Ankylosing spondylitis with widespread arteritis

Cutaneous vasculitis in a patient with ankylosing spondylitis: A case report

RATIONALE

Cutaneous vasculitis is usually found in patients with rheumatoid arthritis (RA) as an extra-articular manifestation, but rare in patients with ankylosing spondylitis (AS). In this case, we describe an AS patient who developed large skin lesions, of which the histological findings were consistent with cutaneous vasculitis.

PATIENT CONCERNS

A 22-year-old male who was diagnosed as HLA-27 positive AS for 5 years. However, in the last year, he suffered a recurrent skin lesion in both lower extremities especially the dorsum of feet, accompanying with intense pruritus.

DIAGNOSIS

The originally diagnosis of the skin lessons was dermatitis, and then a skin biopsy pathology showed it was consistent with cutaneous vasculitis.

INTERVENTION

At first he was treated with gentamycin and ethacridine for nearly 2 weeks, the symptoms were relieved. But then he suffered severe cutaneous lesions with swell at the ulcerous margin in his dorsum of right foot. The patient was treated with dexamethasone 10 mg intravenous drip daily for 2 weeks, and followed by methylprednisolone 160 mg oral administration daily after discharge. The skin lesions were gradually healed in several months OUTCOMES:: This patient was followed up at 1-month, 5-month, and 10-month after discharged, the skin lessons was gradually healed and never occurred.

LESSONS

This case indicated that cutaneous vasculitis might be an extra-articular manifestation of AS in which IgA may plays a pathogenic part. All this may be associated with the damage of cytokines and autoantibodies to vascular endothelial wall caused by active inflammatory phase.

Abdominal aortitis in HLA-B27+ spondyloarthritis: case report with 5-year follow-up and literature review

OBJECTIVES

Aortic disease is a known complication of HLA-B27-associated spondyloarthritis. We present the case of a 52-year-old HLA-B27-positive woman with aortitis of the abdominal aorta and spondyloarthritis.

METHODS

In addition to the case reported, a literature search (MEDLINE) for articles published between 1946 and September 2013 was performed using combinations of the MEDLINE subject headings keywords "spondylarthritis," "ankylosing spondylitis," "reactive arthritis," "psoriatic arthritis," "aortitis," and "abdominal aorta." Relevant references were retrieved.

RESULTS

CASE REPORT

Our patient presented to the ER in June 2008 with a 3-week history of worsening of severe cramping lower abdominal pain. Her history also included recurrent acute episodes of iritis, which eventually led to enucleation of her left eye despite treatment with corticosteroids. CT of the abdomen showed findings suggesting aortitis of the abdominal aorta. She responded to therapy with prednisone, and follow-up imaging showed eventual resolution of the aortitis. She later went on to be diagnosed with psoriatic arthritis with spondylitis.

REVIEW OF LITERATURE

Six previously reported cases of abdominal aortitis in spondyloarthritis were found. Four of these were reported in patients with ankylosing spondylitis, one in reactive arthritis, and one in psoriatic arthritis. The first case reported was in 1958 and the most recent in 2012.

CONCLUSIONS

Rheumatologists should be aware of the possibility of abdominal aortitis occurring in their patients with SpA and should consider it as part of the differential diagnosis in a SpA patient with unexplained visceral pain or systemic features out of proportion to clinically apparent disease.

[Bilateral hydrothorax and hydromediastinum after puncture of the right subclavian vein]

Complications after the percutaneous insertion of central venous catheters are pneumothoraces, catheter-associated infections and thrombosis. In rare cases, late problems occur as a disruption of the main thoracic duct or vascular erosion. The developing pleural effusion must be analysed for other causes such as congestive heart disease, inflammatory or tumorous disease, pancreatitis, low blood protein, or subdiaphragmatic abscess. The following case report describes a rare catheter complication in a 16-year-old polytraumatised patient. The differentiation to a chylothorax and suitable therapy are described.

Unusual complications in an inflammatory abdominal aortic aneurysm

An unusual case of an inflammatory abdominal aortic aneurysm (IAAA) associated with coronary aneurysms and pathological fracture of the adjacent lumbar vertebrae. The associated coronary lesions in cases of IAAA are usually occlusions. In the present case, it was concluded that a possible cause of the coronary aneurysm was coronary arteritis and the etiology of the pathological fracture of the lumbar vertebrae was occlusion of the lumbar penetrating arteries due to vasculitis resulting in aseptic necrosis. Inflammatory AAA can be associated with aneurysms in addition to occlusive disease in systemic arteries. The preoperative evaluation of systemic arterial lesions and the function of systemic organs is essential.

Systemic vasculitis associated with seronegative spondylarthropathy (Reiter's syndrome)

A first case of Reiter's syndrome developing a severe systemic necrotising vasculitis is reported. After a disease course with major complications, aggressive consistent immuno-suppressive treatment was successful.

[Nailfold capillaroscopy and ankylosing spondylarthritis: incidence of anomalies, but absence of diagnostic and prognostic value]

Vascular involvement is seldom reported in ankylosing spondylitis (AS). In this study, microcirculation was evaluated by nailfold capillaroscopy in 32 defined AS patients compared to a control group (C) of 14 sciatica. Capillary findings were divided into five groups: normal, minor dystrophies, edema, microangiopathy, stagnation. Capillaroscopic abnormalities were more frequent in SA as compared to C, for edema (40% vs 7%) and microangiopathy (15% vs 0%). P = 0.01. There were neither clinical nor biological differences between AS patients with and without microangiopathy. Capillaroscopy abnormalities seem frequent in AS and may be secondary to an immune complex mechanism.

Vasculitis

Inflammatory changes in blood vessels are a prominent feature of several diseases, which can be categorized by the size of the vessels, the nature of the inflammatory exudate, and the specific organs involved. The clinical and laboratory findings are variable and frequently nonspecific. Therapy ranges from essentially just observation to high-dose steroids combined with immunosuppressive agents, but treatment must be individualized. Early and correct diagnosis is thus important, but because there is considerable overlap between diseases, especially in the leukocytoclastic vasculitis group, one should never delay initiation of therapy while one is trying to finalize the diagnosis, particularly when the patient may be deteriorating rapidly.

Ankylosing spondylitis and an aortic arch syndrome

A 63 year old woman with a 16 year history of ankylosing spondylitis and peripheral joint involvement later presented with a large vessel arteritis affecting the branches of the arch of the aorta.