Diffuse idiopathic skeletal hyperostosis as acause for dysphagia in apatient with ankylosing spondylitis.

Abstract

Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by ankylosing spinal alterations which are often asymptomatic but may typically cause back pain and spinal stiffness. Presence of DISH may complicate spinal trauma and lead to unstable fractures requiring surgical intervention. Treatment options include physical activity, symptomatic treatment, local heat application, and optimization of metabolic comorbidities. Amultimorbid older patient was admitted to the gastroenterological ward for the investigation of progressive dysphagia and weight loss. Gastroscopy revealed adorsal impression of the esophagus at 25 cm from the incisor. Clinical work-up including computed tomography (CT) and magnetic resonance imaging (MRI) ruled out malignancy but showed ankylosing spondylophytes and non-recent fractures of vertebrae C5-C7, compatible with DISH of the cervicothoracic spine as acause for the esophageal impression. Notably, imaging diagnostics showed ankylosing spine alterations extending to the lumbar spine and both sacroiliac joints, suggestive of ankylosing spondylitis (AS). Typical imaging characteristics, ahistory of psoriasis, and positive HLA*B27 status supported the diagnosis of underlying AS in this patient with dysphagia as an unusual primary symptom of DISH. Additionally, pulmonary alterations compatible with ausual interstitial pneumonia (UIP)-like pattern were seen on lung CT. Overlaps among AS, DISH and pulmonary abnormalities including UIP have been described previously; however, they represent unexpected findings in this older patient. This case underlines the importance of interdisciplinary collaboration and consideration of DISH as adifferential diagnosis in patients with atypical symptoms.