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Spondyloarthropathies
Table 1: Modified New York Criteria for Ankylosing Spondylitis
nationwide sample of Belgian AS patients. The patients were followed at
different academic and non-academic centres. In the study, 83% of the
1. Low-back pain of at least three months’ duration that is improved by exercise and
patients (n=847) fulfilled the New York modified criteria for definite AS,
not relieved by rest.
and 17% of patients (n=176) were considered as probable AS.
27
2. Limited lumbar spinal motion in sagittal and frontal planes.
3. Chest expansion decreased relative to normal values for sex and age.
In a sub-analysis of the 847 patients diagnosed with definite AS, 42%
4. Bilateral sacroiliitis grade 2–4 or unilateral sacroiliitis grade 3 or 4.
presented with at least one extra-articular manifestation: 27% were
Definite ankylosing spondylitis if criterion 4 and any one of the other criteria are fulfilled.
diagnosed with anterior uveitis, 11% with psoriasis, 10% with IBD and
Table 2: Extra-articular Manifestations of Ankylosing Spondylitis
5% had more than one extra-articular manifestation.
14
These data
provide important information on clinical and radiological features of the
Ocular Uveitis
disease and confirm that many patients who present with AS are also
Skin Psoriasis nail lesions (onycholysis)
suffering from other extra-articular inflammatory diseases. Moreover, this
Gastrointestinal Painless oral ulcerations, asymptomatic gut inflammation,
inflammatory bowel disease
highlights the importance of recognising and treating co-morbid
Cardiac Aortitis
inflammatory diseases in patients with AS.
Valvular insufficiency
Heart block
Additionally, a second arm of the study in Belgium suggests that patients
who present with extra-articular manifestations associated with AS may
tests and imaging should be utilised in patient assessment. These suffer from a different disease phenotype in terms of more peripheral
components should all refer to the clinical presentation, as well as to the articular disease than those who suffer from the primary disease alone.
28
ASAS core set that was developed to assess disease status in AS.
16,17
The The analysis showed that uveitis-associated AS patients developed the
core components for patient assessment and their recommended disease at a younger age (24.3 versus 27.3 years) compared with primary
measurement instruments have been selected based on the best available AS patients (p=0.0019). Furthermore, oligoarthritis (odds ratio (OR) 1.49,
evidence and consensus of opinion. Laboratory markers of disease, such as 95% confidence interval (CI) 1.08–2.05) and hip arthritis (OR 1.44, 95%
the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, CI 1.02–2.03) were more frequent in uveitis-associated AS patients
are elevated in 50–70% of AS patients.
18
However, these markers generally (p=0.014 and p=0.036, respectively). Similar results were observed when
do not correlate with disease activity and have been shown to be unhelpful contrasting AS patients with IBD with those without IBD. In AS patients
in monitoring the response to treatment.
18,19
with psoriasis, 52% presented with oligoarthritis compared with only
31% in AS-only patients (OR 2.26, 95% CI 1.32–3.87; p=0.029). There
Extra-articular Manifestations of Ankylosing Spondylitis were no significant differences seen in Bath Ankylosing Spondylitis
Peripheral disease and extra-articular manifestations are common features Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional
of AS that can significantly add to the burden of the disease.
20
Extra-articular Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), CRP,
manifestations of AS can involve almost any organ system (see Table 2). The HLA-B27 or sacroiliitis grading.
most frequent extra-articular manifestation in AS is anterior uveitis, which
can occur in 25–30% of patients.
19
The uveitis is usually acute, unilateral and Conclusions
recurrent. Presenting signs include eye pain, red eye, blurry vision, The clinical assessment of AS remains a challenge; however, over the
photophobia and increased lacrimation. It is important not to mistake uveitis last decade standards of treatment and assessment of outcome in AS
for a viral or bacterial infection. B27-negative AS is associated with a less patients have improved considerably. Moreover, the international
frequent prevalence of acute anterior uveitis than B27-positive AS.
12
A close community of AS researchers has made important advances in creating
relationship exists between gut inflammation and SpAs, and several studies and validating outcome measures in AS, although there is still a need
have demonstrated that 5–10% of AS patients have overt inflammatory for suitable biomarkers to help diagnose and monitor disease activity.
bowel disease (IBD), with approximately two-thirds of patients The identification of the origin of inflammatory back pain using
demonstrating microscopic, subclinical gut inflammation.
21–23
Cardiac magnetic resonance imaging (MRI) has the potential to improve earlier
involvement is a very rare complication of AS. Cardiac extra-articular diagnosis of AS-related pain and thus facilitate earlier treatment.
features include aortic incompetence and associated cardiac conduction Additionally, enhanced therapeutic options have the potential to
disturbances or heart block.
24–26
improve outcomes, particularly in terms of functional ability and quality
of life. In terms of extra-articular manifestations of AS, the significant
The ASPECT Study and Extra-articular Manifestations of impact of these clinical features on AS patients suggests that clinicians
Ankylosing Spondylitis should consider adjusting their approach to total disease management
As mentioned previously, the ASPECT study was a representative, in this population. ■
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26 EUROPEAN MUSCULOSKELETAL REVIEW 2007
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