I find it really hard to remember the features of the individual rheumatic conditions because there is so much overlap, so I started making stories for each to try and get it straight in my head. Today’s is Ankylosing Spondylitis, one of the several seronegative spondyloarthropathies that is not massively common (1/100 000) but still important as it has a huge impact on the person’s life, and you might be able to do something about it!
You are a GP in your surgery, and you call for your next patient to come in. Three caucasian males all come limping in and very slowly sit down with a grown on the bed. One of them is 27, the next is his dad, and the third his grandad.
- 3:1 male:female ratio
- Caucasians more affected (higher HLA B27 prevalence)
- Enthesitis (inflammation of tendinous insertions, particularly in the lower limbs)
- Inflammatory back pain with reduced flexion of the lumbar spine
- Family history
- Usually between 20-30 years of age
You take ask them what it is that’s brought them in today.
The first man pipes up, “Well doc, I’ve just been feeling really tired, and this pain in my back has been getting worse and worse on both sides”
- Gradual onset
- Bilateral sacroiliitis
- Fatigue is common early sign (often before any physical symptoms)
You examine him and the first thing you notice is he has one very red eye, as does his father, and grandfather. You ask him when his eye became red, and he said it was when they were cooking sausages on the barbecue and some of the fat spat up into his eye. The father and grandfather nod bashfully.
- Anterior uveitis
- Iritis – typically unilateral
- Sausage fingers – dactylitis
You then continue your exam and notice he’s got a mangled left leg, which you ask about:
“Well doc, I was on my motorbike with my girlfriend Amy, and the engine started coughing and spluttering. Then a valve blew and we crashed, she died and I snapped my achilles and fractured my leg! I lost loads of blood and I’ve been having temperatures ever since – but I’ve lost some weight so that’s good I guess…”
- Main causes of mortality in Ankylosing Spondylitis
- Amy – Renal amyloidosis
- Coughing – Respiratory disease (upper lobe bilateral fibrosis)
- Valve – Cardiovascular (particularly valve disease)
- Achilles – enthesitis particularly affecting insertion of Achilles tendon and plantar fascia (also intercostals)
- Extra-articular features:
- low grade fever
- weight loss