Pôster:

Ankylosing spondylitis has several differentiated phenotypes and usually courses with axial skeletal involvement, lower limb oligoarthritis, enthesopathy and a large number of extra-articular manifestations. New drugs have broadened the therapeutic possibilities for these patients, and the various forms of clinical presentation are a challenge for proper management. Secuquinumab is an immunobiological inhibitor of IL-17A, approved as monotherapy, for the treatment of psoriasis, psoriatic arthritis and ankylosing spondylitis. We present the case of a patient with predominantly axial manifestations, who had a response with secuquinumab, but progressed with worsening of peripheral arthritis and tenosynovitis.

Case report

Male, 32 years old, referred inflammatory low back pain and knees for 1 year, without arthralgia or calcaneodynia, intensified in the last 6 months, becoming incapacitating. The patient made recurrent use of anti-inflammatories, with improvement. He denied personal or family history of psoriasis. Father with ankylosing spondylitis. Physical examination: signs of bilateral sacroiliitis, left knee arthritis and pain on active and passive right shoulder mobilization. Investigations: PCR 8.1 mg / L; HLA-B27 positive; X-ray: sacroiliac sclerosis (mainly left); Magnetic resonance imaging: sacroiliac with bilateral periarticular subchondral bone marrow edema (compatible with active sacroiliitis) and subchondral sclerosis, confirming the diagnosis of predominantly axial ankylosing spondylitis. Prescribed methotrexate and naproxen. After 6 months, without objective improvement, treatment with secuquinumab was initiated. There was an improvement in axial symptoms, but an important worsening of knee pain and the onset of disabling pain in cheirodactyls, ankles and feet. Ultrasonography: erosive synovitis with signs of active microcirculation by Power-Doppler in hands and feet and tenosynovitis in digital left 1st and left ankle flexor tendons (figures 1,2). We opted for prescription of subcutaneous methotrexate, new NSAID cycle and immunobiological maintenance. After 4 months, there was significant clinical and ultrasonographic improvement, maintaining only knee arthritis, for which intra-articular infiltration was scheduled with triamcinolone.

Conclusion

Secuquinumab shows an improvement in activity index and metrics in ankylosing spondylitis. However, it has not yet been possible to determine if there is a direct temporal relationship between improvement of axial and peripheral symptoms or if worsening of peripheral arthritis can occur immediately after initiate treatment. This is due, in part, to the wide variation in clinical profiles of patients with spondyloarthritis, making it difficult to design studies. Thus, we emphasize the need for individualization of the management of these patients.