A 47-year-old male patient, diagnosed with AS 25 years ago with a main presenting complaint of gradually progressive neck and back pain. This was associated with morning stiffness, lasting more than 1 hour, affecting his daily activity with limited range of motion and improving on non-steroidal anti-inflammatory drugs (NSAIDs). He had no other joints' involvement, ocular pain, redness or any acute visual disturbance, no shortness of breath, chest pain, abdominal pain, or bowel disturbances. There was no skin rash or lesions. He was not known to have any medical illnesses before. He sought multiple medical advice and was diagnosed with AS based on bilateral sacroiliitis on MRI. He is HLA-B27 positive.
Initially, he was started on methotrexate by a rheumatologist for 1 year hoping that it might help his back pain. There was no significant improvement in his symptoms. Another rheumatologist shifted him to adalimumab 40 mg per 2 weeks due to the persistence of pain and lack of efficacy of methotrexate. He showed significant improvement with adalimumab. Later on, after 2 years of treatment, adalimumab was discontinued, and he was started on etoricoxib 60 mg once daily alternating with celecoxib 200 mg twice daily and topical diclofenac with minimal improvement. Adalimumab was resumed by his rheumatologist after 6 months due to an active disease, patient had considerable improvement and he remained on this regimen with avid exercise with no mentionable changes of complications. He had a flare of his disease in 2011 despite being on adalimumab and he was switched to etanercept 50 mg per week, during this time he suffered from recurrent infections in the form of skin abscesses and recurrent sinusitis. There were episodes of holding the treatment until his infections were cured and then resuming etanercept. His recurrent infections were bothering, and subsequently, he was started on secukinumab 150 mg per week for a total of five loading doses and he did not notice a major improvement in his symptoms then it was increased to 300 mg once monthly in May 2019. Later on, in Nov 2019 and after a total of 11 doses, he presented to an ophthalmologist with cloudy vision and painful red eye. He was diagnosed with the first episode of anterior uveitis. He denied any previous similar complaints or symptoms and after excluding all other infectious causes such as TB, syphilis, and HSV he was started on local corticosteroid eye drops for 2 months. The patient was reluctant to initiate systemic corticosteroid and he was maintained on secukinumab 150 mg once monthly with close monitoring in the clinics. His eye symptoms started to improve by the first week of local treatment and by the fifth week, his uveitis was totally resolved. His disease remained controlled while he was maintained on secukinumab. He showed no major limitations in movement. His C-reactive protein (CRP) was normal. His disease was mainly monitored based on symptoms and other objective measures such as the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). His BASDAI score was 0.9. Physical examination in his last visit in Feb 2020 showed limitation of his lumbar spine flexion with a positive modified Schober test. He also demonstrated mild limitation in lateral flexion, chest expansion, and occiput to wall distance of 5 cm. His medication was maintained even during the era of COVID-19 pandemic and he had no more ocular symptoms.