Case report

A 24 year old man presented with acute swelling of the right ankle. Two weeks before presentation, he had been given a booster tetanus toxoid vaccination. Within a few days of the injection, he felt pain and noticed swelling of the right ankle. The swelling and pain worsened, such that at presentation he was walking with a pronounced antalgic gait. There was no preceding history of trauma, infection, or any past history of psoriasis, iritis, inflammatory bowel disease, or inflammatory back pain. There was no family history of ankylosing spondylitis.

Three years previously he had presented to another rheumatologist with acute synovitis of the left ankle, mid-foot, metatarsophalangeal joint of the left big toe, and tenosynovitis of the long flexor of the right middle finger. This was associated with conjunctivitis and chlamydial urethritis, with raised levels of chlamydia-specific IgG. His plasma viscosity was raised at 1.69 mPa.s; haemoglobin was 139 g/l, rheumatoid factor negative, and HLA-B27 positive. Plain radiographs of the left …