Morning Stiffness, Dry Eyes, Back Pain in a Fit 58-Year-Old

Kristine M. Lohr, MD, MS; Muhammad Sohail Khan, MD


November 10, 2022

Extra-articular/extraskeletal manifestations of axial spondyloarthropathy/ankylosing spondylitis include:[1]

  • Cardiac: Aortic insufficiency (2%-6%), ascending aortitis, and other manifestations, such as conduction abnormalities (3%-5%), diastolic dysfunction, pericarditis, and ischemic heart disease (30%)

  • Neurologic: Atlantoaxial (C1-2) subluxation (2%), cauda equina syndrome from spinal arachnoiditis, traumatic spinal fractures with myelopathy (C5-6, C6-7 most commonly), ossification of the posterior longitudinal ligament with spinal stenosis

  • Kidney: Secondary amyloidosis, IgA nephropathy (5%), chronic prostatitis

  • Skin: Psoriasis (10%) and, to a lesser extent, erythema nodosum, keratoderma blennorrhagicum, and pyoderma gangrenosum

  • Pulmonary: Upper lobe fibrosis, restrictive changes

  • Ocular: Acute anterior uveitis (20%-30%)

  • Discitis or spondylodiscitis (Andersson lesions)

In addition, 30%-60% of patients have asymptomatic microscopic colitis or Crohn's disease–like lesions in their terminal ileum and colon, although overt inflammatory bowel disease occurs in only 7% of patients with axial spondyloarthropathy. Patients with peripheral arthritis are more likely to have colitis lesions.

In the differential diagnosis of axial spondyloarthropathy/ankylosing spondylitis, other conditions to consider include:

The patient in this case did not have any personal history or physical examination findings of psoriasis. Her family history was also negative for psoriasis.

The onset of reactive arthritis is usually acute. Patients typically present with an asymmetric oligoarthritis, usually 1-4 weeks after the inciting infection. In at least half of patients, all symptoms resolve in less than 6 months; in most patients, symptoms resolve within 1 year. It would be atypical for reactive arthritis to persist and worsen over the course of 18 months, as this patient's symptoms did.

The patient does not have any history suggestive of inflammatory bowel disease. Moreover, the results of a recent colonoscopy were normal. Finally, she does not have typical stigmata of SAPHO syndrome: synovitis, acne, pustulosis, hyperostosis, or osteitis.

The prevalence of spondyloarthritis (SpA) reported worldwide widely varies, depending on the genetic background in the country or region under study and, to a certain extent, on the criteria used by the surveyors. The prevalence rate for SpA is about 0.9%-1.7%; peripheral SpA accounts for approximately 25% of the total.[1] Reactive arthritis is the least common form of SpA.

The major clinical features that differentiate SpA from other forms of arthritis are the distribution and type of musculoskeletal manifestations and certain extra-articular features. Patients with axial SpA characteristically have chronic low back pain. Patients with peripheral SpA can exhibit peripheral musculoskeletal features, which include dactylitis (sausage digits), enthesitis (heel pain and/or swelling), and peripheral arthritis (as the patient in this case had). Patients with peripheral SpA may experience one or more of these peripheral manifestations concurrently or in the past. Patients can also have both axial and peripheral manifestations. Certain extramusculoskeletal manifestations can be associated with the musculoskeletal features seen in SpA, including uveitis, psoriasis, features of inflammatory bowel diseases, and others. Reactive arthritis is sometimes associated with genital lesions. Atypical presentations can include radiographically negative SpA or rapid progression of the disease (as occurred in the patient in this case).

Three physical examination tests are used to assess the severity of sacroiliac and spinal joint involvement in axial spondyloarthropathy:

  • Occiput-to-wall test

  • Chest expansion test

  • Schober test (modified)

The occiput-to-wall test assesses the exaggerated kyphosis in more advanced disease. Normally, with the heels and scapulae touching the wall, the occiput should also touch the wall. The distance from the occiput to the wall represents the magnitude of thoracic/cervical involvement. The tragus-to-wall test could also be used.

The chest expansion test detects limited chest mobility. It is measured at the xiphisternum. Normal chest expansion varies by age and possibly sex, although it is usually abnormal if < 2.5 cm and normal if ≥ 5 cm.

The Schober test (modified) detects limitation of forward flexion of the lumbar spine. Place a mark at the level of the posterior superior iliac spine (dimples of Venus) and another 10 cm above in the midline. With the patient in maximal forward spinal flexion with straight knees, the distance measured between the marks should increase from 10 cm to ≥ 14.5 cm in a young adult man. Other spinal mobility tests will show diminution in lateral flexion and spinal rotation, illustrating that the patient has a global loss of spinal mobility. Lateral flexion is measured by having the patient stand with heels and back against the wall and hands flat on the lateral thighs. The patient bends sideways toward the floor without bending the knees or lifting heels. The difference in the distance of the middle finger between neutral position and maximal lateral flexion is recorded and averaged for the left and right sides.

Imaging studies that are usually helpful in the diagnosis of spondyloarthropathies include axial radiographs, radiographs of peripheral joints, MRI of the sacroiliac joints, and MRI of the spine.


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