammatory spondyloarthropathy predominantly affecting the axial skeleton. Extra-articular manifestations such as acute anterior uveitis may precede prominent musculoskeletal symptoms, making early diagnosis challenging. We report an atypical presentation of AS initially dominated by cutaneous and ocular manifestations. A case of a 24-year-old male presenting with cutaneous rash, acute ocular symptoms, and subsequent musculoskeletal manifestations was evaluated through clinical assessment, immunological investigations, and magnetic resonance imaging (MRI). The patient initially presented with generalized rash, eye redness, pain, photophobia, and blurred vision and was diagnosed with anterior uveitis. Seven days later, he developed left foot pain and swelling, low backache, and neck pain. Detailed history revealed intermittent inflammatory back pain for four months and a maternal family history of ankylosing spondylitis. Rheumatoid factor, anti-CCP antibodies, and ANA were negative, while HLA-B27 was positive. MRI demonstrated sacroiliitis, along with subtle marrow edema and minimal joint effusions in the left foot. Based on the clinical, laboratory, family history, and imaging findings, ankylosing spondylitis with extra-articular manifestations was diagnosed. Treatment with naproxen, sulfasalazine, exercise, physiotherapy, and subsequently tofacitinib resulted in improvement of back pain and foot swelling, with complete resolution of the rash and anterior uveitis. Acute anterior uveitis and cutaneous manifestations may precede characteristic axial symptoms in ankylosing spondylitis. Recognition of this association and appropriate use of HLA-B27 testing and MRI can facilitate early diagnosis and treatment.