A 26-Year-Old With Fever and Malaise Now Can't Tie His Shoes

Jeremy J. Logan, MD; Gautam Dehadrai, MD;  Herbert S Diamond, MD


September 09, 2021


The anteroposterior and lateral radiographs of the spine demonstrated the classic "bamboo-spine" finding seen in cases of ankylosing spondylitis. The images show sclerosis and ankylosis of the vertebral bodies, without loss of disc space. Bone formation extends across the anterior and lateral margins of the intervertebral disks of the lower thoracic and lumbar spine (syndesmophytosis). The sacroiliac joints showed extensive periarticular sclerosis and focal ankylosis.

Ankylosing spondylitis is a chronic inflammatory disorder of multiple articular and para-articular structures that principally involves the axial skeleton. It usually affects the sacroiliac joints and the spinal facet joints of the vertebrae. It sometimes involves the appendicular skeleton as well, including the greater trochanter, patella, and calcaneum.

Other extraspinal manifestations include iritis/uveitis, aortitis and aortic insufficiency, and pulmonary involvement. The basic pathologic lesion of ankylosing spondylitis occurs at the entheses, which are sites at which ligaments, tendons, and joint capsules attach to bone. In the outer layers of the annulus fibrosis of the intervertebral disks, the condition manifests as a formation of new bone.

The name of the disease is derived from Greek; "ankylos" means stiffening of a joint, and "spondylos" means vertebra. The disease is classified as a chronic and progressive form of seronegative arthritis.

Ankylosing spondylitis affects men 4-10 times more frequently than women. Onset of symptoms is most common among those aged 15-35 years. The disease has a strong genetic component. More than 90% of White persons with ankylosing spondylitis have the HLA-B27 gene, as do approximately 50% of African Americans; however, only 1% to 2% of those with this gene of those with the gene develop the disease, as do 15% to 20% of those with a first-degree relative with the disease.[1,2] Some subtypes of the B-27 gene are more strongly associated with the disease than others. Multiple other genes increase the likelihood of developing the illness; however, none are as strongly associated with the disease as the B-27 allele. Environmental factors are also important, with evidence suggesting that gastrointestinal tract bacteria play a role.

Symptoms of ankylosing spondylitis include back pain and stiffness, peripheral joint and chest pain, sciatica, anorexia, weight loss, and low-grade fever. Pain is typically worse in the mornings and improves with exercise. Back pain at night is characteristic. The pain is usually centered over the sacrum but may radiate to the groin, buttocks, and down the legs. The presence of 4 of the following 5 features suggest inflammatory back pain: insidious onset of pain, onset before age 40 years, pain that is worse in the mornings, pain that improves with exercise, and pain that is present at night.

Over time, the back pain may progress up the spine. It may involve the costovertebral joints, leading to pain upon inspiration and restriction of chest expansion and diaphragmatic breathing (observed as ballooning of the abdomen during inspiration). The cervical spine may be ankylosed late in the course of the disease, leading to restriction in neck movement and head rotation. The spine may eventually become completely rigid, with development of kyphosis, leading to a C-shaped spine.[1,2]


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