Diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department

The onset of tuberculous spondylitis is insidious in nature, with various clinical presentations, slow development of radiographic abnormalities, and nonspecific constitutional symptoms. This lack of specific symptoms causes delays in diagnosis. Magnetic resonance imaging demonstrates osteitis, intraosseous abscesses, paravertebral and epidural soft tissue extensions and abscesses, discitis, multilevel involvement of spinal cord or nerve root compression, and scoliosis. We present six patients with tuberculous spondylitis referred to our outpatient department with back pain resistant to medical therapy. All of them were women aged from 25 to 58 years (mean 44.6). The diagnosis of tuberculous spondylitis was based on clinical presentation, radiographic and/or MRI evidence of focal destructive vertebral lesions (with paravertebral mass), and positive bacteriological findings of Mycobacterium tuberculosis. The combined antituberculous chemotherapy consisted of 1.0 g/day streptomycin for 1 month, 25 mg/kg ethambutol or 25 mg/kg pyrazinamide, 600 mg/day rifampicin, and 300 mg/day isoniazid. The duration of therapy was 12 months. All the patients recovered without any sequelae. The mean follow-up period was 28 months (range 12–48). Magnetic resonance imaging is considered the main imaging modality for patients with suspected tuberculous spondylitis; it must be included in differential diagnosis of back pain and, if it is diagnosed in early stages, antituberculous chemotherapy enables satisfactory outcome.     

Ankylosing spondylitis in rheumatology patients in Ouagadougou (Burkina Faso)

The aim of this work was to study ankylosing spondylitis (AS) prevalence and its clinical, radiological and genetic features in Ouagadougou. This was a cross-sectional study over two first years of rheumatologic practice (March 2006 to March 2008). All the patients having AS met the modified criteria of New York. HIV serology was negative. Thirteen cases of AS (0.9%) with 11 men were diagnosed among 1,439 rheumatologic patients. The average age of the patients at the beginning of the disease was 27.1?±?11.5 years. Bath Ankylosing Spondylitis Disease Activity Index and Bath Ankylosing Spondylitis Functional Index mean scores were, respectively, 47.8/100 and 44.46/100. No patient had presented extra-articular manifestations. Four (31%) patients had hip joint involvement. HLA B 27, among 11 patients, was positive in six (55%). Semiological features of AS among patients seen in Ouagadougou were similar to those of white race. HLA B27 prevalence in AS patients of Burkina Faso was similar to those of Afro-Americans.     

Ankylosing spondylitis and trauma: the medicolegal implications. A comparative study of patients with non-specific back pain.

Ankylosing spondylitis (AS) arising as a result of injury was reported by five of 113 hospital patients who completed questionnaires on the historical and symptomatic features of their disease. Identical questionnaires were given to a group of 51 patients with non-specific back pain (NSBP) attending an orthopaedic clinic. Five of these patients developed their first symptoms after trauma. A further four patients with ankylosing spondylitis believed that their disease was initiated by injury, however, x-ray photographs showed that they had already developed AS at the time of their injuries. It is suggested that injury does not cause AS but brings it to the patient's attention, possibly through immobilisation, in 7% of hospital cases.     

Ankylosing spondylitis associated with osteoporosis and vertebral deformity

Summary We report a 56-year old man with ankylosing spondylitis associated with osteoporosis and vertebral deformity.     

Ankylosing spondylitis associated with vitiligo: a case report

 Vitiligo is a very common disease and is suspected to be autoimmune in its pathogenesis. Many autoimmune complications, such as Hashimoto's thyroiditis, are reportedly associated with vitiligo. The pathogenesis of ankylosing spondylitis (AS) is also suspected to be autoimmune, triggered by some infection. We report a 56-year-old man with concurrent vitiligo and AS, and suggest that both diseases could have a common autoimmune background. Received: September 5, 2001 / Accepted: April 4, 2002 Correspondence to:M. Mukai     

Ankylosing spondylitis and the shoulder: commonly involved but infrequently disabling

OBJECTIVE: To undertake 2 independent studies of shoulder involvement in patients with ankylosing spondylitis (AS) and assess the frequency of shoulder pain, stiffness, and loss of movement and function. To evaluate and correlate shoulder symptoms, function, range of movement, and radiology. METHODS: A cross sectional design was used in both studies. In Study A, a self-administered questionnaire was sent to members of the National Ankylosing Spondylitis Society of the UK and patients attending the Royal National Hospital for Rheumatic Diseases. In Study B, a clinical assessment of 88 patients with AS was undertaken that included a radiological assessment of 26 consecutive patients. RESULTS: In Study A, 15.2% and 13.8% of subjects had severe/very severe shoulder pain or stiffness, respectively. In Study B the corresponding findings were 9.6% and 17.6%. Patient reported disability associated with shoulder involvement was uncommon. Study A revealed that patients with severe/very severe shoulder pain were more likely to have significant hip and knee involvement. Significant shoulder involvement appears to be as common as involvement of the hip joint. In Study B radiological changes were common, being present in 31% of patients, but were often minor. There was a significant correlation between the sum of the stiffness, abduction, and flexion scores for both shoulders and the total radiological score (r = 0.87; p<0.001). CONCLUSION: The results suggest that shoulder symptoms and loss of shoulder mobility are common in patients with AS, and correlate with higher pain scores and influence of AS on their lives as assessed by the Arthritis Impact Measurement Scale, but are rarely disabling. Involvement of the shoulder joint in AS correlates with involvement of other peripheral joints as well as the extent of radiographic change on shoulder radiographs.     

Performance of referral recommendations in patients with chronic back pain and suspected axial spondyloarthritis

BACKGROUND: Ankylosing spondylitis (AS) and its early form account for up to 5% of all patients with chronic back pain. Interest has recently focused on shortening the delay of 5-10 years between the appearance of first symptoms and the diagnosis of AS, particularly because effective treatments have now become available. Referral parameters that are easy for doctors in primary care to apply to patients presenting with possible AS could contribute to earlier diagnosis. METHODS: Orthopaedists and primary-care doctors were requested to refer patients with (1) chronic low back pain (duration >3 months) and (2) onset of back pain before <45 years of age to a specialist rheumatology outpatient clinic for further diagnostic investigation if at least one of the following screening parameters was present: (1) inflammatory back pain, (2) positive human leucocyte antigen B27, and (3) sacroiliitis detected by imaging. The final diagnosis was made according to expert opinion. RESULTS: In total, 350 referred cases were analysed. A diagnosis of definite axial spondyloarthritis (axial SpA), comprising established AS and pre-radiographic axial SpA, could be made in 45.4% of all referred patients (of which 50.3% were classified as AS and 49.7% as preradiographic axial SpA), whereas 45.4% were classified as non-SpA and 9.1% as possible SpA. A diagnosis of definite axial SpA could be made in 34.2% if only one referral parameter was positive, and in 62.6% if there was >1 positive referral parameter. CONCLUSIONS: The proposed referral parameters have proven useful when applied in primary care in identifying patients with AS/pre-radiographic axial SpA among young to middle-aged patients with chronic low back pain.     

Ankylosing spondylitis: a contemporary perspective on diagnosis and treatment

OBJECTIVES: In recent years, great progress has been made in the development of diagnostic tools, therapeutic approaches, and validated outcome measures in the understanding of the pathogenesis of ankylosing spondylitis (AS). The purpose of this review was to summarize these developments. METHODS: We performed a PubMed search for the period 1978 to 2005, using the keyword, "ankylosing spondylitis," resulting in a total of 4878 publications, including 778 reviews. Articles were then selected based on their discussion of recent diagnostic tools and new treatment approaches in the pathogenesis of AS, leading to a final total of 104 articles. RESULTS: In recent years, there have been 2 major developments in the management of AS that make earlier diagnosis possible and offer the hope of alleviating pain and preventing structural changes that result in loss of function. These developments include the use of magnetic resonance imaging to visualize the inflammatory changes in the sacroiliac joint and the axial spine, and the demonstration that tumor necrosis factor blocking agents are highly efficacious in reducing spinal inflammation and possibly in slowing radiographic progression. CONCLUSIONS: There have been major advances in both the diagnostic tools and the therapeutic regimens available for patients with AS.     

Relationship between diagnosis delay and disease features in Moroccan patients with ankylosing spondylitis

We aimed to evaluate diagnosis delay and its impact on disease in terms of activity, functional disability, and radiographic damage in Moroccan patients with ankylosing spondylitis (AS). We recruited 100 Moroccan patients who fulfilled New York Classification criteria for AS. Diagnosis delay was defined as the interval between the first symptom of AS and the moment of a correct diagnosis. Disease activity was evaluated by the bath ankylosing spondylitis disease activity index (BASDAI), functional status by the bath ankylosing spondylitis functional index (BASFI), and radiographic damage by the bath ankylosing spondylitis radiologic index (BASRI). Measurements of spinal mobility were assessed. The average age at disease onset was 28.56 ± 10.9 years. Of the patients, 16% had juvenile-onset AS. Disease duration was 9.5 ± 6.8 years, and the average of diagnosis delay was 4.12 ± 3.99 years. There were no differences in diagnosis delay according to the age at onset, educational level, or the presence of extra-articular involvement. Our patients had altered functional ability. Patients with late diagnosis (>5 years) had statistically significant higher structural damage (BASRI) and severe limited spinal mobility. There was no correlation between diagnosis delay and the activity of disease. Few studies focused on diagnostic delay and its impact in patients with AS. It is necessary in our context to establish an early diagnosis taking into account the high frequency of severe functional disability in Moroccan AS.     

The direct healthcare costs associated with ankylosing spondylitis patients attending a UK secondary care rheumatology unit

OBJECTIVES: To explore the direct healthcare resources associated with ankylosing spondylitis (AS) in the UK. A secondary objective was to establish if resources, and thus healthcare costs, vary by disease severity. METHODS: Medical records of 147 sequential AS patients attending a UK secondary care rheumatology unit were examined to assess the direct healthcare resources used over the previous 12 months. Starting with a detailed inventory and measurement of resources consumed, unit cost multipliers were applied to the quantity of each type of resource consumed. The mean cost per patient was estimated using the total cost divided by the number of patients included. RESULTS: The mean (median) annual cost per patient was 1852 pounds sterling (892 pounds sterling). The distribution of cost data was skewed, with 11% of patients incurring 50% of the total costs. The three most relevant cost domains were physiotherapy, hospitalization and medication costs at 32, 21 and 20% of the total costs, respectively. Twenty percent of the patients received physiotherapy, 13% received inpatient care and almost all incurred medication costs. Thirty-four percent of patients were prescribed disease-modifying anti-rheumatic drugs and 85% non-steroidal anti-inflammatory drugs. Over 50% of patients had at least one comorbidity. CONCLUSION: Direct costs accelerate steeply with disease activity (Bath Ankylosing Spondylitis Disease Activity Index >6.0) and increasing loss of function (Bath Ankylosing Spondylitis Functional Index >6.0) in patients with AS. The most severely affected patients incur 50% of the total costs, and physiotherapy accounts for 32% of the total healthcare costs in the UK.     

Weather changes and pain in rheumatology patients

Objective: Many rheumatology patients report exacerbation of joint symptoms with weather changes. We report the first of a two‐part study on the influence of weather on rheumatological conditions. This survey aims to describe perceived weather sensitivity in our patient population. Methods: Two hundred rheumatology patients seen consecutively in a tertiary hospital were given a 10‐item questionnaire (Jamieson). This questionnaire has been well validated with good test‐retest reliability (r = 0.91) and ability to distinguish patients with weather sensitivity. New patients and soft tissue clinic patients were not included. Results: Seventy‐four percent of patients reported weather sensitivity, with humidity and low temperature reported most frequently as being associated with worsening of symptoms (66% and 72%, respectively). Seventy percent of weather sensitive subjects described pain exacerbation prior and/or during weather changes. Various rheumatological conditions had similar rates of weather sensitivity, except fibromyalgia which reported 100% weather sensitivity. Conclusion: A significant proportion of rheumatology patients report weather sensitivities. Further studies would be useful to further explore actual versus perceived effects of weather as this may have behavioural, housing and medical implications. Our discussion includes a brief summary of current literature and various postulates why patients may have increased weather sensitivity.     

Low back pain: cost-effective diagnosis and treatment

This systematic approach to low back pain limits the use of imaging studies and surgery. The natural history of this condition and its resolution show that such modalities are best restricted to a minority of patients.