Concomitant systemic lupus erythematosus and ankylosing spondylitis

Comorbid Ankylosing Spondylitis and Systemic Lupus Erythematosus: A Therapeutic Challenge

Ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE) are common rheumatologic ailments that cause multiorgan system disease. The incidence of lupus and AS in the same patient is rare and has seldom been described in the literature. Comorbid lupus and AS provide interesting diagnostic and therapeutic challenges. Here, we present a case of comorbid lupus and AS, discuss the diagnostic challenges in diagnosing these conditions, and put forth possible therapeutic interventions that may benefit similar patients.

Sacroiliitis in systemic lupus erythematosus : The rates of involvement of the forgotten joint

OBJECTIVE

Although musculoskeletal system involvement is a well-known manifestation in systemic lupus erythematosus (SLE), the probability of sacroiliac joint involvement and its effect on patients might be ignored. The aim of the study was to investigate the association between SLE and sacroiliitis and to evaluate the relationship between clinical parameters and sacroiliitis in SLE.

METHODS

The study was designed as a case-control study. A total of 63 patients with SLE and 31 age- and sex-matched healthy controls were included in the study. The clinical and demographic variables of the study population were documented. The sacroiliac joints of patients and controls were evaluated with sacroiliac magnetic resonance imaging. Human leukocyte antigen (HLA) B27 was assessed using flow cytometry (Beckman Coulter Navios-model 3, Beckman Coulter Inc., Brea, CA, USA). Multinomial logistic regression analysis was used to determine the clinical risk factors related to sacroiliitis.

RESULTS

Among the 63 patients, acute sacroiliitis was found in 25 patients (39.7%) and chronic sacroiliitis was found in 21 patients (33.3%). Sacroiliitis was higher in patients than in controls (p = 0.001). Acute sacroiliitis was more frequently observed in patients when compared with the control group (p = 0.001). Higher C‑reactive protein (CRP) concentrations (odds ratio = 1.75, 95% confidence interval: 1.30-2.35; p < 0.001) were found to be a risk factor for acute sacroiliitis.

CONCLUSION

The ratio of sacroiliitis was higher in patients with SLE than in controls. Increased CRP concentrations were determined as a risk factor for acute sacroiliitis. Thus, one should keep in mind that patients with SLE and higher CRP concentrations may have sacroiliitis.

Coexistence of ankylosing spondylitis and discoid lupus: A case report

Coexistence of ankylosing spondylitis with connective tissue diseases is very rare. Here, in this study, we describe a coexistence of ankylosing spondylitis and discoid lupus erythematosus in a 35-year-old man. He presented with a 5-year history of low back pain and concurrent development of a discoid rash. Inflammatory low back pain, HLA-B27 positivity and bilateral active sacroiliitis confirmed the diagnosis of ankylosing spondylitis. Discoid lupus erythematosus was diagnosed based on a skin biopsy. There are reports of discoid lupus associated with medications, particularly with tumour necrosis factor-alpha (TNF-α) blocking drugs. However, the patient presented here had coexistence of ankylosing spondylitis and discoid lupus before starting such treatments.

Patient with ankylosing spondylitis and scleroderma renal crisis

We report a 56-year-old man with a history of ankylosing spondylitis and systemic scleroderma. The patient had been diagnosed with ankylosing spondylitis 20 years ago and had been receiving treatment with NSAIDs and anti TNFα drugs. He referred to our rheumatology department for Raynaud’s phenomenon, arthralgias and weight loss. Physical examination revealed stiffness of the skin with difficulty in pinching (mainly at lower extremities, from knee to ankle). Soon after his first visit to our department, he developed renal scleroderma crisis with abrupt increase in blood pressure, decline in renal function, and microangiopathic haemolytic anaemia in accordance with positive antinuclear autoantibodies and positive anti-topoisomerase I antibody (anti-Scl70). This is one of the few reports in the literature of coexistence of ankylosing spondylitis and systemic scleroderma. A genetic correlation seems to be an explanation in some patients who carry one or two susceptibility alleles to both diseases. Thus, this might be the case of a ‘genetic trap’ in which distinct genes are cooperating to favour the susceptibility to two different HLA-associated systemic autoimmune diseases.

Entheseal involvement in systemic lupus erythematosus: are we missing something?

Background Musculoskeletal involvement is extremely common in patients with systemic lupus erythematosus (SLE). Continuing the research initiated in patients with inflammatory arthritis, recent studies have shown the potential role of musculoskeletal ultrasound (MSUS) in the evaluation of clinical and subclinical lupus synovitis. The inflammatory process in SLE is traditionally considered to be localized at synovial tissue areas while enthesis is not included among the possible targets of the disease. Patients and methods Entheses included in the Glasgow Ultrasound Enthesitis Scoring System were scanned in a cohort of 20 SLE patients serving as disease controls in an MSUS study aimed at assessing enthesitis in patients with psoriatic arthritis. We describe in detail four cases with unexpected and unequivocal expressions of MSUS enthesitis according to the OMERACT definition. Three out of four patients had no predisposing factors for enthesopathy. Case no. 2 was treated with a variable-dose prednisone regimen. Results In the four cases MSUS examination revealed relevant grey-scale and power Doppler abnormalities at the entheseal level, most commonly at the distal insertion of the patellar tendon. Signs of clinical enthesitis were detected in only one patient. Conclusions This case series shows for the first time the presence of clearly evident MSUS findings indicative of enthesitis in four out of 20 SLE patients (20%), raising the hypothesis that enthesis could be a missing target in the clinical evaluation of SLE patients. Our case series justifies further investigations for a better evaluation of the prevalence, characteristics and clinical relevance of entheseal involvement in SLE.

Sacroiliac joint involvement in systemic sclerosis

AIM

One of the major problems for systemic sclerosis (SSc) patients is suggested to be articular involvement. Mostly involved joints in SSc were reported as wrist, carpometacarpal-interphalangeal, foot, knee, hip and shoulder; however, there has been little knowledge on the sacroiliac joint. Our aim was to evaluate sacroiliac joint involvement in SSc.

METHODS

Fifty-seven SSc patients, 54 rheumatoid arthritis patients and 64 healthy subjects were included. Anteroposterior pelvic radiographs were obtained and graded twice by three blinded rheumatologists. One competent radiologist has re-evaluated the X-ray results. The ASAS (Assessment of Spondylo Arthritis International Society) scoring method was applied for grading sacroiliac involvement. Inflammatory back pain was also evaluated. Other clinical and laboratory data were collected as proposed by the European Study Group.

RESULTS

In the SSc group sacroiliitis was found in 13 patients (23%) and was significantly different from RA patients (two patients, 4%), P = 0.003; and the healthy control group (one participant, 2%), P < 0.001. The frequency of inflammatory back pain in SSc patients with sacroiliitis (8/13 patients, 62%) was significantly higher in SSc patients without sacroiliitis (4/44 patients, 9%), P < 0.001. The SSc patients with sacroiliitis and with inflammatory back pain (8/57 patients, 14%) were regarded as axial spondyloarthritis overlap. Male gender, diffuse subtype, inflammatory back pain and high C-reactive protein levels (odds ratio: 1.069, 1.059, 1.059 and 3.698, respectively) were found to be the significant risk factors for sacroiliitis.

CONCLUSION

We suggest that, sacroiliitis may be a concern to be considered in SSc practice.

Coexistence of systemic lupus erythematosus and ankylosing spondylitis: another case report and review of the literature

The coexistence of systemic lupus erythematosus (SLE) and ankylosing spondylitis (AS) is very rare, and, to the best of our knowledge, there are only 8 reported cases in the English literature. Here, we present another case with the coexistence of these two diseases, and review the clinical and laboratory features of the previously reported cases. A 55 year-old female patient, with a diagnosis of SLE with locomotor, skin, renal and hematopoietic system involvement, which had been confirmed by relevant autoantibody positivity, and hypocomplementemia and biopsy-proven membranous lupus nephritis, was referred to our clinic suffered from typical inflammatory low-back pain after eight years of follow-up. Sacroiliac magnetic resonance imaging (MRI) confirmed the presence of bilateral active sacroiliitis with bone marrow oedema. HLA-B27 was positive and bilateral calcaneal spurs were also detected by conventional radiography. Therefore, the additional diagnosis of AS was made, eight years after the diagnosis of SLE. Inflammatory low-back pain typically responded to treatment with non-steroidal anti-inflammatory drugs. Including the present case, most of the reported cases of the coexistence of SLE and AS are female, and SLE generally precedes the occurrence of AS. The present case is also notable as the patient had both MRI confirmation of bilateral active sacroiliitis and HLA-B27 positivity. The coexistence of these two diseases with different genetic backgrounds in the same patient is much lower than expected based upon their prevalence in the general population. Although it has been suggested that the very rare combination of the susceptibility genes of each disease may explain the rarity of coexistence, epidemiological data concerning the genetic risks for the coexistence of SLE and AS are not available.

Unusual association of ankylosing spondylitis with congenital spinal deformity

STUDY DESIGN

In all, 4 cases of the coexistence of congenital spinal deformity (CSD) and ankylosing spondylitis (AS) were reviewed.

OBJECTIVE

To provide an insight into the unusual association between CSD and AS.

SUMMARY OF BACKGROUND DATA

CSD combined with musculoskeletal anomalies, including clubfeet, Sprengel deformity, Klippel-Feil syndrome, and developmental dysplasia of the hip, has been described in the literature. Additionally, the rare coexistence between AS and other inflammatory joint diseases, such as systemic lupus erythematosus, mixed connective tissue disease, or Behçet disease, has also been reported. However, to the authors' knowledge, the coexistence of CSD and AS has not been described in the literature.

METHODS

In all, 4 patients presented with symptoms of lower back pain for at least 1 year. Among them, 3 patients (cases 1, 2, and 3) were initially diagnosed as CSD, and classified as butterfly vertebra in 2 patients (case 1, case 3), incarcerated hemivertebra in 1 patient (case 2). Furthermore, a diagnosis of coexistence of CSD and AS was proposed in these 3 cases with a delay in the diagnosis of AS for 1 to 10 years. The fourth patient sought initial medical attention in our hospital without delay in diagnosis. In case 1, polysegmental Smith-Petersen osteotomy and transpedicular fixation were performed, and drugs were administrated. Case 2, case 3, and case 4 were treated with amethopterin, folic acid, salicylazosulfapyridine, and celecoxib.

RESULTS

At the latest follow-up, 4 patients had no back pain and were satisfied with the outcome.

CONCLUSION

The coexistence of CSD and AS is very rare. However, it is necessary to consider the diagnosis of AS in CSD patients who present with symptoms such as inflammatory low back pain, morning stiffness, loss of global sagittal balance, and other clinical features can not be exclusively explained by CSD solely.

Coexistence of ankylosing spondylitis and systemic lupus erythematosus

Coexistence of ankylosing spondylitis with connective tissue diseases is uncommon. We describe here the coexistence of ankylosing spondylitis and systemic lupus erythematosus in a 35-year-old man. He presented with a 4-year history of pain in the hip joint and lower spine, and he later developed a malar rash and discoid rash. Immunological tests revealed that antinuclear antibody and double stranded DNA antibody were positive. The human leukocyte antigen B27 antigen was also found to be positive. We propose that development of systemic lupus erythematosus in this case may have been due to low grade chronic inflammation.

Ankylosing spondylitis and systemic sclerosis: a rare combination

We report a case of diffuse systemic sclerosis (skin, joints, esophagus, and Raynaud's phenomenon) in a 41-year-old Caucasian male with a 15-year history of ankylosing spondylitis and an episode of severe myocarditis of unknown origin. His HLA type included both the B27 allele conferring susceptibility to ankylosing spondylitis and the B35, DRB1 11, and DQB1 03 described as associated with systemic sclerosis. This case-report confirms that two inflammatory joint diseases may co-exist, particularly in patients carrying one or two susceptibility alleles to both diseases.

Systemic lupus erythematosus and dermatomyositis with symptomatic bilateral sacroiliitis: an unusual and interesting association

Systemic lupus erythematosus (SLE) is a multisystem autoimmune connective-tissue disease with a complex phenotype and varying disease course. Although SLE often causes a polyarticular synovitis, there are only a few case reports of abnormalities of the synovial lined sacroiliac joints. We report a case with an overlap syndrome of SLE and dermatomyositis who subsequently developed bilateral symptomatic sacroiliitis. We conclude that sacroiliitis, although rare, can occur in patients with active SLE as a manifestation of the disease per se.

Coexistence of ankylosing spondylitis and undifferentiated connective tissue disease

We report the case of a 45-year-old Caucasian woman suffering from ankylosing spondylitis and undifferentiated connective tissue disease in whom the prevailing clinical features were retinal vasculitis and inflammatory low back pain. HLA typing revealed the concomitant presence of B27 and DR2 antigens. We hypothesise that the uncommon coexistence of ankylosing spondylitis and connective tissue disease in the same patient could be due to the exceptional association of HLA- B27 with the DR2 antigen.