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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 21
| Issue : 3 | Page : 204-207 |
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Clinical profile of ankylosing spondylitis at a teaching hospital
Yogesh Karoli1, Sachin Avasthi1, Swagat Mahapatra1, Ritu Karoli2
1 Department of Orthopedics, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| Date of Submission | 27-Oct-2020 |
| Date of Decision | 27-Apr-2021 |
| Date of Acceptance | 05-Aug-2021 |
| Date of Web Publication | 26-Sep-2022 |
Correspondence Address:
Ritu Karoli
Department of Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/aam.aam_103_20
 Abstract | | |
Introduction/Background: Ankylosing spondylitis (AS), a type of spondyloarthropathy, is an autoimmune disease that mainly involves spine joints, sacroiliac joints and their adjacent soft tissues, such as tendons and ligaments. Progression of disease can lead to fibrosis and calcification, resulting in the loss of flexibility and mobility of the spine. The common clinical presentation is inflammatory back pain which is often neglected. The aim of our study was to assess the demographic and clinical proflie of patients of ankylosing spondylitis diagnosed on the basis of radiographic sacroillitis. Methods: In a cross sectional hospital based study, the patients visiting to outpatient departments with inflammatory back pain were evaluated and 200 patients who had sacroiliitis according to modified New york criteria were diagnosed to have ankylosing spondylitis.The demographic and clinical profile was studied. Disease activity was assessed by using the ASDAS and BASDAI and function by BASFI and BASMI.Results: Amongst the study participants, 72 % were males and 28 % were females. The mean age of participants was 46± 12years. The mean duration of symptoms was10± 3 years. Out of all, 92% patients were HLA B27 positive. High BASDAI score (>4) was positively correlated with elevated CRP, ESR ,neutrophil lymphocyte ratio and had negative correlation with serum vitamin D levels. Conclusion: Most of the patients in our study had advanced disease might be due to delay in the diagnosis. They had high BASDAI with elevated inflammatory markers. Awareness for early and definite diagnosis of ankylosing spondylitis is needed to prevent irreversible structural damage, and worsening of quality of life.
| Abstract in French | | |
Résumé
Introduction/Contexte: La spondylarthrite ankylosante (AS), un type de spondyloarthropathie, est une maladie auto-immune qui implique principalement Les articulations de la colonne vertébrale, les articulations sacroiliaques et leurs tissus mous adjacents, tels que les tendons et les ligaments. La progression de la maladie peut entraîner une fibrose et Calcification, entraînant la perte de flexibilité et de mobilité de la colonne vertébrale. La présentation clinique courante est les maux de dos inflammatoires qui est souvent négligé. Le but de notre étude était d'évaluer le proflie démographique et clinique des patients de la spondylarthrite ankylosante diagnostiquée sur la base de la sacroie radiographique. Méthodes: Dans une étude en section d'hôpital transversal, les patients visitant des services ambulatoires avec des maux de dos inflammatoires ont été évalués et 200 patients souffrant de sacro -iliite selon les critères modifiés de New York ont été diagnostiqués avoir une spondylite ankylosante. Le profil démographique et clinique a été étudié. L'activité de la maladie a été évaluée en utilisant les Asdas et Basdai et fonction par Basfi et Basmi. Résultats: Parmi les participants à l'étude, 72% étaient des hommes et 28% étaient des femmes. La moyenne L'âge des participants était de 46 ± 12 ans. La durée moyenne des symptômes était de 10 ± 3 ans. Sur tous, 92% des patients étaient positifs HLA B27. Le score de Basdai élevé (> 4) était positivement corrélé avec le rapport lymphocytaire CRP, ESR, ESR élevé et avait une corrélation négative avec taux sériques de vitamine D. Conclusion: La plupart des patients de notre étude avaient une maladie avancée pourraient être dus à un retard dans le diagnostic. Ils avaient Basdai élevé avec des marqueurs inflammatoires élevés. Une conscience pour un diagnostic précoce et définitif de la spondylarthrite ankylosante est nécessaire pour prévenir Dommages structurels irréversibles et aggravation de la qualité de vie.
Mots-clés: spondylarthrite ankylosante, indice d'activité de la spondylarthrite ankylosante du bain, maux de dos inflammatoires, spondyloarthropathie
Keywords: Ankylosing spondylitis, bath ankylosing spondylitis activity index, inflammatory back pain, spondyloarthropathy
How to cite this article:
Karoli Y, Avasthi S, Mahapatra S, Karoli R. Clinical profile of ankylosing spondylitis at a teaching hospital. Ann Afr Med 2022;21:204-7 |
| Introduction | |  |
Axial spondyloarthropathy is chronic inflammatory arthritis mainly comprising ankylosing spondylitis (AS) and nonradiographic axial spondyloarthropathy affects the axial skeleton.[1] AS is characterized by inflammatory back pain, radiographic sacroiliitis, excess spinal bone formation, and a high prevalence of HLA–B27.[2] The severity of arthralgia, stiffness, and limited flexibility varies widely among patients and over the course of illness. Skeletal disease may be accompanied by uveitis, psoriasis, and inflammatory bowel disease. Disease activity in AS is normally measured by using the AS disease activity score (ASDAS)[3] and Bath AS Activity Index (BASDAI),[4] which is a patient-based questionnaire. AS left unmanaged may lead to irreversible structural damage and reduced spinal mobility. These patients can experience considerable physical, economic, and emotional burden. Therefore, early diagnosis and treatment before irreversible changes occur are crucial for managing patients with AS.[5],[6]
The aim of our study was to assess the demographic and clinical profile of patients of AS diagnosed on the basis of radiographic sacroiliitis.
| Materials and Methods | | |
This was a cross-sectional hospital-based study conducted in Departments of Medicine and Orthopedics at a Medical College Hospital from May 2018 to December 2018. A written informed consent form was obtained from each participant in the study. The study protocol was approved by Institutional Ethics Committee.
All the patients who had a history of inflammatory back pain were enrolled. Criteria for inflammatory back pain were (1) morning stiffness of >30 min, (2) improvement in back pain with exercise but not with rest, (3) awakening because of back pain during the second half of the night only, (4) alternating buttock pain.[7]
In all patients, radiography of sacroiliac joints and lumbar spine were taken. Grading sacroiliitis was according to the New York criteria[2] (0: Normal, 1: Suspicious, 2: Minimal sacroiliitis, 3: Moderate sacroiliitis, 4: Ankylosis). Peripheral joints radiography depending upon their involvement was also performed.
A total of 200 patients diagnosed with AS after fulfilling the modified New York criteria for AS were consecutively selected.
Patient demographics, including age, gender, body mass index, and smoking, rural or urban background were recorded. Each patient's ASDAS was assessed by ASDAS and Bath BASDAI, and the BASDAI was used to assess patient-reported disease activity which includes six items: fatigue, spinal pain, peripheral arthritis, enthesitis, intensity, and duration of morning stiffness. It is scored from 0 (none) to 10 (very severe). A cut-off value of 4 has been accepted in the BASDAI scale and scores, equal to or above the cut-off value, indicate that the disease was more active. The Bath Ankylosis Spondylitis Functional Index (BASFI) was used to assess patient-reported physical function which includes 10 items and scores from 0 (easy) to 10 (impossible).[8] Spinal mobility was assessed by the Bath Ankylosis Spondylitis Metrology Index (BASMI), distance to wall, and finger to floor distance.
The BASMI is an objective instrument with a total score of 10 which includes five clinical measurements: lateral lumbar flexion, tragus to wall distance, lumbar flexion, maximal intermalleolar distance, and cervical rotation.[9]
Laboratory parameters including hemoglobin, white blood cell count (neutrophil count and lymphocyte count), platelet count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and HLA-B27 were recorded.
25-hydroxycholecalciferol (25-[OH] D3) was measured with the electrochemiluminescence method. Vitamin D levels were classified according to the standard definitions of Vitamin D status: 25-(OH) D3 ≥30 ng/ml = normal; 25-(OH) D3 between 20 and 29.9 ng/ml = insufficient Vitamin D; 25-(OH) D3 between 10 and 19.9 ng/ml = Vitamin D deficiency; 25-(OH) D3 between 0 and 9.9 ng/ml = severe Vitamin D deficiency.[10]
Statistical analysis
The statistical analysis was performed using the Statistical analysis was performed using Statistical Package for the Social Sciences (version 17.0, SPSS, Chicago, IL, USA). The descriptive statistics were presented as the mean ± standard deviation for the continuous variables and as frequencies and proportions (%) for the categorical variables. The Pearson's correlation test was performed to determine the relationship between the variables and high BASDAI scores. P < 0.05 was considered as statistically significant.
| Results | | |
The present study included 200 patients with AS. The demographic and clinical profile has been shown in [Table 1]. Among the study participants, 72% were males and 28% were females. The mean age of participants was 46 ± 12 years. A total of 62% patients were from rural background and farmers or laborers by occupation. History of current or past smoking was present in 56% patients. The mean duration of symptoms was 10 ± 3 years. All the patients (100%) had a history of inflammatory back pain and 86% patients had a history of nonsteroidal anti-inflammatory drug intake. Family history for inflammatory back pain was positive in 64 patients. History of enthesitis was present in 35%, anterior uveitis in 14%, ulcerative colitis in 4%, and psoriasis in 3% patients. Disease activity was assessed by using the ASDAS and BASDAI and function by BASFI and BASMI as displayed in [Table 3] after vitamin D levels. | Table 3: Correlation of various parameters with high bath ankylosing spondylitis disease activity index score
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Laboratory parameters of study participants have been depicted in [Table 2]. Out of 200, 92% patients were HLA B27 positive. More than two-third of the patients (72%) had Vitamin D deficiency.
High BASDAI score (>4) was positively correlated with elevated CRP, ESR, neutrophil–lymphocyte ratio and had negative correlation with serum Vitamin D levels as shown in [Table 4] after physical labor. Radiography of the pelvis (anteroposterior view) was performed in all the patients which showed advanced disease in 22% patients. The findings suggestive of advanced disease included bilateral sacroiliitis (Grade 4), squarring, reduced hip joint space, dagger sign, new bone formation near acetabular margins, and diffuse syndesmophytic ankylosis leading to bamboo spine appearance. Advanced radiographic disease was positively correlated with duration of symptoms, smoking, rural background, and physical labor. | Table 4: Correlation of various parameters with radiographically advanced disease
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| Discussion | | |
AS, a type of spondyloarthropathy, is an autoimmune disease that mainly involves spine joints, sacroiliac joints, and their adjacent soft tissues, such as tendons and ligaments. In more advanced cases, this inflammation can lead to fibrosis and calcification, resulting in the loss of flexibility and mobility of the spine. The common clinical presentation is inflammatory back pain which is often neglected either by patients or specialists and results in substantial delay between symptom onset and diagnosis.[11],[12] Early diagnosis and appropriate management can slow the progression of disease.
The present study was conducted to assess the demographic and clinical profile of ankylosing spondylosis patients attending the outpatient departments. In our study, all the patients had typical history of inflammatory back pain. Peripheral arthritis and enthesitis were observed in 35% patients. Family history was positive in 32% patients which was same to earlier reports.[13]
Out of all, 92% patients were found to have HLA B27 positivity which is same as has been reported earlier from North India.[14] Most of the patients in our study had advanced stage of AS the reason of this might be due to delay in the diagnosis of AS in these patients. Sonkar and Usha in their study also showed that HLA-B27-positive patients had more severe disease and systemic manifestation.[15]
The observations of our study included predominantly males, longer disease duration, more axial symptoms at disease onset, higher BASMI indicative of decreased spinal mobility, and more syndesmophytes. Kiltz et al. also reported a higher proportion of males and increased inflammatory markers in patients with AS.[16]
Duration of symptoms, HLA-B27 positivity, and physical labor have been positively correlated with advanced radiographic disease similar to other studies.[17] Smoking, lifestyle factors, and heavy physically strenuous activity have also been shown to strongly influence the disease progression.[18]
ASDAS and BASDAI are markers of disease activity. BASFI is measure of limitation activities of daily living. BASMI is indicative of decreased spinal mobility and more syndesmophytes indicative of more osteoproliferation. The number of syndesmophytes is a well-known factor predicting progressive disease with damage.[19]
High BASDAI was positively correlated with markers of inflammation such as ESR, CRP, and high neutrophil–lymphocyte ratio in concordance with other studies.[20] It has been suggested that baseline levels of inflammatory mediators strongly correlate with disease progression.[21]
In the present study, we measured levels of Vitamin D in all study participants to find Vitamin D status and relation of Vitamin D deficiency with BASDAI. We observed that severe Vitamin D deficiency had a positive correlation with BASDAI >4. A meta-analysis was done by Cai et al. to examine the association between serum Vitamin D levels and susceptibility and disease activity of AS.[22] They concluded that higher levels of serum Vitamin D were associated with a decreased risk and showed an inverse relationship with AS.
This study was conducted in a government run hospital which caters low socioeconomic section of our society. In this study, we used radiographic criteria of sacroiliitis for diagnosis of AS which indicates that disease is already established. It is important that the history of inflammatory back pain should be addressed early and if possible magnetic resonance imaging can be performed. Attention on extra-articular manifestations, HLA-B27, and elevated inflammatory markers help in early diagnosis of AS so that early referral to rheumatologist is done and treatment strategy can be initiated before the occurrence of irreversible damage.
The study has limitations of cross-sectional design and small sample size. The prospective studies with large number of patients of our resource-poor population are in progress which will throw more light on the spondyloarthropathies. Public health initiatives are also needed to guide primary care physicians so that poor long-term outcomes are avoided.
| Conclusion | | |
AS is a chronic inflammatory disease with that primarily affects the axial skeleton and can cause chronic back pain and damage to the spinal vertebrae. Most of the patients in our study had advanced stage of AS the reason of this might be due to delay in the diagnosis of AS in these patients. They had high BASDAI with elevated inflammatory markers. Awareness for early and definite diagnosis of AS is needed to prevent irreversible structural damage and worsening of quality of life.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Table 1], [Table 2], [Table 3], [Table 4]
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