Clinical Manifestation and Diagnosis of Ankylosing Spondylitis / 대한내과학회지

Ankylosing spondylitis (AS) is the main disease entity within spondyloarthritides. AS patients can present with both articular and extra-articular manifestations. Especially, inflammatory back pain has been recognized as the main symptom of AS, however it should be noted that mechanical back pain could also ensue in advanced cases. Peripheral arthritis mostly involves in lower extremities in the form of asymmetric oligoarthritis. Enthesitis could develop in the heel, iliac crest, anterior tibial tuberosity, or anterior chest wall. As for imaging, plain radiographs are used to assess the presence or degree of sacroiliac joint and spinal involvement. Magnetic resonance imaging (MRI) is useful in detecting non-radiographic sacroiliitis, for its ability to delineate bone marrow edema. In this regard, MRI has recently been incorporated as a modality to help diagnose axial spondyloarthritis (2010 ASAS classification). Early diagnosis of AS should be based on the combination of clinical, laboratory, and imaging findings, not on solely structural changes.

The Concept and Overview of Spondyloarthritis / 대한내과학회지

The spondyloarthritis (SpA) is a group of chronic inflammatory rheumatic diseases in association with HLA-B27. They share the clinical features including sacroiliitis, spondylitis, oligoarthritis, enthesitis and extra-articular involvement. Recently ASAS proposed new classification criteria sets of axial and peripheral SpA. They were designed to include non-radiographic SpA, thus can guide the early diagnosis of disease before the structural damage occurs. SpA has a strong genetic predisposition. Non-MHC genes, such as IL23R and ERAP1, as well as HLA-B27 were confirmed as susceptibility genes through several GWAS. Major pathology in SpA is entheseal inflammation and new bone formation. Intrinsic ability of HLA-B27 to trigger innate immune response and several proinflammtory cytokines may contribute to the inflammation in SpA. New bone formation could be explained by a mechanism, partly or completely independent of the inflammatory process.

Patología inflamatoria de columna en niños y adolescentes / Inflammatory spine pathology in children and adolescents

Chronic inflammatory axial pain is an uncommon pediatric syndrome, brings a number of diseases affecting the axial skeleton. It is characterized by unknown etiology, with recognizing genetic susceptibility factors. The medical clinician should be performed to establish the diagnosis, making accurate therapy for long-term success and working to get a good quality of life. Current classifications established for children and young patients forms are limited by the pediatric medical short follow-up age. Two international classifications (a) International League of Associations for Rheumatology and (b) Classification of juvenile spondyloarthropathies Spondylarthropathy European group Study Group to achieve approximate diagnosis for pediatric rheumatology forms. The adult rheumatologist usually who will establish the definitive diagnosis and prognosis. The chronic inflammatory axial pain needs an unification of classification criteria for children and adults in order to facilitate the scientific communication and medical transition.

El dolor axial inflamatorio crónico es una entidad infrecuente en Pediatría, y agrupa una serie de patologías que afectan el esqueleto axial. este grupo de enfermedades son de etiología aún desconocida, reconociendo factores de susceptibilidad genética en ellas. Su importancia está en el enfoque que el clínico debe realizar para establecer el diagnóstico, realizar una terapia precoz para obtener buenos resultados a largo plazo y procurar que el paciente obtenga una buena calidad de vida. Las clasificaciones actuales establecidas para las formas infantojuveniles se ven limitadas por lo breve del periodo de seguimiento etario, además que se hace necesario aplicar dos clasificaciones internacionales (a) International League of Associations for Rheumatology y (b) Clasificación de Espondiloartropatías Juveniles del European Spondyloarthropathy Study Group para lograr el diagnóstico aproximado. Es necesario considerar que en muchos casos será el reumatólogo de adultos quien establecerá el diagnóstico y pronóstico definitivo. Se reconoce que este grupo de patología inflamatoria crónica requiere unificación de criterios de clasificación en niños y adultos para facilitar la comunicación científica y de transición.

A Case of Ankylosing Spondylitis with Follicular Lymphoma

Several autoimmune and chronic inflammatory conditions have been consistently linked with an increased risk of hematologic malignancies. Although ankylosing spondylitis (AS) is a chronic inflammatory disease, previous studies have demonstrated that it is not associated with an increase in risk of malignant lymphomas. Cases of AS accompanied by hematologic malignancies such as multiple myeloma, chronic myelogenous leukemia, and Hodgkin's disease have been reported. In Korea, AS with non-Hodgkin's lymphoma or follicular lymphoma has not been reported. We experienced a 38-year-old male who had been diagnosed with follicular lymphoma with bone metastasis, who achieved complete remission after having been treated with chemotherapy, developed new inflammatory back pain. An MRI of his hip showed an active inflammation of the left sacroiliac joint and a positive HLA-B27. The patient was diagnosed with AS and was treated with naproxen, which improved the pain in his back and buttock.

Diagnostic Approach in Patients Presenting with Inflammatory Back Pain

OBJECTIVE: To investigate the etiologic diseases of inflammatory back pain (IBP) and to propose a diagnostic algorithm for approaching the patients with IBP. METHOD: One-hundred-and-forty patients with IBP visiting the clinic for spinal disorders were involved. Clinical features of spondyloarthropathy (SpA) through medical records, presence of intervertebral disc disease, sacroiliitis and degenerative spondylosis through plain radiography and magnetic resonance image (MRI) of spine and pelvis, HLA B27 positivity, and quantitative laboratory results of acute phase reactant were retrospectively reviewed. RESULTS: Diverse spinal disorders were indentified as etiologic diseases for IBP that were SpA (44 patients), diffuse idiopathic skeletal hyperostosis (DISH) (15 patients), degenerative spondylosis (15 patients), HLA B27 associated IBP (14 patients), lumbosacral radiculopathy (4 patients), and others (48 patients). When onset age was less than 45 years, the most frequent cause was SpA. When onset age was more than 45 years, DISH and degenerative spondylosis were the most frequent causes. Onset age (p=0.002), age at presenting to clinic (p=0.001), number of items satisfying IBP criteria (p=0.001), HLA B27 positivity (p=0.000), and elevated acute phase reactant (p=0.002) were statistically associated with SpA. CONCLUSION: The relative frequency among various etiologic disease of IPB is different depending on the onset age of IPB. Onset age of IBP, numbers of items satisfying IBP criteria, and laboratory test for HLA B27 and acute phase reactant can be useful factors for determining the causes of IBP, especially for diagnosing SpA. Diagnostic algorithm for approaching the patients with IBP is proposed according to the sensitivity and specificity of the factors which have statistically meaningful relationship with diagnosis of SpA.