Ankylosing Spondylitis

A 23 year old male patient was presented to the medical ward with one year history of joint pains. He was mainly complaining of large joint involvement. He complained of back pain, shoulder, elbow, hip and knee joint pains, but there was no small joint involvement. The pain was more in the morning and there was significant morning stiffness.  He was having the symptoms for a long period of time hasn't got any regular treatment up until now.

On examination, he had restricted movements of his spine, but there were no joint deformities. Schoeber's test was positive indicating the presence of significant spinal stiffness. Schoeber's test is performed by marking a spot on the back, at the mid line, at the level of iliac crest. Then two points vertically 10 cm above and 5 cm below this point is marked while the patient is standing. The the patient is asked to bend as much as he can and the distance between the two marked point is measured. A reading less than 5 cm implies spinal stiffness. The reading of this particular patient was only 2 cm. The patient also had reduced chest expansion as a result of costochondral junction involvement (normal chest expansion should be at least 5 cm at the nipple level).

With all these findings, the patient is clinically diagnosed to have ankylosing spondylitis. Three out of four of following clinical criteria should be there to diagnose a patient as having ankylosing songilitis. These clinical features are,

1. Morning stiffness lasting more than 30 min. 
2. Improvement of back pain with movements but not with rest.
3. Awakening because of back pain during second half of the night only
4. Alternating buttock pain.

Ankylosing spondylitis, as the name implies, is a inflammatory disorder of the spine. This is mainly seen among young males who are in their late teen or early twenties. Even though both men and women (2.5: 1) can be affected but symptoms are more prominent in men. The disease has a strong association with HLA B27 gene. These patients are also more susceptible to develop iritis also.

Investigations are performed to confirm the diagnosis.

1. ESR - elevated
• The patient's ESR was 112 mm/1st hour
2. CRP (C reactive proteins) - elevated
• The patients CRP level was 24
3. HLA B 27 testing 
4. MRI - shows sacroilitis before it is seen on X rays
5. X rays 
• X ray lumbar spine
• The fusion of vertebra leads to a
  bamboo spine
• X ray sacroiliac joint
• The following radiograph is taken from our patient. There is sclerosis of either sides of the joint with irregular joint space suggestive of sacroilitis, but there is no ankylosis of the sacroiliac joint.

Ankylosing sondylitis - Sacroilitis

Treatment

• Exercising - Exercising plays a major role in preventing the progression of the disease and improving the symptoms.
• NSAIDs - Sometimes, the pain makes it impossible for the patient to carryout exercises. This is where NSAIDs come in to play. An evening dose of slow releasing NSAID, oral or as a suppository will reveal pain and help in carrying out an active lifestyle and improve sleep.
• Methrotexate is helpful if there is peripheral joint involvement, but will not improve spinal disease.
• Sustained and dramatic reduction of inflammation can be achieved by TNF alpha blocking drugs.
• Rituximab does not help in seronegative arthritis.

Prognosis

The prognosis is good with adequate exercises. Fifty percent of the HLA B27 positive patients have the risk of transmitting the gene to their offspring. Thirty percents of these offspring may get the disease eventually.