Non-inflammatory Back Pain Research Articles

OA07 Is the SPADE tool a suitable way of screening patients for possible axial spondyloarthropathy

Abstract Background/Aims There are often significant delays to the diagnosis of axial spondyloarthritis (AxSpA). The imaging modality of choice to investigate for AxSpA is an MRI with a specific AxSpA protocol (MRI AS protocol). A common route of referral for MRI scans looking for AxSpA is via the community physiotherapy team. The Spondyloarthritis Diagnosis Evaluation (SPADE) tool has been designed to estimate the probability of patients having AxSpA. This study aimed to look at the relationship between SPADE tool probability score and MRI AS protocol results in patients who were referred from community physiotherapy. Methods This was a retrospective service evaluation. The sample was obtained from 200 MRI AS protocol requests between 6 January 2020 and 15 December 2021. For each patient, the MRI result was obtained from ICE electronic results software. MRI results were categorised as AxSpA, not AxSpA, or equivocal. For equivocal results, electronic patient notes were reviewed to identify whether patients went on to be diagnosed with AxSpA. The patient SPADE score (improbable, additional tests necessary, probable diagnosis, or definite diagnosis) was recorded for each patient. Information was obtained from the electronic physiotherapy notes to determine a SPADE score. Results Of the 200 scans requested, 21 scans were excluded (eight due to AS protocol not being performed; six due to duplicate requests; four not investigating for AxSpA; two where radiology had suggested MRI AS protocol; one patient awaiting recall for a repeat scan). Of the 179 patients who had MRI scans, 9.5% (n = 17) showed AxSpA, 8.9% were equivocal (n = 16) and 81.6% (n = 146) were negative. A SPADE score was determined for 177 patients (two had insufficient data to determine a score). 30% (n = 53) of patients were ‘improbable’, 56% (n = 99) were ‘additional tests necessary’, 8% (n = 14) were ‘probable’ and 6% (n = 11) were ‘definite’. Of the ‘improbable’ cases, three had MRI demonstrating AxSpA and one was equivocal (4/53 [7.5%]). 49 patients had no MRI evidence of AxSpA. Of the patients with MRI positive scans, 3/17 (17.6%) were ‘improbable’ using the SPADE tool. Conclusion Having a tool to screen patients in the community may help to better identify those who warrant further investigation for AxSpA. The SPADE tool may be a useful aid to identify who to refer for further investigation of inflammatory back pain. Many patients identified as ‘improbable’ by the SPADE tool did not have evidence of AxSpA. If the tool was applied prospectively, this may lead to large reduction in the number of MRI AS protocol scans performed. However, there were a small number of ‘improbable’ cases who had MRI evidence of AxSpA and could therefore be misdiagnosed as non-inflammatory back pain. Disclosure T. Nadin: None. S. Crompton: None. A. Chopra: None. N. Kotnis: None. L. Dunkley: Honoraria; Abbvie, UCB, Pfizer and Novartis. Other; Speakers fees from Abbvie, UCB, Pfizer and Novartis.

The relationship between kinesiophobia severity and clinical parameters in patients with mechanical low back pain.

Low back pain is an important widespread health problem that can occur at any age, causing serious socioeconomic losses. The objective of this study is to investigate the relationship between kinesiophobia severity and pain severity, depression, and quality of life in patients with mechanical low back pain. The study sample consisted of 155 patients, of whom 72 were female and 83 were male, aged between 18 and 75years with mechanical low back pain. Quality of life was assessed with the 36-Item Short Form Health Survey (SF-36), pain intensity with the Visual Analogue Scale (VAS), kinesiophobia with the Tampa Kinesiophobia Scale (TKS), and depression with the Beck Depression Inventory (BDI). Patients were divided into the low (TKS ⩽ 37) and high kinesiophobia (TKS > 37) groups according to the scores they obtained from TKS. VAS-pain severity and BDI scores were significantly higher in the high kinesiophobia group than in the low kinesiophobia group (p< 0.001). On the other hand, the SF-36 subscale scores were significantly higher in the low kinesiophobia group than in the high kinesiophobia group (p< 0.001). The TKS scores were moderately correlated with VAS-pain severity (r= 0.470; p< 0.001) and BDI scores (r= 0.584; p< 0.001) in the positive direction, and strongly correlated with all sub-parameters of quality of life in the negative direction (p< 0.001). The results indicated that the severity of kinesiophobia in patients with non-inflammatory low back pain is associated with pain severity, depression, and poor quality of life.

Spine abnormalities associated with bone edema on sacroiliac joints MRI in patients with non-inflammatory chronic back pain.

To investigate whether bone marrow edema (BME) fulfilling the ASAS definition of magnetic resonance imaging (MRI) sacroiliitis is associated with non-inflammatory spine abnormalities in patients with definite mechanical chronic back pain (CBP). Patients with definite mechanical CBP, according to the physician, started before the age of 45 and be lasting for more than 3months but less than 3years underwent a protocolized MRI and radiographs of sacroiliac joint (SIJ) and spine. BME and structural changes were scored, by three readers, for SIJ as well as non-inflammatory abnormalities for spine, including degenerative lesions and static disorders. Univariate analysis by Chi2 test was performed to search a statistical association between BME fulfilling the ASAS definition of MRI sacroiliitis and the presence of at least one non-inflammatory spine abnormality. A total of 94 patients were analyzed, 27 (29%) patients had BME and 16 (17%) patients had BME fulfilling the ASAS definition of MRI sacroiliitis; 86 (91.5%) patients had at least one non-inflammatory spine abnormality which are associated into 3 distinct clusters. BME was slightly more frequent at the lower and posterior part of the SIJ. MRI sacroiliitis was associated with interspinous bursitis, facet joint effusion and lateral spinal deviation and was more likely in patients with at least one non-inflammatory spine abnormality (OR: 4.96, 95% CI [1.47; 16.72]). BME fulfilling the ASAS definition of MRI sacroiliitis is significantly associated with non-inflammatory spine abnormalities in patients with mechanical CBP.

MRI lesions in SpA: a comparison with noninflammatory back pain using propensity score adjustment method.

Background:Magnetic resonance imaging (MRI) is important in the management of axial spondyloarthritis (SpA). However, many MRI lesions are not exclusive to axial SpA. Further characterization of these lesions may lead to better clinical decisions.Objective:The objective of this study was to compare the frequency of individual spinal MRI lesions between axial SpA and noninflammatory back pain. The factors associated with individual lesions in participants with axial SpA were also determined.Design:This was a cross-sectional observational study.Methods:MRI lesions in 447 participants with axial SpA and 122 participants with noninflammatory back pain were compared using the propensity score adjustment method. Individual lesions included discovertebral lesions (DVL), Modic type 1 lesions, DVL without Modic type 1 lesions, facet joint lesions, costovertebral joint lesions, corner inflammatory lesions (CIL), and fatty corner lesions (FCL). The factors associated with the lesions were determined using regression analyses.Results:Among participants with axial SpA, 81.9% were HLA-B27-positive, 55.0% had radiographic axial SpA, and 60.5% had radiographic features of spinal damage (mSASSS >2). Almost half (48.6% in axial SpA versus 31.1% in noninflammatory back pain) had inflammatory lesions on spinal MRI. In propensity score matching with noninflammatory back pain, axial SpA had an increased occurrence of DVL without Modic type 1 lesion (OR = 3.43, p = 0.01), costovertebral lesion (OR = 11.89, p = 0.02), number of CIL (B = 1.19, p < 0.001), and number of FCL (B = 3.33, p < 0.001). Similar associations were found in the regression models in the radiographic axial SpA subgroup: DVL without Modic type 1 lesion (OR = 2.46, p = 0.001), costovertebral lesion (OR = 3.86, p < 0.001), number of CIL (B = 1.13, p < 0.001), and FCL (B = 2.29, p < 0.01).Conclusion:MRI lesions including DVL without Modic type 1, costovertebral joint lesions, CIL, and FCL were more specific in axial SpA.

Uvéites : que doivent savoir le rhumatologue et l’interniste ?

Rheumatologists and internists may need to establish the etiological diagnosis and handle the therapeutic management of adults with uveitis. A prospective study named ULISSE (Uveitis: clinical and medicoeconomic evaluation of a standardized strategy for etiological diagnosis) has shown that a standardized strategy for the etiological diagnosis of uveitis was neither inferior nor superior to an open strategy. Subsequent analysis showed that only a few diagnostic tests were useful for the etiological assessment of uveitis. These tests were often inexpensive, simple, usually guided by clinical findings, and allowed an etiological diagnosis to be made for many patients. Three systemic diseases are particularly prevalent in patients referred to internists or rheumatologists: HLA-B27- and spondyloarthritis-associated uveitis, Behçet's disease, and sarcoidosis. Uveitis associated with spondyloarthritis follows a « rule of 90 »: around 90 of cases are unilateral, anterior, and acute. Among patients with uveitis and spondyloarthritis, about two thirds are diagnosed with joint disease during a uveitis assessment. Patients with inflammatory or noninflammatory low back pain should be routinely evaluated for spondyloarthritis, which is the leading cause of uveitis in western countries. The risk of blindness is extremely low, and the main complication is recurrent uveitis, seen in 50 to 60 % of cases. Sulfasalazine decreases the frequency, duration, and severity of uveitis and can be used prophylactically. Sarcoidosis is an underestimated cause of uveitis, which occurs in 15 % of cases, with a predilection for middle-aged women. The treatment of sarcoid uveitis largely follows the general principles of idiopathic uveitis. Behçet's disease uveitis affects young people of both sexes and of all origins and usually presents as panuveitis and retinal vasculitis. The treatment of Behçet's uveitis aims at a complete disappearance of the ocular inflammation. The prognosis of the severe and refractory forms has been dramatically changed by the introduction of TNF-α antagonists.

POS0039 MRI LESIONS IN SPA: A COMPARISON WITH AGE AND SEX MATCHED PARTICIPANTS WITH NON-INFLAMMATORY BACK PAIN

Background:Magnetic resonance imaging (MRI) is becoming increasingly important in axial spondyloarthritis (SpA) due to its unique role in early diagnosis, classification, and monitoring of disease (1, 2). It is the only disease assessment tool that has been validated with histological inflammatory cellularity in tissue biopsy of the sacroiliac (SI) joint (3). However, many MRI lesions are not exclusive to axial SpA and may occur in other conditions such as infection, degeneration and malignancy. Further characterization of these lesions may guide more targeted therapies.Objectives:The objective of this study was to describe, investigate associated factors, and to compare individual MRI lesions with age and sex matched controls.Methods:This was a cross-sectional observational study of MRI lesions of 431 participants with axial SpA compared with 53 age and sex matched participants with non-inflammatory back pain. Individual lesions identified included: discovertebral lesions (DVL), facet joint lesions, costovertebral joint lesions, corner inflammatory lesions (CIL), and fatty corner lesions (FCL). Associated factors of the lesions were determined by regression analyses.Results:Compared to the control group, participants with axial SpA had more costovertebral lesions (12.5% vs 1.9%; p=0.02), CIL (46.6% vs 15.1%; p=0.03), and FCL (55.5% vs 39.6%; p=0.03). Multivariate regression showed that age (OR=1.02; p=0.03), regular alcohol use (OR=0.40; p=0.04) and radiographic axial SpA (OR=1.89; p=0.01) were associated with DVL; Chinese ethnicity (OR=0.06; p=0.01) and radiographic axial SpA (OR=3.63; p=0.01) were associated with facet joint lesion; radiographic axial SpA (OR=4.26; p&lt;0.001) was associated with costovertebral joint lesion; male gender (ß=1.10; p=0.01), HLA B27 (ß=1.02; p=0.02), and radiographic axial SpA (ß=1.05; p=0.01) were associated with CIL; age (ß=0.10; p&lt;0.01), male gender (ß=1.96; p=0.01), body weight (ß=0.11; p&lt;0.01), HLA B27 (ß=3.23; p&lt;0.001), and radiographic axial SpA (ß=1.77; p=0.02) were associated with FCL.Conclusion:The individual MRI lesions more specific to axial SpA when compared to non-inflammatory back pain were costovertebral joint lesions, CIL, and FCL.

O13 Back to the Future: attempting to distinguish between inflammatory and non-inflammatory back pain

Case report - IntroductionBack pain is highly prevalent, affecting 40% of the paediatric population, with non-inflammatory causes accounting for the majority cases. However, the presentation of inflammatory back pain can be non-specific and a high degree of suspicion is necessary, particularly with the presence of risk factors such as HLA B27 positivity and personal and family history of psoriasis, inflammatory bowel disease, and acute uveitis.Case report - Case descriptionA previously well 14-year-old Caucasian girl was referred due to persistent lower back pain, HLA B27 positivity, and a history of acute uveitis. She reports that her pain began around the time of a road traffic accident two years previously. The pain was persistent but varied in intensity, worsened throughout the day, on bending forwards, and during bumpy car journeys, and on occasion was mildly relieved by ibuprofen. She later also developed neck pain and right lateral thigh pain. Despite her pain she was able to continue walking and swimming but found that she had to stop trampolining and cycling. She had recently been treated for a painful, red eye with topical treatment.On examination she had full range of movement of her spine and tenderness over her sacroiliac joints and plantar fascia insertion points, as well as more widespread muscle tenderness. Her bloods demonstrated normal inflammatory markers and MRI of her lumbar spine, pelvis, and sacroiliac joints showed a subtle disc degeneration with bulge at L5/S1 without nerve root compression or evidence of inflammation.An MDT approach was taken to manage her pain, with input from occupational therapy, discussing pain processing, pacing, pain management strategies, and sleep hygiene, and physiotherapy including hydrotherapy and a home exercise programme. Despite these interventions, her pain progressed and resulted in further functional impairment. Following MDT discussion, an MRI, already repeated after her first appointment, was performed for the third time which on this occasion demonstrated bilateral sacroiliitis with subchondral sclerosis, erosions, and bone marrow oedema. A diagnosis of enthesitis-related arthritis was made and treatment with diclofenac and etanercept was initiated.Case report - DiscussionWith HLA B27 positivity and a history of acute uveitis, she was clearly at risk of developing inflammatory arthritis, but without evidence of inflammation on imaging or bloods, treatment with immunomodulatory drugs was not indicated. With a high prevalence of non-inflammatory musculoskeletal pain in adolescent females and the significant rate of persistent chronic pain into adulthood for untreated patients, early MDT input in this patient’s management was essential. While management of non-inflammatory pain is primarily driven by therapists, this case highlights the benefit of communication within the MDT and the important role of the medical team, in regularly reviewing the diagnosis, particularly where symptoms evolve or do not follow the expected clinical course.Case report - Key learning pointsIn the presence of risk factors for spondyloarthropathy, a diagnosis of non-inflammatory back pain needs to be regularly reviewed and evolving symptoms, clinical deterioration, and patient or parent concerns need to be addressed. Although important, HLA B27 positivity has an overall penetrance of less than 20% and therefore does not exclude a diagnosis of non-inflammatory back pain. However, when coupled with history of uveitis or significant family history, repeat imaging should be considered.

Axial Spondyloarthritis after bariatric surgery: a 7-year retrospective analysis

BackgroundIn recent decades, obesity has become a public health problem in many countries. The objective of this study was to evaluate the main joint and extra-articular manifestations related to spondyloarthritis (SpA) after bariatric surgery (BS) in a retrospective cohort.MethodsDemographic, clinical, laboratory and imaging data from nine patients whose SpA symptoms started after a BS have been described. Modified New York (mNY) criteria for ankylosing spondylitis (AS) and the Assessment of Spondyloarthritis International Society (ASAS) criteria for axial (ax-SpA) and peripheral (p-SpA) spondyloarthritis were applied.ResultsThe mean weight reduction after BS was 49.3 ± 21.9 kg. The BS techniques were Roux-en-Y gastric bypass (n = 8; 88.9%) and biliopancreatic diversion with duodenal switch (n = 1; 11.1%). Four (44.4%) patients had no axial or peripheral pain complaints before BS, while the other four (44.4%) had sporadic non-inflammatory back pain that had been attributed to obesity. One patient (11.1%) had persistent chronic back pain. In all nine cases, patients reported back pain onset or pattern (intensity or night pain) change after BS (mean time 14.7 ± 18 months). In addition, 8 of them (88.9%) were human leukocyte antigen (HLA)-B27 positive. All nine patients could be classified according to ASAS criteria as ax-SpA and five (55.6%) patients were classified as AS, according to the mNY criteria.ConclusionOur data highlight a temporal link between SpA onset symptoms and the BS, suggesting a possible causal plausibility between the two events.

Prevalence of rheumatic disease in Colombia according to the Colombian Rheumatology Association (COPCORD) strategy. Prevalence study of rheumatic disease in Colombian population older than 18 years

IntroductionRheumatic diseases are the leading cause of permanent disability. The COPCORD model is an effective tool in the determination of the prevalence of diseases. The objective of this study is to estimate the prevalence of rheumatic disease in a Colombian population over 18 years of age. MethodsA prevalence study was carried out using a probabilistic method of stratified random sampling in three stages: cartographic sectors in each city, selection of the blocks of each sector, and the households of each block. The COPCORD questionnaire adapted for Colombia was applied by standardized interviewers. Confirmation of the diagnosis was made by a rheumatologist with access to all the information. ResultsOut of a total of 6693 patients that completed the questionnaire, 64% were women. Pain not associated with trauma was reported by 48% of the participants. The most frequent locations were: knees 35%, hands 26%, lumbar spine 20%, and shoulders 16%. Non-specific skeletal muscle discomfort, osteoarthritis, regional appendicular syndrome, and non-inflammatory low back pain, were the most prevalent diseases. Rheumatoid arthritis and chronic inflammatory low back pain were the most common inflammatory conditions. The prevalence of Chikungunya fever was estimated at 6.68%. ConclusionThe prevalence of rheumatoid arthritis in Colombia is higher than commonly reported, lower than for fibromyalgia and gout, and similar for osteoarthritis, systemic lupus erythematosus and spondyloarthritis. In Colombia these diseases are a public health problem without awareness of their impact on the general population.

Prevalencia de la enfermedad reumática en Colombia, según estrategia COPCORD-Asociación Colombiana de Reumatología. Estudio de prevalencia de enfermedad reumática en población colombiana mayor de 18 años

IntroductionRheumatic diseases are the leading cause of permanent disability. The COPCORD model is an effective tool in the determination of the prevalence of diseases. The objective of this study is to estimate the prevalence of rheumatic disease in a Colombian population over 18 years of age. MethodsA prevalence study was carried out using a probabilistic method of stratified random sampling in three stages: cartographic sectors in each city, selection of the blocks of each sector, and the households of each block. The COPCORD questionnaire adapted for Colombia was applied by standardised interviewers. Confirmation of the diagnosis was made by a rheumatologist with access to all the information. ResultsOut of a total of 6,693 patients that completed the questionnaire, 64% were women. Pain not associated with trauma was reported by 48% of the participants. The most frequent locations were: knees 35%, hands 26%, lumbar spine 20%, and shoulders 16%. Non-specific skeletal muscle discomfort, osteoarthritis, regional appendicular syndrome, and non-inflammatory low back pain, were the most prevalent diseases. Rheumatoid arthritis and chronic inflammatory low back pain were the most common inflammatory conditions. The prevalence of Chikungunya fever was estimated at 6.68%. ConclusionThe prevalence of rheumatoid arthritis in Colombia is higher than commonly reported, lower than for fibromyalgia and gout, and similar for osteoarthritis, systemic lupus erythematosus and spondyloarthritis. In Colombia these diseases are a public health problem without awareness of their impact on the general population.

Inflammatory back pain in psoriatic arthritis is significantly more responsive to corticosteroids compared to back pain in ankylosing spondylitis: a prospective, open-labelled, controlled pilot study

BackgroundThe efficacy of corticosteroids in patients with psoriatic arthritis (PsA) and inflammatory back pain has not been studied to date. In this controlled trial, we aimed to investigate the comparative performance of corticosteroids in patients with active axial-PsA (AxPsA) versus those with active ankylosing spondylitis (AS).MethodsPatients with AxPsA and AS (naïve to biologic therapies), who not only had clinically active disease, but also had bone marrow oedema on magnetic resonance imaging of the sacroiliac joints, were recruited. Clinically active disease was defined as inflammatory back pain (fulfilling Assessment of Spondyloarthritis International Society (ASAS) expert criteria), with spinal pain score (numerical rating scale 0–10) ≥4 and Bath AS Disease Activity Index (BASDAI) score ≥4 despite taking nonsteroidal anti-inflammatory drugs. Moreover, we recruited a control group of patients with non-inflammatory lower back pain. All patients received a single, intra-muscular dose of depot corticosteroid injection (triamcinolone acetonide 80 mg) at baseline. The intra-muscular corticosteroid option was used to overcome any drug compliance issues. Clinical outcome assessments were made at the following time points: baseline, week 2, and week 4. The primary efficacy end point was mean change in Ankylosing Spondylitis Disease Activity Score (ASDAS) at week 2. Key secondary outcomes were mean change in the BASDAI, Bath Ankylosing Spondylitis Functional Index (BASFI) and Ankylosing Spondylitis Quality of Life (ASQoL) at weeks 2 and 4.ResultsIn total, 40 patients were recruited (15 with AxPsA, 15 with AS, and 10 controls). At week 2 following corticosteroid treatment, patients with AxPsA had significantly greater improvement in the mean ASDAS compared to patients with AS (1.43 ± 0.39 vs. 1.03 ± 0.30, p = 0.004), and also when compared to controls (p < 0.001). At week-4, similar significant trend of ASDAS improvement was seen among AxPsA patients compared to AS patients (1.09 ± 0.32 vs. 0.77 ± 0.27, p = 0.007) and controls (p < 0.001). Similarly, the mean BASDAI, visual analogue scale spinal pain score, ASQoL and BASFI improved significantly among patients with AxPsA compared to patients with AS and controls at week 2 (p < 0.05), with this trend also largely maintained at week 4.ConclusionsAxial inflammation in patients with PsA responds significantly better to corticosteroids than in patients with AS. This furthers the argument and adds to the growing evidence that AxPsA and AS are distinct entities.

Soluble erythropoietin receptor levels associate with inflammatory mediators but not with disease activity or cumulative organ damage in patients with systemic lupus erythematosus

The erythropoietin receptor (EpoR) stimulates erythrocyte proliferation after erythropoietin binding. EpoR belongs to the cytokine receptor superfamily and can be found on macrophages and endothelial cells. As there are no data on the role of EpoR systemic autoimmune diseases, we investigated the role of soluble EpoR (sEpoR) in patients with systemic lupus erythematosus (SLE). In a cross-sectional study we recorded clinical characteristics, disease activity (SLEDAI-2K) and organ damage (SDI). sEpoR, autoantibodies and cytokines were measured by enzyme-linked immunosorbent assay (ELISA) in SLE patients (n = 100) and compared with a rheumatoid arthritis (RA) cohort (n = 57) and a cohort with non-inflammatory back pain (NIBP; n = 89). Data were analysed with non-parametric techniques. We found no significant difference in sEpoR levels across the SLE, RA and NIBP groups and sEpoR levels were similar in patients with (6% of SLE and 31% of RA) or without anaemia. sEpoR levels were unrelated to haemoglobin levels, SLEDAI-2K or SDI scores, but in both cohorts correlated with levels for C-reactive protein (CRP), interleukin-6 (IL-6), tumour necrosis factor (TNF) and IL-1 (all P &lt; 0.001). sEpoR levels are not involved in anaemia or erythropoietin resistance in SLE and RA patients, but closely mirror the underlying inflammatory process. This suggests that increased shedding of sEpoR during inflammation occurs at other sites than bone marrow.

Pain in ankylosing spondylitis: a neuro-immune collaboration.

Clinicians have commonly differentiated chronic back pain into two broad subsets: namely, non-inflammatory (or mechanical) back pain and inflammatory back pain. As the terminology suggests, the latter category, in which ankylosing spondylitis (AS) is prominent, presupposes a close link between pain and inflammation. Advances in research into the genetics and immunology of AS have improved our understanding of the inflammatory processes involved in this disease, and have led to the development of potent anti-inflammatory biologic therapeutic agents. However, evidence from clinical trials and from biomarker and imaging studies in patients with AS indicate that pain and inflammation are not always correlated. Thus, the assumption that pain in AS is a reliable surrogate marker for inflammation might be an over-simplification. This Review provides an overview of current concepts relating to neuro-immune interactions in AS and summarizes research that reveals an increasingly complex interplay between the activation of the immune system and pain pathways in the nervous system. The different types of pain experienced by patients with AS, insights from brain imaging studies, neurological mechanisms of pain, sex bias in pain and how the immune system can modify pain in patients with AS are also discussed.

Uveitis in adults: What do rheumatologists need to know?

Rheumatologists may need to establish the etiological diagnosis and handle the therapeutic management of adults with uveitis. To date, no diagnostic strategy for uveitis has been validated by prospective studies. Investigations are selected based on the clinical features and on the anatomic location of the ocular abnormalities. Infections such as syphilis, Lyme disease, tuberculosis, and Whipple's disease may cause uveitis, with concomitant joint inflammation in a few cases. In patients with a known history of chronic inflammatory joint disease, causes of uveitis include bisphosphonate therapy and immunodepression-related infections (e.g., due to Toxoplasma or a herpes virus). Sarcoidosis is an underestimated cause of uveitis, which occurs in 15% of cases, with a predilection for middle-aged women. In spondyloarthritis, uveitis is almost always acute, unilateral, and anterior. Among patients with uveitis and spondyloarthritis, about two thirds have their joint disease diagnosed during an evaluation for uveitis. Therefore, patients with inflammatory or noninflammatory back pain should be routinely evaluated for spondyloarthritis, which is the leading cause of uveitis in western countries. The risk of blindness is extremely low, and the main complication is recurrent uveitis, seen in 50% to 60% of cases. Sulfasalazine decreases the frequency, duration, and severity of uveitis and can be used prophylactically.

Isotretinoin-induced skeletal hyperostosis.

We describe a case of skeletal hyperostosis in a 29 year old man presenting with non-inflammatory back pain with a past history of isotretinoin therapy for acne. The development of skeletal hyperostosis, predominantly of the spine, has been reported in association with isotretinoin use and has a radiographic picture similar to diffuse idiopathic skeletal hyperostosis. The prevalence and severity of this condition appears to correlate with duration of therapy. Isotretinoin is a well-established treatment for severe acne. It is important for the rheumatologist be aware of this phenomenon when assessing young patients with musculoskeletal symptoms and evidence of radiological abnormalities.

Burden of Rheumatic Diseases in A Rural Community of Bangladesh

Objective: To estimate the magnitude, burden of illness and help-seeking behavior of patients with musculoskeletal complaints and to provide incidence of osteoarthritis, low back pain, fibromyalgia, rheumatoid arthritis, gout, and other inflammatory and non-inflammatory rheumatic diseases in a rural community of Bangladesh. Methods: The study was conducted in a few villages near Dhaka city which were considered to be a fairly representative sample of Bangladeshi rural population. Data were collected with the help of modified Community Oriented Program for Control of Rheumatic Diseases (COPCORD) questionnaire and a diagnosis using American College of Rheumatology (ACR) criteria was established. Results: During the 18 months study period, 2685 adults (15 years and above) were included. A total of 441 (M=163, F=278) developed new musculoskeletal (MSK) pain. The incidence rates were 10.9/100 person-years (PY) for the whole population, 8.2/100 PY for males and 13.6/100 PY for females. Nonspecific low back pain (NSLBP), fibromyalgia and osteoarthritis of knee were common MSK problems. A total of 302 patients had complaints of low back pain, of them 204 persons had noninflammatory low back pain; 262 respondents had complaints of knee pain, 38 had satisfied the criteria of knee OA; a total of 116 respondents suffered from fibromyalgia during the study period. Of the respondents (M=17, F=24) 41 had inflammatory arthropathy. Among the incidences of inflammatory arthritis, rheumatoid arthritis 120 (M=101, F=147), spondyloarthropathies 150 (M=252, F=49), ankylosing spondylitis 75 (M=151, F=0), reactive arthritis 50 (M=101, F=0), and psoriatic arthritis 256 (M=0, F=49) per 100,000 / PY respectively were observed, Conclusions: Rheumatic diseases are common in the rural community of Bangladesh, affecting nearly a quarter of adult population. Non-specific low back pain (NSLBP), fibromyalgia and osteoarthritis of knee joints are common joint disorders; point prevalence estimates of most common diagnoses were similar to other community surveys using COPCORD methodology.DOI: http://dx.doi.org/10.3329/jom.v15i2.20685 J MEDICINE 2014; 15 : 125-130

Evaluation of Pain Intensity and Oxidative Stress Levels in Patients with Inflammatory and Non-Inflammatory Back Pain

To investigate the relationship between pain threshold and oxidative stress levels in patients with acute and chronic inflammatory or non-inflammatory back pain. A total of 137 patients were recruited for the study, including 33 acut back pain (32 lumbar disk herniation, 1 lumbar spondilosis) (16 men, 17 women), 35 with chronic back pain (33 lumbar disk herniation, 1 lumbar spondilosis, 1 sacralisation) (16 men, 19 women), 34 with ankylosing spondylitis (21 men, 13 women) (AS) and 35 without any back pain (15 men, 20 women). The visual analogue scale (VAS) was used to evaluate pain levels and algometry was used to evaluate the pain threshold in all cases. In addition, serum malondialdehyde (MDA) levels were assessed in all patients. The mean ages for groups 1, 2, 3, and 4 were 40.3p10.3, 39.9p9.7, 40.6p10.4, and 38.5p8.1 years, respectively. There was no significant difference between the ages of the groups (p=0.851) (Table 1). The VAS scores of all groups were significantly higher compared to the control group. Particularly, the acute and chronic back pain groups had significantly higher VAS scores than those of the AS group. All three back pain groups had significantly higher serum MDA levels compared to those of the control group (p

Pituitary Gigantism: A Case Report

Objective:To present a rare case of gigantism.Case Report:A 25-year-old lady presented with increased statural growth and enlarged body parts noticed since the age of 14 years, primary amenorrhea, and frontal headache for the last 2 years. She has also been suffering from non-inflammatory low back pain with progressive kyphosis and pain in the knees, ankles, and elbows for the last 5 years. There was no history of visual disturbance, vomiting, galactorrhoea, cold intolerance. She had no siblings. Family history was non-contributory. Blood pressure was normal. Height 221 cm, weight 138 kg, body mass index (BMI)28. There was coarsening of facial features along with frontal bossing and prognathism, large hands and feet, and small goitre. Patient had severe kyphosis and osteoarthritis of knees. Confrontation perimetry suggested bitemporal hemianopia. Breast and pubic hair were of Tanner stage 1. Serum insulin like growth factor-1 (IGF1) was 703 ng/ml with all glucose suppressedgrowth hormone (GH)values of >40 ng/ml. Prolactin was 174 ng/ml. Basal serum Lutenising Hormone (LH), follicle stimulating Hormone (FSH) was low. Oral glucose tolerance test (OGTT), liver and renal function tests, basal cortisol and thyroid profile, Calcium, phosphorus and Intact Parathyroid hormone (iPTH) were normal. Computed tomographyscan of brain showed large pituitary macroadenoma. Automated perimetry confirmed bitemporal hemianopia. A diagnosis of gigantism due to GH secreting pituitary macroadenoma with hypogonadotrophichypogonadism was made. Debulking pituitary surgery followed by somatostatin analogue therapy with gonadal steroid replacement had been planned, but the patient refused further treatment.

Comparative study of MRI and power Doppler ultrasonography of the heel in patients with spondyloarthritis with and without heel pain and in controls

IntroductionImaging of heel enthesopathy in spondyloarthritis (SpA) could potentially be useful for diagnosis and monitoring. The aim of this study was to assess the diagnostic capacities of MRI and power...

Baseline and 1-year magnetic resonance imaging of the sacroiliac joint and lumbar spine in very early inflammatory back pain. Relationship between symptoms, HLA-B27 and disease extent and persistence

Background:The precise anatomical location of pathology associated with inflammatory back pain (IBP) in early spondyloarthropathy (SpA) remains unclear.Objective:To use MRI to study the sacroiliac joint (SIJ) and lumbar spine (LS)...