Inflammatory Spondyloarthropathy Research Articles

Assessment of the relationship between hematological indices and remission duration in patients with inflammatory spondyloarthropathies treated with tumor necrosis factor inhibitors

Assessment of the relationship between hematological indices and remission duration in patients with inflammatory spondyloarthropathies treated with tumor necrosis factor inhibitors

Combined associations of obesity and physical activity with pain, fatigue, stiffness and anxiety in adults with spondyloarthropathies: UK Biobank study.

Inflammatory spondyloarthropathies are associated with pain, fatigue, stiffness and anxiety. The National Institute for Health and Care Excellence and the EULAR provide limited lifestyle guidance for managing symptoms with inflammatory spondyloarthropathies. We investigated the combined associations of obesity and physical activity with symptom severity in inflammatory spondyloarthropathies. The relationship between BMI, physical activity and symptom severity (spinal and general pain, fatigue, anxiety, mobility) was examined in people with ISpAs (n = 1577). BMI categories were normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2) and obese (≥30 kg/m2). Physical activity was assessed via the International Physical Activity Questionnaire (low < 600 metabolic equivalent of task (MET)-min/week, moderate ≥ 600 METs, high ≥ 3000 METs). Statistical models adjusted for confounders, including medication, estimated the likelihood (odds ratios, OR) of higher symptom severity across BMI and physical activity categories. Overweight and obesity, compared with normal weight, were linked to higher severity of all symptoms, with stronger associations for obesity (OR ≥ 2.34, P < 0.001) than overweight (OR ≥ 1.37, P ≤ 0.032). Moderate activity, compared with low, was associated with lower severity of all symptoms (OR ≤ 0.77, P ≤ 0.032). High activity, compared with low, was associated with lower severity of fatigue, anxiety and mobility issues (OR ≤ 0.74, P ≤ 0.029), but associations with spinal and general pain were not significant (OR ≤ 0.80, P ≥ 0.056). No BMI-by-physical activity combinations were detected, indicating physical activity benefits all BMI groups to a similar extent. National Institute for Health and Care Excellence and EULAR guidance for inflammatory spondyloarthropathies should emphasize maintaining a normal weight. Moderate physical activity is optimal for reducing symptom severity and should be promoted in lifestyle guidance.

Ankylosing spondylitis in patients undergoing total hip arthroplasty increases the risk of medical and implant-related complications: a case control analysis.

Ankylosing spondylitis (AS) is an inflammatory spondyloarthropathy, often involving the spine and sacroiliac joints. Total hip arthroplasty (THA) has been shown to be effective in improving pain and function in patients with AS with hip involvement. However, extraskeletal manifestations and altered mechanics in those with AS leads to increased complications. Thus, the aims of this study were to assess the effects that AS has on medical and implant complications, falls, length of stay, and readmissions following THA. A retrospective review of the Mariner private insurance claims database was conducted from 2010 to 2020. All cases of THA and those with AS were identified using Current Procedural Terminology, and International Classification of Disease 9th and 10th revision codes. Patients who underwent THA with a diagnosis of AS were matched to non-AS patients 1:5 based on demographic and comorbidity profiles. 90-day medical complications, falls, and readmission rates, as well as 2-year implant complications were compared between cohorts. A total of 6509 AS patients were matched to 32,489 control patients. The AS group had significantly higher rates of myocardial infarction, cerebrovascular accident, deep vein thrombosis, pulmonary embolism, urinary tract infection, wound complications, acute kidney injury, pneumonia, sepsis, transfusions, and falls when compared to the control group. The AS group had significantly higher rates of prosthetic joint infection, dislocation, mechanical loosening, and periprosthetic fracture (all p < 0.0001). Likewise, mean length of stay and readmissions were significantly greater in the AS group. Ankylosing spondylitis in patients undergoing THA is associated with significant risk of medical and implant complications, as well as fall risk, length of stay, and readmission rates. These findings may allow orthopaedic surgeons to be more attentive in identifying those patients at risk and allow for more educated patient counseling and perioperative planning.

The gut microbiome and HLA-B27-associated anterior uveitis: a case-control study

BackgroundThe human gut microbiome (GM) is involved in inflammation and immune response regulation. Dysbiosis, an imbalance in this ecosystem, facilitates pathogenic invasion, disrupts immune equilibrium, and potentially triggers diseases including various human leucocyte antigen (HLA)-B27-associated autoinflammatory and autoimmune diseases such as inflammatory bowel disease (IBD) and spondyloarthropathy (SpA). This study assesses compositional and functional alterations of the GM in patients with HLA-B27-associated non-infectious anterior uveitis (AU) compared to healthy controls.MethodsThe gut metagenomes of 20 patients with HLA-B27-associated non-infectious AU, 21 age- and sex-matched HLA-B27-negative controls, and 6 HLA-B27-positive healthy controls without a history of AU were sequenced using the Illumina NovaSeq 6000 platform for whole metagenome shotgun sequencing. To identify taxonomic and functional features with significantly different relative abundances between groups and to identify associations with clinical metadata, the multivariate association by linear models (MaAsLin) R package was applied.ResultsSignificantly higher levels of the Eubacterium ramulus species were found in HLA-B27-negative controls (p = 0.0085, Mann-Whitney U-test). No significant differences in microbial composition were observed at all other taxonomic levels. Functionally, the lipid IVA biosynthesis pathway was upregulated in patients (p < 0.0001, Mann-Whitney U-test). A subgroup analysis comparing patients with an active non-infectious AU to their age- and sex-matched HLA-B27-negative controls, showed an increase of the species Phocaeicola vulgatus in active AU (p = 0.0530, Mann-Whitney U-test). An additional analysis comparing AU patients to age- and sex-matched HLA-B27-positive controls, showed an increase of the species Bacteroides caccae in controls (p = 0.0022, Mann-Whitney U-test).ConclusionIn our cohort, non-infectious AU development is associated with compositional and functional alterations of the GM. Further research is needed to assess the causality of these associations, offering potentially novel therapeutic strategies.

Role of endoplasmic reticulum aminopeptidase-1 gene polymorphism (rs13167972) in occurrence susceptibility of ankylosing spondylitis in a sample of Iraqi male patients.

Ankylosing spondylitis (AS) is a chronic and systemic seronegative inflammatory spondyloarthropathy, an autoimmune disease that has been associated with impaired Endoplasmic Reticulum Aminopeptidase (ERAP)-1 activity, which is involved in priming antigenic peptides. The purpose of this study is to investigate the association of 3-UTR of ERAP1 gene polymorphism (rs13167972) with the AS occurrence susceptibility in a sample of Iraqi male patients. The AS patients were diagnosed clinically and by magnetic resonance imaging (MRI) and other clinical and laboratory criteria like symptoms, increased C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). The blood grouping and Body Mass Index (BMI) were also investigated to be associated with AS occurrence. The genotyping of the 3-UTR region of the ERAP1 gene (rs13167972) was done by Sanger sequencing. The results revealed that the AS occurred significantly in the age group of 20-35years (p = 0.013). The BMI shows that the AS patients were overweighted males (p = 0.013) and the most predominant blood group in AS patients was O- (p = 0.002). The ESR and serum level of CRP were significantly raised in AS patient sera (< 0.001). The results of the receiver-operating characteristics curve analysis (ROC) revealed that the CRP (AUC: 0.995, cut-off: 2.48mg/L, had 95% %sensitivity, 100% specificity, p < 0.001) is more discriminative than BMI (AUC: 0.300, cut-off: 46.91kg, had 0% sensitivity, 100% specificity, p = 0.001), and ESR (AUC: 0.808, cut-off: 7.50mm/hr, had 60% sensitivity, 88% specificity, p < 0.001) in distinguishing between AS patients and control group. The genotyping of the 3-UTR region of ERAP1 gene (rs13167972) result shows that the AG and GG genotypes are significantly occurring in AS patients (70%, OR: 2.33, 95%CI: 1.02-5.36, p = 0.04). The G allele is significantly occurring in AS patients (47%, OR: 2.07, 95CI%: 1.15-3.71, p = 0.01). The AS occurred in young overweight males with blood group O-. The AG and GG genotypes are risk factors for AS development while the G allele is a risk factor that increases the chances for disease incidence.

Imaging assessment of spine infection.

This article comprehensively reviews current imaging concepts in spinal infection with primary focus on infectious spondylodiscitis (IS) as well as the less common entity of facet joint septic arthritis (FSA). This review encompasses the multimodality imaging appearances (radiographs, CT, MRI, and nuclear imaging) of spinal infection-both at initial presentation and during treatment-to aid the radiologist in guiding diagnosis and successful management. We discuss the pathophysiology of spinal infection in various patient populations (including the non-instrumented and postoperative spine) as well as the role of imaging-guided biopsy. We also highlight several non-infectious entities that can mimic IS (both clinically and radiologically) that should be considered during image interpretation to avoid misdiagnosis. These potential mimics include the following: Modic type 1 degenerative changes, acute Schmorl's node, neuropathic spondyloarthropathy, radiation osteitis, and inflammatory spondyloarthropathy (SAPHO syndrome).

Short-Term Efficacy and Adverse Effects of Sulfasalazine in the Management of Axial Spondyloarthropathy.

Ankylosing spondylitis (AS) is an inflammatory spondyloarthropathy that involves the sacroiliac joints and the axial skeleton. Sulfasalazine's efficacy in treating the axial symptoms of AS has been a subject of controversy. This prospective observational study recruited AS patients and categorized them into two groups: the first group had AS for less than or equal to four years and the second group had AS for more than four years. Erythrocytic sedimentation rate (ESR) and C-reactive protein (CRP) levels were recorded at baseline and at six-month follow-up. Disease severity was assessed using the ankylosing spondylitis disease activity score (ASDAS), Bath ankylosing spondylitis disease activity index (BASDAI) score, and Bath ankylosing spondylitis functional index (BASFI) score. A total of 33 patients diagnosed with AS were recruited in this study, mostly males (88%) and within 21-30 years of age. ESR and CRP values were measured at baseline and at six months post-treatment with sulfasalazine. Mean ESR and mean CRP values showed a statistically significant reduction of 43.5% (p=0.001) and 58.45% (p=0.0012) respectively, at the 6-month follow-up. Four patients (12.12%) reported gastrointestinal intolerance. The mean reduction in the ASDAS score was 24% (p=0.002), the BASDAI score was 40.08% (p=0.001), and the BASFI score was 39.54% (p=0.01). Additionally, the duration of symptoms did not appear to influence with efficacy of sulfasalazine. Sulfasalazine is a safe alternative therapy for patients with AS who cannot afford biologics, due to its reasonable short-term efficacy, good tolerability, cost-effective nature, and low incidence of adverse effects.

The adult with low back pain: causes, diagnosis, imaging features and management.

Low back pain is the leading cause of disability worldwide. This article highlights the importance of succinct history taking and a thorough clinical examination when managing a patient with lower back pain in hospital. Furthermore, it encourages the clinician to consider the pertinent causes of low back pain such as age-related degeneration, malignancy, trauma, infection and seronegative inflammatory spondyloarthropathies, and looks at the diagnosis, imaging features and key management options which are available in secondary care.

OA03 Trauma secondary to a horse riding accident as a potential accelerating factor in inflammatory axial sponyloarthropathy: a case report and literature review

Abstract Introduction Ankylosing spondylitis (AS) is a chronic inflammatory rheumatic disease characterised by axial involvement and sacroiliitis. The etiology of AS remains elusive, with genetic and environmental factors implicated in disease development and progression. This case report aims to investigate the potential association between trauma and the acceleration of AS in individuals positive for HLA-B27. Furthermore one purpose of this case-report is to ascertain any link between horse riding accidents in jockeys or professionals undertaking horse riding as a career choice. Is there a correlation between trauma and development of inflammatory axial spondyloarthropathy subsequently or not. Case description A 24-year-old female patient with a medical history of eczema and Graves' disease, currently undergoing propylthiouracil treatment, was referred to the rheumatology clinic due to persistent back pain for the past six to seven years following a horse riding accident. The patient had previously received physiotherapy and found relief with naproxen and co-codamol. The pain primarily affects her lower spine and radiates down her legs. While movement provides some relief, lying down exacerbates the pain. The patient experiences stiffness for approximately 30 minutes in the morning but does not exhibit peripheral joint symptoms. Exercise helps alleviate her symptoms. The patient reported a family history of psoriasis but denied any history of uveitis, inflammatory bowel disease, weight loss, night sweats, heartblock or achilles tendinitis. She also gave a history of joint hyper mobility with reduced flexion at the spine over the years. Blood tests revealed normal levels of ANA, CCP, ESR, rheumatoid factor, B12, HbA1c, and thyroid function. Ferritin levels were 30.2, and HLA B27 was positive. Joint examination did not reveal any signs of synovitis. The patient exhibited good range of motion in the spine. SLR's were positive on both sides and no tenderness over spine or sacroiliac joints. Systemic Examination was normal. BASDAI score was 4. Occiput to wall distance of 0 centimeters. Beighton score 4/9. Subsequently MRI whole spine/SI Joints were organised and results indicated a central disc protrusion at the L4-L5 level leading to critical spinal stenosis and likely impinging on the transitioning L5 and S1 nerve roots. Additionally, a disc protrusion at the L5-S1 which was impinging on the left S1 nerve root. Bilateral sacroiliitis was also observed. Patient was treated with NSAIDs and physiotherapy with good results with a view for a subsequent MRI, and escalation to biologics if symptoms were to worsen. Discussion The presented case raises the question of whether trauma accelerates the progression of ankylosing spondylitis (AS) in individuals who are positive for HLA-B27. Although this specific case involves a 24-year-old female patient with a history of back pain following a horse riding accident, additional research and studies would be required to draw definitive conclusions regarding the relationship between trauma and the development or acceleration of AS in HLA-B27 positive individuals. The question this case report poses and there is little in terms of research and case reports present, whether the involvement of the lady in question in a horse riding accident unmasked her ankylosing spondylitis given her HLA B27 positivity and the presence of sacroilitis on MRI scans. Literature review revealed a potential role of trauma accelerating the progression of ankylosing spondylitis in individuals who are also positive for HLA B-27, in addition in some cases it lead to detection and unmasking of chronic back pain which was inflammatory in nature rather than mechanical or a combination of both. This was revealed by the horse riding accident given the nature of the pain which had been constant and worsening which lead to a suspicion of a possible inflammatory component and hence further investigations were done. In conclusion this case report highlights the importance of a possible correlation between AS in HLA B27 positive individuals and raises the question whether trauma secondary to sports injuries like horseback riding accidents in our patients case, accelerates the progression of AS in individuals who are positive for HLA-B27. Key learning points This case report highlights the potential role of trauma following a sports injury as a contributing factor in the acceleration of AS in individuals positive for HLA-B27. Further investigations, including prospective studies, are warranted to elucidate the complex interplay between trauma, genetic predisposition, and disease progression in AS. The purpose of this case report is to remind sports medicine physicians of the prevalence of rheumatologic diseases in general and ankylosing spondylitis in particular and of the various ways in which spondyloarthropathies may present in athletes/sports personnel. Increased suspicion may lead to earlier diagnosis and treatment, potentially reducing illness severity and duration and improving the performance of athletes with this condition.

Ankylosing Spondylitis Presenting as Buttock Pain in a Military Tactical Athlete: A Case Report

BACKGROUND: Ankylosing spondylitis (AS) is an inflammatory condition that most commonly affects the spine. In the absence of spinal symptoms, consideration of atypical symptom behavior and the use of diagnostic criteria can be helpful in recognizing this condition. The purpose of this case was to detail AS presenting as buttock pain in a military tactical athlete. CASE PRESENTATION: A 20-year-old white male military intelligence specialist was referred to physical therapy for reports of right buttock pain. Symptoms developed during recruit training, which led to an initial diagnosis of overuse syndrome. He was managed by multiple health care providers, including physical therapists, during recruit training and a year following onset while deployed overseas. OUTCOME AND FOLLOW-UP: Lack of treatment response and presence of atypical symptoms necessitated further medical workup, including radiography, laboratory, and rheumatology referrals. Following consultation with a rheumatologist, a diagnosis of AS was confirmed and the patient was provided definitive and appropriate management that resulted in improved outcomes. DISCUSSION: Spinal pain is often associated with AS. Indicators of AS such as an insidious onset of nonresolving symptoms, night disturbances, patient demographics, a positive HLA-B27 laboratory value, and evidence of active inflammation or sacroiliitis on imaging may help guide detection in the absence of spinal pain or absence of specific criteria established to assist in the identification of inflammatory spondyloarthropathies. Diagnostic accuracy is essential for appropriate care earlier in the disease process. In this case, a definitive diagnosis led to improvement in the management of this patient. JOSPT Cases 2023;3(2):110–116. Epub: 13 April 2023. doi:10.2519/josptcases.2023.11596

Tofacitinib experience in patients with enteropathic arthritis.

Background/aim: The JAK-STAT pathway is involved in the pathogenesis of both the inflammatory bowel disease (IBD) and spondyloarthropathy group of diseases. The purpose of this study was to evaluate the effectiveness of tofacitinib, a Janus kinase inhibitor, in the treatment of enteropathic arthritis (EA). Materials & methods: The study included seven patients, four from the authors' follow-up and three from the literature. All cases were recorded for demographic characteristics, comorbidities, IBD and EA symptoms, medical treatments and changes in clinical and laboratory results with treatment. Results & conclusion: Clinical and laboratory remission in terms of IBD and EA was achieved in three patients after tofacitinib treatment. For both spondyloarthritis spectrum diseases and IBD, tofacitinib may be an appropriate choice, as its efficacy has been shown in both conditions.

Spondyloarthropathies That Mimic Ankylosing Spondylitis: A Narrative Review.

Ankylosing spondylitis is the most common type of seronegative inflammatory spondyloarthropathy often presenting with low back or neck pain, stiffness, kyphosis and fractures that are initially missed on presentation; however, there are other spondyloarthropathies that may present similarly making it a challenge to establish the correct diagnosis. Here, we will highlight the similarities and unique features of the epidemiology, pathophysiology, presentation, radiographic findings, and management of seronegative inflammatory and metabolic spondyloarthropathies as they affect the axial skeleton and mimic ankylosing spondylitis. Seronegative inflammatory spondyloarthropathies such as psoriatic arthritis, reactive arthritis, noninflammatory spondyloarthropathies such as diffuse idiopathic skeletal hyperostosis, and ochronotic arthritis resulting from alkaptonuria can affect the axial skeleton and present with symptoms similar those of ankylosing spondylitis. These similarities can create a challenge for providers as they attempt to identify a patient's condition. However, there are characteristic radiographic findings and laboratory tests that may help in the differential diagnosis. Axial presentations of seronegative inflammatory, non-inflammatory, and metabolic spondyloarthropathies occur more often than previously thought. Identification of their associated symptoms and radiographic findings are imperative to effectively diagnose and properly manage patients with these diseases.

Uveitis in spondyloarthropathies

Background: Uveitis is associated with several systemic disorders. It may be the initial presentation or manifestation of a systemic disease. It is the most common ocular complication and is sometimes the earliest manifestation of spondyloarthropathies. This study aimed to review the current literature on spondyloarthropathies and associated uveitis.&#x0D; Methods: A narrative review was performed using various combinations of the keywords spondyloarthropathies, seronegative spondylarthritis-related uveitis, and human leukocyte antigen-associated uveitis using PubMed/MEDLINE and Google Scholar from January 1, 2000, to September 30, 2022. We describe the disease mechanisms, genetics, and classification of spondyloarthropathies, the clinical patterns of their related ocular diseases, and the current modalities for the management of their ocular or systemic manifestations.&#x0D; Results: Seronegative spondyloarthropathies are a group of rheumatic disorders including ankylosing spondylitis, reactive arthritis, psoriatic arthritis, inflammatory bowel disease-related spondyloarthropathy, juvenile-onset spondyloarthritis, and undifferentiated spondyloarthritis. These are characterized by enthesitis in the absence of serum rheumatoid factor and have a strong association with human leukocyte antigen B27. The clinical courses and features of spondyloarthropathies are remarkably diverse. Ocular inflammation is common in spondyloarthropathies, often precedes the onset or diagnosis of systemic disease, and responds well to topical therapy. Timely diagnosis of systemic diseases may improve quality of life and help avoid ocular and skeletal complications. Recurrence of ocular inflammation is frequent; on occasion, it may be associated with etanercept administration.&#x0D; Conclusions: Eye care professionals should be able to recognize spondyloarthropathies, manage ocular disease, and collaborate with related specialties for modification of systemic treatment if associated with ocular complications. Timely referral and early management could attenuate or prevent ocular or systemic morbidities associated with spondyloarthropathies.

P18 A case report on Atypical Polymyalgia Rheumatica in Young Adult

Introduction/BackgroundPolymyalgia Rheumatica is a common inflammatory condition after the age of 50 years. It typically presents with shoulder, neck and pelvic pain and stiffness associated with raised inflammatory markers. We report a case of Polymyalgia Rheumatica in a young male of 40 years in which clinical presentation was not typical.Description/MethodA 40-year-old male manager in a retail shop was reviewed in Rheumatology Outpatient clinic with a few months history of back and pelvic pain with progressively worsening early morning stiffness for upto 40 minutes associated with marked fatigue ability. There was also pain in the right shoulder following a trauma causing rotator cuff tear shown on MRI done a year ago. His CRP was 19 and ESR 52. Initial assessment was inflammatory Axial Spondyloarthropathy.MRI of spine and SI joints as discussed in radiology MDT didn’t show inflammatory changes in the spine or SI joints. It showed bilateral Osteonecrosis of Femoral heads and ill-defined oedema in left acetabulum. A repeat MRI and CT of pelvis showed sclerotic lesion in left Acetabulum. The patient was discussed in bone and soft tissue tumour MDT with conclusion of non-malignant lesion without requiring biopsy and seen by orthopaedics.The pain progressed to involve left shoulder as well despite regular use of NSAIDs. The stiffness deteriorated and became generalised for up to 2 hours. The fatigability also got worse with some interference in his Job. CRP readings were 19, 19, 25 and 20 whereas ESR was 52, 48, 32 and 40 with an interval of a month each.Multiple other investigations including WCC, Hb, U& Es, LFTs, TSH, CK, bone profile, RF, anti CCP, ANA, ENA, ANCA, Serum protein electrophoresis, Myeloma screen, urine analysis, XR chest and ECG were normal.He went on to have PET CT that showed increased uptake suggestive of arthritis in both shoulders, sternoclavicular joints, 1st Costochondral joint, left hip and posterior spinal ligament. The findings were discussed in Radiology MDT again with a conclusion of diagnosis of Polymyalgia Rheumatica based on the distribution of joints involved.Discussion/ResultsThe patient was started on Prednisolone at a dose of 20mg daily. His symptoms improved within 3 to 4 days of start of Prednisolone. Inflammatory markers also improved were checked after 4 weeks with CRP 4 and ESR 18 and they remained normal in two subsequent readings after two and three months. He is currently on tapering dose of Prednisolone without recurrence of symptoms as well as rise in inflammatory markers.Pattern of joint involvement on PET CT and dramatic response to steroids confirmed the diagnosis of PMR.Key learning points/ConclusionAlthough PMR is most commonly seen in adults over 50 years but it can present in young adults like in this patient.Because of young age and atypical presentation mutiple investigations including PET CT was required to reach to the diagnosis of PMR that otherwise is made based on clinical presentation associated with raised raised inflammatory markers.Osteonecrosis of Femoral heads in the absence of any other positive investigation was thought most likely secondary to Inflammation that again is not very common presentation of PMR.A long term follow up is required for this patient to monitor the response of reducing and then stopping of steroids.

OA21 Ankylosing Spondylitis management with Secukinumab but related Inflammatory bowel disease phenomenon

Introduction/BackgroundAnkylosing spondylitis is a HLA B27 associated inflammatory spondyloarthropathy. It can be a debilitating disease affecting mobility and quality of life, therefore, effective symptom and disease control is crucial and consists of pharmacological, including biologics, and non-pharmacological modalities. Until recently, pharmacological treatment options for spinal inflammatory disease control was limited to mainly NSAIDs. Development of biological drugs such as TNF inhibitors and selective Interleukin-17 inhibitors have revolutionized the management especially for patients refractory to conventional treatment. However, use of these novel biologics can come at a cost of side effects including risk of infection and exacerbation of underlying inflammatory conditions.Description/MethodThis 60-year-old Afro-Caribbean female was referred to Rheumatology department with 1-year history of non-radiating lower back pain, alternating buttock pain and morning stiffness. On spinal and sacral MRI, she was found to have multiple thoracic and lumbar spine Romanus lesions and active sacroiliitis and had bilateral grade 2-3 sacroiliitis on plain x-rays of the sacroiliac joints. She also had a raised ESR. There was no peripheral joint involvement, psoriasis, inflammatory eye disease or previous history of inflammatory bowel disease. Her HLA-B27 was negative. Subsequently, she was diagnosed with AS. Previously, she had tried NSAIDs via GP including Diclofenac and Naproxen. She was started on Etoricoxib.Other issues included spinal canal stenosis at L4/L5 due to disc degeneration, facet joint and ligamentum flavum hypertrophy.For non-pharmacological management she was under the care of physiotherapy team who advised for regular physiotherapy, acupuncture and hydrotherapy.On follow up, she did not derive benefit from the Etoricoxib (BASDAI 8.5 and VAS 75), consequently underwent pre-biologic work up. After these were confirmed as normal she was started on Secukinumab 150mg monthly injections (after weekly loading) as per the patient’s preferred biologic choice.After initiating Secukinumab, her AS improved significantly (reductions in BASDAI to 2.5 and VAS 30). However, after six months, she developed gastrointestinal symptoms with mainly bloating, intermittent diarrhoea and epigastric abdominal pain. She then developed gradual unintentional weight loss.Under gastroenterologist care, she had extensive diagnostic workup including upper GI endoscopy and colonoscopy (with biopsies), CT-TAP, MRI small bowel and faecal elastase, all of which were normal. However, her faecal calprotectin was high at 130mg/kg (normal range 0-51mg/kg).Secukinumab was continued given her spinal disease improvement, however, after 18 months of therapy and ongoing gastrointestinal symptoms, Secukinumab was stopped in May-2021. Within weeks of stopping her GI symptoms completely resolved.Discussion/ResultsUse of Secukinumab has been licensed for rheumatological diseases such as psoriatic arthritis, AS and plaque psoriasis. It works by antagonizing interleukin 17, which is a pro-inflammatory cytokine. We started Secukinumab in this patient as per patient choice.Considering she developed gastrointestinal symptoms it was important to rule out IBD as Secukinumab has been associated with exacerbating underlying IBD or even inducing new cases. For this purpose, part of our workup included faecal calprotectin, colonoscopy and MRI to rule out IBD.We recommend for patient who are being treated with Secukinumab that if they develop gastrointestinal symptoms it is important to consider iatrogenic IBD. It is recommended in such cases to discontinue Secukinumab and consider alternative biologics with a different mode of action.It is still not clear what risk factors may help to predict which patients treated with Secukinumab for AS (or other seronegative disorders) could develop iatrogenic IBD. It is also unclear why the epiphenomenon of IBD can be exacerbated by IL17 inhibition when it is clear that such cytokine targeting in AS, psoriasis and psoriatic arthritis is evidently beneficial. Is there a role in pre-biologic screening and monitoring during treatment using faecal calprotectin?Key learning points/ConclusionThough Secukinumab is an effective biologic in the management of symptoms and disease control in Ankylosing spondylitis it can be associated with either flare or development of Inflammatory Bowel Disease phenomenon.

Clinical Features and Outcomes of Coronavirus Disease 2019 in Patients with Inflammatory Bowel Disease and Spondyloarthropathies.

Background:We aimed to determine the clinical features, predictive factors associated with severe disease, and outcomes of coronavirus disease 2019 in patients with immune-mediated inflammatory diseases and report data on the comparison of coronavirus disease 2019 between patients with inflammatory bowel disease and spondyloarthropathies.Methods:A total of 101 patients with inflammatory bowel disease and spondyloarthropathies who had confirmed diagnosis of coronavirus disease 2019 were retrospectively analyzed. Demographics, comorbidities, immunosuppressive treatments, and the impact of immunosuppression on negative outcomes were assessed.Results:The median age of the patients was 47 (38-57) years. The most common rheumatologic diagnosis was ankylosing spondylitis (n = 24), psoriatic arthritis (n = 17), and reactive arthritis (n = 1). In the inflammatory bowel disease group, 47 patients had ulcerative colitis, 11 Crohn’s disease, and 1 unclassified. The most commonly used treatments were biologics (55%) in the spondyloarthropathies group and aminosalicylates (66.1%) in the inflammatory bowel disease group. Overall, 18.8% of the patients required hospitalization, 5% developed severe complications, and 2% died. There were no significant differences in coronavirus disease 2019-related negative outcomes between spondyloarthropathies and inflammatory bowel disease patients. The median age was higher in the patients who required hospitalization [57 (46-66) vs 47 (38-57) years, P = .008]. Bilateral opacities on chest radiographs were more common in the patients who required hospitalization in the spondyloarthropathies group [88.9% vs 14.3%, P = .016]. Comorbidity was significantly associated with hospitalization in the inflammatory bowel disease group (P ≤ .05). Baseline therapy with biologics or immunosuppressives was not associated with severe coronavirus disease 2019 outcomes.Conclusion:Older age, comorbidities, and bilateral ground-glass opacities were associated with adverse outcomes, whereas specific immune-mediated inflammatory disease diagnoses or immunosuppressive treatments were not.

37-year-old Male Soccer Player With Low Back Pain

HISTORY: A 37-year-old male with history of acne presented with a several year history of low back pain. His pain acutely worsened 1 year prior to presentation and again 2 weeks prior to presentation without obvious mechanism of injury or trauma. Pain was localized to the midline low back without radiation. He described it as an ache or stiffness. Pain worsened with forward flexion and improved with stretching and ibuprofen. He denied any focal weakness, numbness, tingling, mechanical symptoms, changes in bowel or bladder function, skin changes or family history of back pain. He was previously evaluated by an outside physician and reported to have unremarkable lumbar spine radiographs. Prior treatments included ibuprofen as need, soft tissue work and stretching, which provided modest relief. PHYSICAL EXAMINATION: Strength and light touch sensation were full throughout the bilateral lower extremities. Bilateral patellar and Achilles reflexes were physiologic and symmetric. Gait was antalgic favoring the left leg. Lumbar spine range of motion was limited and painful. There was mild tenderness with palpation of the midline lumbar spine and bilateral SI joints. Modified Schober's test demonstrated only 1 cm of movement. DIFFERENTIAL DIAGNOSIS: 1) Lumbar strain; 2) Spondylosis; 3) Spondylolisthesis; 4) Inflammatory spondyloarthropathy; 5) Radiculopathy TEST AND RESULTS: Lumbar radiographs demonstrated large, asymmetric osteophyte formation at numerous levels from L2-S1 as well as multilevel bridging syndesmophytes compatible with an underlying inflammatory spondyloarthropathy. Hip radiographs demonstrated slight irregularity of the SI joints concerning for chronic sacroiliitis. FINAL WORKING DIAGNOSIS: Low back pain likely secondary to axial spondyloarthropathy. TREATMENT AND OUTCOMES: The patient was prescribed naproxen 500 mg twice daily for 7 days and referred to physical therapy. Referral to Rheumatology was discussed, but the patient elected to wait if no benefit from naproxen. At 1-month follow up, the patient had almost complete resolution of pain after the 7-day course of naproxen. He had only mild pain with extension of the spine and no pain with playing soccer or running.

Prevalence of ideal cardiovascular health and its correlates in patients with inflammatory bowel disease, psoriasis and spondyloarthropathy.

Prevalence of ideal cardiovascular health and its correlates in patients with inflammatory bowel disease, psoriasis and spondyloarthropathy.

Depression in patients with ankylosing spondylitis

AbstractAnkylosing spondylitis (AS) is a chronic inflammatory spondyloarthropathy that can cause severe physical and functional damage. The risk of depression is higher in AS patients than in the general population. Depression in AS patients affects disease prognosis and is receiving greater attention. By mining the literature on depression in AS patients in China and other countries, we analyzed research gaps and flaws in this area. In this review, we describe current knowledge regarding depression status, pathogenesis, disease relevance, and treatment of depression in AS patients. The findings may help to prevent depression, improve treatment, and enhance chronic disease management in AS patients.

Efficacy of thunder-fire moxibustion in treating ankylosing spondylitis of kidney deficiency and governor meridian cold and its influence on TNF-\u03b1 and RANKL: study protocol for a prospective, nonblinded, single-center, randomized controlled trial

BackgroundAnkylosing spondylitis (AS) is a common chronic inflammatory spondyloarthropathy. It is considered in traditional Chinese medicine (TCM) that the pathogenesis of AS is mainly due to Yang deficiency of kidney governor meridian and internal prosperity of cold evil. Thunder-fire moxibustion is a kind of moxibustion that is characterized in abundance in drug composition, high heat radiation, and strong penetration. Thunder-fire moxibustion on the spinal segment of the governor meridian in treating AS seems compatible with the main pathogenesis of kidney deficiency and governor meridian cold. The trial aims to explore the efficacy of thunder-fire moxibustion in patients with AS of kidney deficiency and governor meridian cold and its influence on bone metabolism, through a prospective randomized trial.MethodsSixty patients with AS of kidney deficiency and governor meridian cold will be recruited and randomly assigned to the treatment group (thunder-fire moxibustion three times a week plus basic treatment) and the control group (basic treatment) at the Center of TCM of Beijing Luhe Hospital Affiliated to Capital Medical University (Beijing, China). Each patient will be treated for 4 weeks. The primary outcome is the efficacy of TCM syndrome, and the secondary outcome indexes will include the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Short-Form-36 Questionnaire (SF-36), tumor necrosis factor-α (TNF-α), and receptor activator of nuclear factor-κB ligand (RANKL). TNF-α and RANKL with observation will be determined once respectively before and after treatment, while the other indexes will be observed once prior to the treatment, 2 weeks post-treatment, and at the end of the treatment. Side effects will be recorded and analyzed as well. Inter-group comparison and analysis will be performed based on the intention-to-treat set and per-protocol set.DiscussionThis prospective randomized trial will help verify the efficacy of thunder-fire moxibustion in treating AS of kidney deficiency and governor meridian cold, discuss preliminarily its mechanism in treating this disease, and provide high-quality evidences for scientific researches on clinical treatment with thunder-fire moxibustion against AS.Trial registrationChinese Clinical Trial Registry ChiCTR2100044227. Registered on 12 March 2021