A 40 years old man admitted to our ward due to multiple joint pain and relapsing fever for more than 6 months.

The patient was quite well until 6 months ago he began to notice pain with swelling over bilateral knee joints, left ankle joint and fusiform swelling over the 2^nd and 3^rd digit of his right hand. 1 month before this admission, he started to complain lower back pain with morning stiffness. In addition, hyperkeratotic skin lesions were found over both hand and feet. Deformed and exfoliated nails were also noted over toes of both feet. 2 weeks before these episode, he was suffered from dysuria after an extramarrital sexual contact.

After admission, physical examination revealed mild hyperremic conjunctiva, a shollw-based ulcer was found over his tongue. No lymph nodes were palapble, swelling and local heat of bilateral knee joints. Tenderness along margin of sternum and achill tendon.Shallow ulcer was found in his glans penis but the patient did not ever noticed and no discomfort was complained at the time of examination.Lung and cardiovascular system is unremarkable. Erythematous and hyperkeratotic skin lesions were noted over both palm and sole with scattered lesion in his lower abdomin.

< Laboratory data>

Complete blood count:
WBC: 9680/ul, RBC: 3240000 /ul, Hb: 10.2 g/dl. Platelet: 490000/ul
Biochemistry:
BUN: 12.7 mg/dl, Cr: 0.92 mg/dl, Na: 138 mmol/l, K: 4.62 mmol/dl, AST:36u/l ALP: 32 u/l; Uric acid: 9.6 mg/dl
Hematology:
ESR: 68/1 hour, Ferritin: 786 ng/ml (normal range: 17.9 – 464), Iron: 22 ug/dl (51-180), TIBC: 390 (275-332)
Immunology:
CRP: 24 mg/l (<6.00), RA factor: -, HLA-B27:+,
microbiology: blood culture all negative culture.
                        microbiology: blood culture all negative culture.
Image study:
Unilateral sacroilitis, Gr II/IV, right side
L spine: unremarkable finding
Both knee joint: soft tissue swelling.