Extraspinal Manifestations Research Articles

Distinct clinical outcomes linked to peripheral arthritis and dactylitis in axial spondyloarthritis: findings from a retrospective Irish cohort

IntroductionAxial spondyloarthritis (AxSpA) is a chronic inflammatory condition primarily affecting the axial skeleton. Peripheral features such as peripheral arthritis (PA) and dactylitis are common in AxSpA disease. This study aimed to investigate the independent impact of these manifestations on patient presentation and disease outcomes within an Irish AxSpA cohort.Methods912 Irish AxSpA patients were analyzed in this study. Disease outcomes in patients with and without peripheral arthritis or dactylitis were compared using univariate and multivariate methods. The prevalence of extra-spinal manifestations was further assessed in relation to AxSpA disease duration.Results30.2% of patients reported PA, while 6.6% had dactylitis. PA and dactylitis were strongly linked, with 70% of patients presenting with dactylitis also showing features of PA. Psoriasis was more common in both patients with PA (OR 2.2, P < 0.001) and dactylitis (OR 3.38, P < 0.001). Dactylitis, but not PA was strongly linked to uveitis (OR 2.91, P < 0.001) and inflammatory bowel disease (OR 3.15, P < 0.001), while PA was associated with worse patient functioning and reduced quality of life. PA, but not dactylitis was linked with increased AxSpA disease duration.DiscussionDespite high concurrence of PA and dactylitis in AxSpA patients, each manifestation is independently associated with worse outcomes. While some of these overlapped, several outcomes are specific to either PA or dactylitis. Due to its strong association with uveitis and inflammatory bowel disease, an early presentation of dactylitis may represent a unique subset of patients and serve as a valuable predictive marker for the later onset of these conditions.

Multifaceted aspects of chronic disease: do diffuse idiopathic skeletal hyperostosis affect the quality of life?

Diffuse idiopathic skeletal hyperostosis (DISH) is a common condition that affects the spine and peripheral joints, characterized by the progressive ossification of ligaments and tendons. It is a non-inflammatory degenerative disease that affects predominantly the elderly population. It has been associated with reduced mobility and chronic pain, which can have a significant impact on patients’ quality of life (QOL). Although DISH has always been considered a benign condition, patients with DISH report higher levels of pain, stiffness, and disability compared to the general population. It can affect their ability to perform daily activities and participate in social and recreational activities. In addition, extra-spinal manifestations such as enthesopathy and involvement of peripheral joints, but still dysphagia and airway obstruction have been described in DISH. These, although not as common, when present result in signs and symptoms significantly impacting the patient’s QOL. The objective of this review is to assess the QOL in individual with DISH. This involves an examination of various facets of the condition, including pain, spinal and extraspinal manifestations, fractures, and metabolic syndrome.

Diffuse Idiopathic Skeletal Hyperostosis (DISH): New evidence from micro-XCT scanning

ObjectiveTo observe and describe the development and underlying structure of the spinal manifestations of individuals osteologically diagnosed with DISH (Diffuse Idiopathic Skeletal Hyperostosis), using micro-XCT imaging. MaterialsA total of 72 individuals with DISH were identified in two modern skeletal collections in South Africa. MethodsVertebral columns affected by DISH were scanned at the micro-focus x-ray computed tomography facility at the Nuclear Energy Corporation of South Africa. Four features were macroscopically examined: (1) the origin of the new bone growth; (2) retention of the original vertebral cortex at the site of the new bone formation associated with DISH; (3) evidence of trabecular bone with or without sclerosis on the anterolateral surface of affected vertebrae; and (4) abnormal areas of osteosclerosis beyond features associated with DISH. ResultsConsiderable variation across and between the four recorded features was found. Of note, 81% (n = 58) of individuals had both developed trabecular bone within the flowing new bone formation (feature 3), without retention of the original vertebral cortex (feature 2). ConclusionsPossible localised erosive/inflammatory processes destroyed the original cortex of the vertebral body and resulted in the expansion of trabeculae with new bone formation. SignificanceMicro-XCT imaging shed new light on the development of DISH, adding to literature suggesting that it could be an inflammatory disease. LimitationsClinical histories of the individuals were not known. Suggestions for further researchThe role of chronic inflammatory disease in the development of DISH should be further explored including both the extra-spinal and spinal manifestations.

HTLV-1 encephalomyelitis; a case report of a treatable manifestation of HTLV-1 infection

IntroductionHuman T-cell lymphotropic virus type-1 (HTLV-1) infection remains asymptomatic in &gt;90% of the 20-million people infected worldwide. However in 3%, chronic inflammation within the thoracic spinal cord leads to progressive spastic paraparesis; HTLV-1 associated myelopathy (HAM). This pathological process is not limited to the thoracic cord. We present a case of HTLV-1 encephalomyelitis.CaseA 53-year-old woman with HAM of 9 years duration presented with subacute cerebellar dysfunc- tion, being unable to feed herself, 3-months after cessation of methotrexate. Investigations demonstrated extensive T2-hyperintensity within the brainstem, cortical and subcortical white matter with punctate contrast enhancement; lymphocytic CSF; and high blood (36%) and CSF (72%) HTLV-1 proviral load (DNA copies per 100 lymphocytes). We diagnosed HTLV-1 encephalomyelitis and commenced high dose methylprednisolone with slow steroid taper following which functional independence in the upper limbs was regained.DiscussionRisk of HAM rises exponentially once HTLV-1 proviral load exceeds 1%, while CSF:blood proviral load ratio ≥2:1 indicates CNS infiltration of HTLV-1 infected lymphocytes. This patient’s high HTLV-1 proviral load and widespread MRI changes indicated HTLV-1 associated inflammation of the brain and spine. Prompt immunosuppression resulted in significant recovery and highlights the importance of early rec- ognition and management of extraspinal manifestations of HTLV-1 infection.j.king-robson@nhs.net

Response to a letter by M. Slouma et al

A letter by Slouma et al highlights several important matters regarding the recently reported association of serum levels of interleukin (IL)-22 with the clinical diagnosis of axial spondyloarthritis (AxSpA).1 While the full spectrum of action and pathological significance of IL-22 has not been fully elaborated, the involvement of this cytokine in the pathogenesis of various systemic disorders has been demonstrated or suggested. Thus, the potential diagnostic utility of this test should be limited to the differentiation of AxSpA from non-inflammatory conditions, such as osteitis condensans ilii, fibromyalgia and myofascial pain, enthesopathy, facet joint disease, and diffuse idiopathic systemic hyperostosis, which were diagnosed in this study in the group of patients with an alternative to AxSpA diagnosis. We completely agree with Slouma et al that the presence of some chronic systemic disorders can cause a bias in the interpretation of the test. Thus, it is important to mention that none of the enrolled patients was diagnosed with any malignant or chronic disease with possible inflammatory pathogenesis, excluding 3 smokers with mild chronic obstructive pulmonary disease; serum levels of IL-22 were at the low end in these patients. The IL-22 levels did not depend on the presence of peripheral arthritis, uveitis, psoriasis, or inflammatory bowel disease in our study; however, the numbers of patients with the extra-spinal manifestations were too low to make statistical calculations. The total sample size of the study was also judged to be insufficient for making final recommendations on the practical utilization of IL-22 test for AxSpA diagnosis, and as it was advocated by Slouma et al, and also acknowledged in the manuscript, further prospective studies examining the diagnostic utility of IL-22 testing in patients with suspected AxSpA are warranted. The authors declare no conflict of interest.

P24 Ankylosing spondylitis &amp; uveitis - challenges in management

Case report - IntroductionAnkylosing spondylitis is a chronic inflammatory condition involving spine, chest and sacroiliac joints. It can be associated with extra spinal manifestations which include uveitis and enthesitis, as well as other features of an inflammatory spondyloarthropathy including psoriasis and inflammatory bowel disease. It is characterised by the presence of inflammatory back pain, limited range of spinal movement, sacroiliitis on imaging, excess spinal bone formation and a high prevalence of HLA-B27. The main aims of treatment are to improve symptoms and retain function as well as to prevent disease complications.Case report - Case descriptionA 49-year-old male diagnosed with ankylosing spondylitis at the age of 23 (HLA-B27 positive, classical radiographic features on plain radiographs and MRI), with background of meningitis and subsequent epilepsy (not on treatment since the age of 13), severe hip osteoarthritis and osteoporosis. He has peripheral elbow and knee synovitis. At the age of 27 he developed sight-threatening bilateral recurrent anterior uveitis complicated by cystoid macular oedema (causing central vision loss). Initial management included anti-inflammatories and steroids. He progressed to biologics but developed a rash on adalimumab. He was switched to infliximab in 2010. In 2015 it was switched due to reduced response to golimumab which was non-beneficial. Subsequently he was switched to etanercept but after 3 months it was discontinued due to eye flare. The patient’s therapy was switched to certolizumab, which was non-beneficial for spine and discontinued. In 2016, infliximab was retried as the patient thought it worked best. Unfortunately, in 2018 patient developed Infliximab antibodies and treatment was changed to secukinumab. After 9 months this was stopped owing to ongoing active eye and spine disease. Adalimumab was re-tried; however, it was discontinued as it was showing no benefit. In 2020 Eeanercept (Benepali) was re-tried; however, only for 4 months because of severe flare of joint and eye disease. Tofacitinib was commenced but was non-beneficial and hence it was discontinued. Currently he continues on ixekizumab, oral prednisolone and also receives steroid eye and joint injections. On commencing biologics he was on methotrexate; however, the patient stopped. He was switched to mycophenolate mofetil which he remained on for 10 years. It was switched to methotrexate to try and control peripheral inflammatory joint disease better (re-tried for the second time) which the patient has recently discontinued as he felt it was non-beneficial.Case report - DiscussionThe case is very challenging. The patient’s disease continues to flare despite changing therapies. He continues to get flares in his back disease, eye disease and peripheral synovitis. His latest BASDI was 5.1 and VAS was 9/10. Measurements: intermalleolar distance 15cm, modified Schober’s 4cm, right lateral flexion 3.8cm and left lateral flexion 11cm. His latest MRI of whole spine and SI joints (in 2020) showed signs of previously active seronegative spondyloarthropathy with established cervical and thoracic ankyloses as well as bilateral sacroiliac joint ankylosis. There is a need for repeated steroid injections to the knees as well as the eyes. He continues on oral prednisolone which was first started in 2006. This is associated with multiple side effects, i.e., osteoporosis. The patient has already completed 8 years of bisphosphonate therapy. He is under regular review with the osteoporosis clinic. His bone density scan showed worsening bone mineral density and bisphosphonates had to be restarted. The patient adjusted medications depending on his symptoms. Recently he also discontinued methotrexate as he felt it was of no benefit to him at all. We are very limited at present to find combined medications to manage both the patient’s inflammatory back disease and inflammatory eye disease.Case report - Key learning pointsThis patient was diagnosed with ankylosing spondylitis 26 years ago. To date he has tried 5 different anti-TNF agents (two of which have also been re-tried at a different time point). This failed to control his disease as he continued to experience flares in either inflammatory back or eye disease. The biologic classes were also changed – he has tried one IL-17A agent as well as a JAK-I. Unfortunately, they both failed to control his disease. He currently continues on a second IL-17A; however, he still requires steroid eye and joint injections as well as systemic steroids. Throughout the years he has tried different DMARDs – most recently methotrexate. Unfortunately, the patient decided to discontinue it as he felt it was of no benefit to him. All of the above indicates that there is still a need to find a collaborative treatment option that will control the patient’s inflammatory back disease, inflammatory eye disease and peripheral synovitis. The aim would be, if possible, to decrease the steroid dose as well (currently on prednisolone 15mg daily) in order to prevent the steroid-associated side effects.

Axial Spondyloarthritis: Clinical Characteristics, Epidemiology, and General Approaches to Management

Axial spondyloarthritis (axSpA) is a chronic inflammatory condition, with an age of onset almost exclusively under 45 years. Although symptoms are initially centred on the sacroiliac joints and spine, extraspinal manifestations are common and add considerably to the burden of disease. In this narrative review, the authors provide an update on the epidemiology of the disease and briefly summarise the pathophysiology. The authors detail the clinical manifestations of axSpA, including an overview of axial features, peripheral manifestations, and associated comorbidities. The authors outline the current outcome measures used in the assessment of patients. Finally, the authors provide a summary of the general principles of treatment and briefly outline the role of patient education in the management of individuals with axSpA.

Educational needs and challenges in axial spondyloarthritis.

Axial spondyloarthritis (axSpA) affects 0.5-1% of the population in many regions of the world. This review summarizes the challenges in medical education around axSpA with attention to evidence around delayed diagnosis, clinician familiarity with typical axSpA features, such as inflammatory back pain and adherence to accepted management principles. Clinicians who commonly manage patients with chronic back pain or other typical axSpA features are not consistently aware of the concept of inflammatory back pain and common extra-spinal manifestations. Further, clinicians may not be familiar with the nonradiographic spectrum of axSpA. Management of patients with possible axSpA does not consistently follow principles that would establish an axSpA diagnosis, and diagnosis of axSpA remains delayed by 6-7 years on average, with evidence suggesting management disparities on the basis of sex and race in some cases. Referral recommendations have increased the probability of axSpA diagnosis up to about 40% and, may complement educational efforts in axSpA. Educational efforts in axSpA should focus on providing front-line clinicians with a better understanding of inflammatory back pain, the nonradiographic form of axSpA, and accepted principles in axSpA management.

Ankylosing Spondylitis in a 44-Year-Old Nigerian Man: A Case Report

Ankylosing spondylitis (AS) is a rare inflammatory disorder that affects the axial skeleton. It is characterized by inflammation of the joints of the spine with subsequent bridging of the spinal segments resulting in a reduced mobility of the spine and subsequent stiffness of the spine. It can be a severely limiting condition adversely affecting the quality of life of affected individuals. It has been found to be commoner in Caucasians and Asians but rare in blacks in the Americas with few cases reported amongst the African Black population. It is associated with the occurrence of the major histocompatibility complex (MHC) class 1 allele HLA-B27. We present the case of a 44-year-old Nigerian man presenting with a 21-year history of progressively worsening back pain and stiffness associated with hip pain and difficulty in extending his neck. He had no extraspinal manifestations. He was diagnosed with Ankylosing Spondylitis using the modified New York criteria. He was commenced on selective COX2 inhibitors and a physical therapy program aimed at improving the flexibility of the spine and reducing pain. He had a significant improvement in his pain and improved flexibility of his spine in all planes. Ankylosing spondylitis affects the axial skeleton primarily but there may be some extra spinal manifestations such as anterior uveitis, psoriasis and inflammatory bowel disease. Various modalities are employed in its treatment ranging from physical therapy, drugs e.g. Nonsteroidal anti-inflammatory drugs, tumour necrosis factor inbibitors and surgery where complications arise. These have proven effective in improving the symptoms of the disease and quality of life.

Back to the beginning: Identifying lesions of diffuse idiopathic skeletal hyperostosis prior to vertebral ankylosis

ObjectiveTo better understand the pathogenesis of DISH, identifying early or pre-DISH lesions in the spine and investigating the relationship between spinal and extra-spinal manifestations of DISH. Material44 skeletonized individuals with DISH from the WM Bass Donated Skeletal Collection. MethodsFor each vertebra, location, extension, point of origin and appearance of vertebral outgrowths were recorded. The size of the enthesophytes at the olecranon process, patella and calcaneal tuberosity was measured with digital callipers. ResultsAt either end of the DISH-ankylosed segment, isolated vertical outgrowths arising from the central third of the anterior aspect of the vertebral body can usually be observed. These bone outgrowths show a well-organized external cortical layer, an internal structure of trabecular bone and usually are unaccompanied by or show minimal associated endplate degeneration. Analysis of the relationship between spinal and extra-spinal manifestations (ESM) suggests great inter-individual variability. No correlation between any ESM and the stage of spinal DISH was found. ConclusionsSmall isolated outgrowths represent the earliest stages of the spinal manifestations of DISH. The use of ESM as an indicator of DISH should be undertaken with great caution until the relationship between these two features is understood. SignificanceImproved accuracy of paleopathological diagnostic criteria of DISH. LimitationsSmall sample comprised of only individuals with DISH. Future researchmicro-CT analysis to investigate the internal structure of the spinal lesions. Analysis of extra-spinal enthesophytes in individuals with and without DISH to understand their pathogenesis and association with the spinal lesions in individuals with DISH.

The Pathogenesis of Ankylosing Spondylitis: an Update.

Ankylosing spondyloarthritis (AS) is a chronic inflammatory disease that involves the axial joints and entheses. Extra-spinal manifestations such as anterior uveitis, psoriasis, and colitis also occur frequently. This review on the pathogenesis of AS includes an update on the recent discoveries within the field. HLA-B*27 is still considered of major importance in the pathogenesis, and it has recently been shown to profoundly affect the gut microbiome and its metabolites and the handling of bacteria during infection. Biochemical and biophysical properties of HLA-B*27 influence its ability to misfold, to induce an endoplasmic reticulum stress response, and to promote autophagy/unfolded protein responses (UPR). HLA-B*27 free heavy chains may induce inflammation through T cells, NK cells, and myeloid cells. Induction of UPR genes results in release of tumor necrosis factor-α (TNF-α), interleukin-17 (IL-17), IL-23, and interferon-γ and increase in T helper (Th) 17 cells. Several other HLA-B and non-B molecules have been associated with AS, although their role in the pathogenesis is unknown. Genotypes of endoplasmic reticulum aminopeptidases (ERAP) 1 and 2 have been associated with alterations in the antigenic pool expressed by HLA-B*27 molecules. In the gut, innate immune cells type 3 (ILC3) influence T cell expression of IL-17 and IL-22. Gamma-delta (γ/δ) T cells are induced by IL-23 to produce IL-17. IL-7 induces mucosa-associated invariant T (MAIT) cells to produce IL-17. Besides the microbiome, zonulin may be important through its effects on the permeability of tight junctions in the intestinal epithelial barrier.

Prevalence and factors associated with disturbed sleep in outpatients with ankylosing spondylitis.

Sleep disturbance is prevalent among patients with ankylosing spondylitis (AS) and is considered a multifactorial issue. The study was designed to investigate sleep disturbance and its associated factors in AS outpatients in Southwest China. Patients were recruited by convenience sampling in this cross-sectional study. The Pittsburgh Sleep Quality Index (PSQI), the Bath AS Disease Activity Index (BASDAI), the Bath AS Functional Index (BASFI), the Bath AS Patient Global Score (BAS-G), and the Hospital Anxiety and Depression Scale (HADS) were used to assess sleep quality, disease activity, function status, global well-being, depression, and anxiety. Spearman's correlation, t test, ANOVA, and multiple linear regression analysis were used to explore the associated factors of sleep disturbance. Of the 281 outpatients included in the study, 190 (67.6%) patients had sleep disturbance. The married patients, the patients with extra-spinal manifestation, depression and anxiety, longer duration of diagnostic delay, higher disease activity, worse functional status and global well-being, high level of pain, and fatigue, had poorer sleep quality (P < 0.05). Multiple linear regression analysis revealed age (β = 0.087, P = 0.102), BAS-G (β = 0.181, P = 0.003), fatigue (β = 0.170, P = 0.002), anxiety (β = 0.151, P = 0.002) and nocturnal back pain (β = 0.192, P = 0.001), extra-spinal manifestation (β = 0.120, P = 0.012), and duration of diagnostic delay (β = 0.174, P = 0.001) were the contributors to PSQI. Sleep disturbance is common in AS patients in Southwest China. It may be useful to keep regular exercise, strengthen the management of pain, relieve anxiety, and prevent and treat extra-spinal manifestation for improving sleep quality.

The Impact of Body Mass Index on Disease Progression in Ankylosing Spondylitis

Abstract Obesity can be a factor that affects the course of chronic systemic inflammatory arthritis. The objective of this study was to characterise patients with ankylosing spondylitis (AS) according to an evaluation of their body mass index (BMI) and by exploring the link between the overweightness and obesity with routinely measured disease-specific variables, including disease activity (Bath Ankylosing Spondylitis Disease Activity Index BASDAI; Ankylosing Spondylitis Disease Activity Score, using CRP, ASDAScrp), spinal mobility (Bath Ankylosing Spondylitis Metrology Index, BASMI), functional capacity (BASFI), extraspinal manifestations like fatigue, uveitis, and peripheral arthritis present during the course of the disease. A total of 107 patients were included in the cross-sectional study fulfilling the modified New York criteria for AS. Patients were divided into three groups: with the evaluation of BMI ≤ 24.9, 25.0–29.9 (overweight) and ≥ 30.0 (obesity). The mean BMI was 25.13 (SD 4.07). 33% of patients were overweight and 15% were obese. The mean values of age, duration of AS, ASDAScrp, BASDAI, Bath Ankylosing Spondylitis Functional Index (BASFI), BASMI, pain in spine, and fatigue in the group with BMI ≤ 24.9 were lower than in the other groups (p &lt; 0.05). There was no difference between groups in age of AS onset, uveitis and peripheral arthritis. AS patients who were overweight or obese had a higher level of the disease activity, pain, fatigue, functional disability and spinal mobility impairment with worse values in the case of obesity.

Research Article &lt;i&gt;CD40&lt;/i&gt; rs4810485 &lt;i&gt;T&gt;G&lt;/i&gt; polymorphism and susceptibility to ankylosing spondylitis in the Latvian population

Ankylosing spondylitis (AS) is a potentially disabling form of a systemic chronic inflammatory arthritis affecting mainly the axial skeleton, with or without extraspinal manifestations. The genetic basis of AS is partly known. Moreover, many autoimmunityrelated genes have pleiotropic effects. Multiple functional polymorphisms in the genes encoding the tumor necrosis factor (TNF) superfamily of cytokines, their receptors, and signaling proteins, are associated with susceptibility to autoimmune diseases. These arguments prompted us to conduct a study evaluating a possible association of single nucleotide polymorphism (SNP) rs4810485 of the CD40 gene, found previously to be involved in other inflammatory diseases, with susceptibility to AS in the Latvian population; 98 AS patients from the Center of Rheumatology of Pauls Stradins Clinical University Hospital were selected as the case group and 154 ethnically related healthy subjects from the Genome Database of the Latvian Population were included as a control group. CD40 gene rs4810485 polymorphism was tested by a TaqMan Pre- Designed SNP Genotyping Assay. In the case of CD40 gene rs4810485 polymorphism, the minor allele is T. Compared to the control subjects, the case group had a higher frequency of the minor allele T (28.6% vs. 17.5%; p=0.00345).The T allele was the risk allele for disease onset (OR 1.88 (95% CI 1.23-2.88)). The relationship between the disease and genotypes was of moderate significance (V=0.20). As for genotypes, GT and TT were the susceptibility genotypes for AS (respectively OR 2.42 (95% CI 1.38 – 4.25) and 1.94 (95% CI 0.71-5.32)). The GG genotype had a protective feature (OR 0.43 (95% CI 0.25 – 0.73)). A significant difference was not found in the analysis of the SNP alleles and genotype distribution in the peripheral arthritis (p=0.85 and p=0.86, respectively) and uveitis (p=0.47 and p=0.3, respectively) subgroups of AS patients. The study data showed that CD40 gene rs4810485 polymorphism is associated with risk of AS.

Co-Occurrence and Characteristics of Patients With Axial Spondyloarthritis Who Meet Criteria for Fibromyalgia: Results From a UK National Register.

To estimate the proportion of patients with axial spondyloarthritis (SpA) in a UK national biologics registry who met criteria for fibromyalgia (FM), and to delineate the characteristics of these patients. Two cohorts of patients are prospectively recruited from across 83 centers in the UK for the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis (BSRBR-AS). All patients are required to meet Assessment of SpondyloArthritis international Society (ASAS) criteria for axial SpA. Patients are either newly starting biologic therapy (biologics cohort) or are naive to treatment with biologic agents (non-biologics cohort) at the time of recruitment, and all patients are followed up prospectively. At recruitment and follow-up, clinical information and measurements are recorded while patients complete the 2011 research criteria for FM and assessments of the level of disease activity and work impact. Of the patients registered in the BSRBR-AS, 1,504 (68% male) were eligible for the current analysis, of whom 311 (20.7%) met the 2011 research criteria for FM. Prevalence of FM was similar between patients who fulfilled the modified New York criteria for AS (19.7%) and those who fulfilled ASAS imaging criteria but not the modified New York criteria (25.2%); however, among those who fulfilled only the ASAS clinical criteria, the prevalence of FM was lower (9.5%). Patients who met FM criteria reported significantly worse disease activity, function, global severity scores, and quality of life, and were more likely to have moderate or severe levels of mood disorder and clinically important fatigue. Patients who met FM criteria reported experiencing work impairment around half their working time. Meeting FM criteria was not related to elevated C-reactive protein levels or most extraspinal manifestations, but was associated with a higher likelihood of having received biologic therapy. Developing management approaches that would address the significant unmet clinical needs of the 1 in 5 patients with axial SpA who meet criteria for FM should be a research priority.

Classification criteria for diffuse idiopathic skeletal hyperostosis: a lack of consensus.

DISH is a condition characterized by flowing ossifications of the spine with or without ossifications of entheses elsewhere in the body. Studies on the prevalence and pathogenesis of DISH use a variety of partly overlapping combinations of classification criteria, making meaningful comparisons across the literature difficult. The aim of this study was to systematically summarize the available criteria to support the development of a more uniform set of diagnostic/classification criteria. A search was performed in Pubmed, Embase, Cochrane Library and Web of Science using the term DISH and its synonyms. Articles were included when two independent observers agreed that the articles proposed a new set of classification criteria for DISH. All retrieved articles were evaluated for methodological quality, and the presented criteria were extracted. A total of 24 articles met the inclusion criteria. In all articles, spinal hyperostosis was required for the diagnosis of DISH. Peripheral, extraspinal manifestations were included as a (co-)requirement for the diagnosis DISH in five articles. Most discrepancies revolved around the threshold for the number of vertebral bodies affected and to defining different developmental phases of DISH. More than half of the retrieved articles described a dichotomous set of criteria and did not consider the progressive character of DISH. This systematic review summarizes the available different classification criteria for DISH, which highlights the lack of consensus on the diagnosis of (early) DISH. Consensus criteria, including consecutive phases of new bone formation that characterize DISH, can be developed based upon established diagnostic/classification criteria.

Functional limitation and associated factors in outpatients with ankylosing spondylitis in Southwest China.

Functional limitation is often complained by patients with ankylosing spondylitis (AS). With a rising number of patients suffering from AS, there are a limited number of reports focusing on functional limitation of AS in Chinese patients. This study was conducted to investigate the level of functional limitation and explore its associations with demographic, disease-related factors. A total of 303 AS outpatients were recruited in this cross-sectional study from a tertiary general hospital in Southwest China. Functional limitation was measured by the Bath Ankylosing Spondylitis Functional Index (BASFI). Other data were collected by the following questionnaires: the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Patient Global Score (BAS-G), and the Pittsburgh Sleep Quality Index Questionnaire (PSQI). Finally, 295 outpatients with AS completed this survey. The median BASFI was 0.80. Worse function limitation was found in outpatients with extra-spinal manifestation, older age, lower household income, more back pain, higher disease activity and morning stiffness, poorer sleep, and worse patient's well-being (all P<0.05). Multivariate regression analysis indicated that patient's well-being (P<0.001), disease activity (P<0.001), and disease duration (P<0.05) were the positive predictors of functional limitation. AS outpatients in Southwest China had a mild level of functional limitation. The factors associated with functional limitation included disease duration, disease activity, and patients' well-being, which should be taken into consideration when assessing functional limitation of AS outpatients. Besides, more comprehensive and targeted interventions should be conducted for AS patients as early as possible, which will be effective to improve functional outcome.

Features of extra-spinal musculoskeletal tuberculosis: A retrospective study from an North Indian Tertiary Care Institute

Background: The aim is to study the clinical features and diagnosis of primary extra-spinal musculoskeletal manifestations of tuberculosis (TB) in otherwise healthy individuals. Methods: In this retrospective study of 10 years duration electronic database and case records of patients with musculoskeletal TB were analyzed. Patient's positive for HIV and rheumatic diseases with or without immunosuppressive drugs or biological agents were excluded from the study. Results: Fifty-one patients were identified with the mean age at presentation of 33.35 years (range 4–72), male: female ratio of 1.1:1 and mean duration of disease was 14.65 months (range, 0.25–120). The most frequent manifestation was articular (arthritis/arthralgia n = 40, monoarthritis n = 28, oligoarthritis n = 10, polyarthralgia n = 2) followed by tenosynovitis (n = 6), tuberculous osteomyelitis (n = 5), isolated bursitis (n = 1), and pyomyositis (n = 1). Poncet's disease was diagnosed in five patients. Disseminated TB was detected in four patients. Pain (n = 50) followed by swelling of the involved site (n = 37) were the most common presenting symptoms. Fever was present in 15 (29.4%) patients. Nine patients had a previous history of TB. Concurrent pulmonary TB was present in two patients. Lymph node enlargement was present in 12 (23.5%) patients. A definite diagnosis of musculoskeletal TB was made in 31 (61%) patients and probable TB in 20 (39%) patients. Conclusion: Musculoskeletal manifestations of TB can occur at any age. Chronic monoarthritis is the most common presentation; however, oligoarthritis and/or tenosynovitis may be a presenting manifestation. The absence of fever should not discourage the diagnosis of musculoskeletal TB.

Cervical Disc Arthroplasty Combined with Interbody Fusion for the Treatment of Cervical Myelopathy with Diffuse Idiopathic Skeletal Hyperostosis

Cervical Disc Arthroplasty Combined with Interbody Fusion for the Treatment of Cervical Myelopathy with Diffuse Idiopathic Skeletal Hyperostosis

Extra-spinal musculoskeletal manifestations of tuberculosis – a pictorial review

Extra-spinal musculoskeletal manifestations of tuberculosis – a pictorial review