Saddle Nose Deformity in a Patient with undifferentiated Spondylarthritis:  A Diagnostic Challenge

Case Overview:

36 year old female presented with symmetrical pain, stiffness, and swelling involving her hands, wrists, knees and feet with shoulder impingement and inflammatory back pain.

On review, her sister has ulcerative colitis.

She had some traveler's diarrhea for 4 days upon returning from Mexico Dec 2024, a month prior to presentation.

Exam shows 13 swollen joints and decreased ROM in cervical and lumbar spine. She had dactylitis in her left middle finger. CRP is 61.

She has undifferentiated spondylarthritis with inflammatory back pain, dactylitis, and family history for ulcerative colitis.

Saddle nose is a result of on and off cocaine use for a decade (sober now).  She also gets recurrent sinusitis due to a deviated septum.

No rash or nail changes.

Cardiac normal.

Respiratory normal.

MSK: tender 16 joints, Swollen 13 joints

Started on Methotrexate and prednisone .

Follow-up 1:

• Client completed prednisone course

• Had 4 tender and 2 swollen joint

• Discussed starting Sulfasalazine

Follow-up 2.

• Didn’t start sulfasalazine

• 3 tender and 1 swollen joint

Topic to discuss: Saddle Nose Deformity in a Patient with undifferentiated Spondylarthritis:  A Diagnostic Challenge

Learnings/Clinical Pearls:

Explain that while undifferentiated Spondylarthritis  is a chronic inflammatory arthritis, a saddle nose deformity is not a feature of this and suggests another process. The aim is to explore the differential diagnosis, with a focus on cocaine‑induced midline destructive lesions (CIMDL) and vasculitis.