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Coexisting RA and Ankylosing Spondylitis
Coexisting RA and Ankylosing Spondylitis
Coexisting RA and Ankylosing Spondylitis
Coexisting Spondylitis
Paul Major,1 Philip Kline3 Donald
Rheumatoid
Resnick,1 Murray Dalinka,2
Arthritis
and
and Ankylosing
Rheumatoid sidered
arthritis
and and
ankybosing unrelated
spondylitis diseases,
are readily
condif-
agnosed,
and 5).
with characteristic
A severe peripheral
spinal
arthritis
and sacroiliac
involving the
changes
hands,
(figs.
wrists,
to be separate
farentiatad
sionally disease both examples literature. that other. the
in most
cases.
Diagnostic
confusion
symptoms or, more patient.
may occaof the one rarely, when There are language indicate of either 21
arise when the signs and overlap those of the other entities coexist within the same in from of the batter The cumulative clinical Thus, and diagnostic detailed data
elbows, began.
rheumatoid
distributed erosions, and symmetrical joint space narrowing. There were no subcutaneous nodules. Thepatient was HLA-B27 positive. Rheumatoid factor was present in high titer. The diagnosis was
coexisting rheumatoid arthritis and ankylosing spondylitis.
radiographic
disease
are apparently
unmodified
precision
by the presence
can be achieved
of the
by an
awareness of this potential association. We report two more cases of coexisting rheumatoid arthritis and ankybosing
spondylitis, literature. the first to our knowledge in the radiobogic
Case
Case
Reports
1
M. L. , a 64-year-old white man, had a 36 year history of chronic back pain. Peripheral joint symptoms involving the metacarpophalangeal joints of both hands, wrists, elbows, knees, and ankles first appeared 1 0 years before his most recant admission. Cutaneous nodules were present. The rheumatoid factor was positive, the titer measuring 1 /1 280. HLA-B27 had been positive on two occasions. Radiographs of the lumbar spine (fig. 1) and pelvis (fig. 2) on
admission joint fusion. demonstrated Radiographs syndesmophytes of the hands (fig. and bilateral sacroiliac symmetri3) revealed
cally distributed erosive changes in the metacarpal heads, carpals, ubnar styboid processes, and distal radii associated with carpal subluxations, symmetrical metacarpophalangeal joint space narrowing, and ulnar deviation of the digits. On the basis of clinical, laboratory, and radiographic findings, the diagnosis was coexisting rheumatoid arthritis and ankylosing spondylitis.
Case
2 man developed spinal immobility. low back pain which eventually Ankylosing spondylitis was diFig. 1 -Case 1 . Antenoposterior
racolumbar
junction;
bilateral
sacroiliac
at tho-
Received
Department
5, 1 979;
accepted
Veterans
after
revision
November
Medical
27, 1979.
Center, 3350 La Jolla Village Dr., San Diego, CA 921 61
.
of Radiology,
Administration
Address
reprint
requests
to D. Resnick.
2Present 3Present
AJR
Department Department
May
134:1076-1079,
0361 -803X/80/1
AJR:134,
May 1980
CASE
REPORTS
1077
Fig.
2.-Case
and nonarticulating
involves
articulating
2. Anteroposterior and lateral views of lumbar spine. calcification with ankylosis of apophyseal joints.
Exten-
Fig. 3.-Case 1 . Posteroantenior views of hands. Symmetrically erosions in metacarpal heads, carpals, ulnar styloid processes,
radii with symmetrical joint space narrowing in metacarpophalangeal,
carpal,
and radiocarpal
joints.
Discussion
Ankybosing rheumatoid spondylitis, formerly considered a variant of arthritis, is now regarded as a separate and
,
distinct entity [1 2]. The two diseases are readily tiated in most cases on the basis of characteristic
laboratory, and radiographic manifestations. Briefly,
diffaren-
clinical,
the arFig. 5.-Case 2. AnteroposteriOr
aspects of sacroiliac
thritis of anklyosing spondylitis is characterized by genetic predisposition [3], earlier onset, male predominance, and axial distribution [4]. The radiographic finding of bilaterally
pelvis.
space
Ankylosis
with marked
of articulating
bilateral
and
nonarticulating defects.
protruslo
1078
CASE
REPORTS
AJR:134,
May
1980
persons
purely
[20]. reported
clinical who
General [20-29];
picture
opinion
Including
regards
our two,
the association
23 such the typical cases
as
have
coincidence.
been
acteristic a man
from
has
the cumulative
emerged; ankylosing
data,
a charpatient at about is
initially
develops
spondylitis
age 34 years, and develops rheumatoid arthritis about 15 years later [22]. There is no evidence to suggest that the manifestations of either disease are modified in the presence of the other. An accurate diagnosis is therefore possible when the characteristic changes of both diseases are presant. Thus, the majority of coexisting rheumatoid
have fulfilled the following
examples spondylitis
individ-
these
uals
axial
are
positive titer
with
the
classic
with
radiographic
subcutaneous
changes
of ankybosing symmetrical
spondylitis,
nodules,
peripheral,
Fig. deviation
of rheumatoid
arthropathy
factor,
and
the
erosive
of rheumatoid
6.-case
of wrists;
2. Posteroanterior
symmetrically
hands.
distributed
Ulnar
of hands; space
joints.
radial
heads,
arthritis.
erosions and
in metacarpal
The
arthritis
paucity
and
of reported
ankybosing
cases
spondylitis
of coexisting
is probably
rheumatoid
due to (1) (2) a to
carpals,
involving
distal
radii,
and ulnar
styloid
processes;
narrowing
metacarpophalangeal,
intercarpal,
of this potential association, and to attribute the observed abnormalities process. differentiating It is likely
bamboo rheumatoid
coexisting entity
basis
rheumatoid Either
arthritis disease
and
the characteristic
features
genetic and
susceptibility a peripheral
of rheumatoid
[6], a later onset, female distribution [4]. The radioarthritis are periarticubar
are lacking.
of the dominant
is than
We
diagnosed
recommend
on the
that in with process methods
abnormalities.
hallmarks
cases and
of rheumatoid
arthritis
or ankylosing
spondylitis
joint these
classi[7].
reviewed.
Although
coexistence can
of rheurnabe strongly
An extremely
two ing factor
ant in
useful
is the [8,
clinical
rarity 9].
normal
point
of distinction
nodules and they and HLA-B27 markers,
between
rheumatoid may
the
ankybosing
spondylitis
of rheumatoid disease
Although
suspected requires
laboratory
sensitive
individuals
in other and
states
nonspecific.
arthritis confusion; in 20% of is present or HLA-B27 of these in individuals Radiography examples identified disease. sacroiliitis patients [15, in 50% may diseases who is of be
REFERENCES
1 . McEwen C, Ziff M, Carmel P, Ditata D, Tanner M. The relationship to rheumatoid arthritis of its so called variants. Arthritis Rheum 1 958; 1:481-496 2. Graham W. Is rheumatoid spondylitis a separate entity? Arthritis Rheum 1960;3:88-9O
and
factor
3.
of either
especially useful in such atypical cases, since subtle, but distinctive differences exist between the two entities in their appearance and distribution. Thus, a chronic, erosive peripherab arthritis is rarely seen with ankybosing spondylitis;
if present, it occurs in an asymmetrical distribution and is
Emery AEH, Lawrence JS. Genetics of ankylosing spondylitis. J Med Genet 1 967;4 : 239-244 4. Copeman WSC. In: Scott JT, ad. Copeman s textbook of the rheumatic diseases. Edinburgh: Churchill Livingstone, 1978 5. McEwan C, Ditata D, Lingg C, Porini A, Good A, Rankin T. Ankylosing spondylitis and spondylitis accompanying ulcarativa colitis, regional enteritis, psoriasis and Raiters disease: a
associated with proliferative bony changes [1 8]. Sacroiliitis is rarely the initial manifestation of rheumatoid arthritis, and
lumbar distinctly involvement unusual [19]. eventuating in extensive ankybosis is
Another
both diseases
possible
coexist
source
in the
of diagnostic
same patient.
error
On
arises
the
when
of
basis
prevalence
spondybitis
rates
in the
of rheumatoid
general population,
arthritis
such
and
ankylosing
an association
has
been
conservatively
estimated
to occur
in 1 :100,000
comparative study. Arthritis Rheum 1 971 ;1 4:291-318 6. Meyorwitz 5, Jacox RF, Hess DW. Monozygotic twins discordant for rheumatoid arthritis: a genetic, clinical and psychological study of 8 sets. Arthritis Rheum 1968;1 1 : 1 -21 7. Bywatars EGL. The early radiological signs of rheumatoid arthritis. Bull Rheum Dis 1960;1 1 :231-232 8. Simpson NRW, Stevenson CJ. Analysis of 200 cases of ankylosing spondylitis. Br Med J 1949;1 :214-216 9. Forbech V. Do mutual features really dominate separating features in rheumatoid arthritis and rhamatoid spondylitis? Acta Med Scand 1 958; 1 62 : 43-46
AJR:134,
May
1980
CASE
REPORTS
1079
WaIler M, Toone EC, Vaughan E. Study of rheumatoid factor in a normal population. Arthritis Rheum 1 964;7 :513-520 1 1 . Bartfield H. Distribution of rheumatoid factory activity in nonrheumatoid states. Ann NY Acad Sci 1 969;1 68 : 30-40 1 2. Cohen LM, Mittal KM, Schmid FR. Increased risk for spondylitis stigmata in apparently healthy HA-AW27 men. Ann Intern Med 1976;84:1 -7 1 3. Brewerton DA, Nicholls A, Caffrey M, Walters D. HL-A27 and arthropathies associated with ulcerative colitis and psoriasis. Lancet 1974;1 :956-958 1 4. Brewerton DA, Nicholls A, Caffrey M, Oates JK, Walters D, James DCO. Aeiters disease and HL-A27. Lancet 1973;2:
996-998
1 0.
sequent
development
rheumatoid
of rheumatoid
vasculitis.
nodules,
Arthritis
Sjogrens
syn-
Rheum
1978;21:
21
Falbet GH, Mason M, Barry H, Mowat AG, Boussina JC. Rheumatoid arthritis and ankylosing spondylitis
I, Gerster occurring
22.
23.
together. Br Med J 1976;1 :804-807 Good AE, Hyla JF, Rapp A. Ankylosing spondylitis with rheumatoid arthritis and subcutaneous nodule (letter). Arthritis Rheum 1977;20: 1434-1437 Luthra HS, Ferguson RH, Conn DL. Coexistence of ankylosing spondylitis and rheumatoid arthritis. Arthritis Rheum I 976;1 9:
111-114
24.
Wilkinson
M, Bywaters
1 5. 1 6.
1 7. 1 8. 1 9.
Martel W, Duff I. Pelvo-spondylitis in rheumatoid arthritis. Radiology 1961 :77:754-756 Dixon AS, Lience E. Sacro-iliac joint in adult rheumatoid arthritis and psoriatic arthropathy. Ann Rheum Dis 196120: 247-257 Polley H. The diagnosis and treatment of rheumatoid spondylitis. Med Clin North Am 1955;39:509-528 Resnick D. Patterns of peripheral joint disease in ankylosing spondylitis. Radiology 1974;1 1 0 : 523-532 Dilsen N, McEwen C, Poppel M, Gersh WJ, Ditata D, Carmel
0. A comparative roentgenologic study of rheumatoid Arthritis arthritis Rheum
25.
26.
ankylosing Rosenthal
EGL. Clinical features and course Ann Rheum Dis 1 958;1 7 : 209-228
of
with nodules
27.
28. 29.
and 20.
rheumatoid
-368
(ankylosing)
spondylitis.
1962;5:341
following ankylosing spondylitis. JAMA 1968;206 :2893-2894 Espinoza LA, Dove FB, Osterland CK. Co-existence of ankylosing spondylitis and rheumatoid arthritis in a single family (letter). Arthritis Rheum 1979;22 : 203-204 Fallet GH, Mason M, Berry H, Mowat A, Boussina I, Gerster JC. Co-existence of rheumatoid arthritis and ankylosing spondylitis. J Rheum 1 977;4 [suppl 3]: 70-73 Huskisson EC. Ankylosing spondylitis and rheumatoid arthritis. Proc R Soc Med 1970;63:620 London MG, Bland JH. Ankylosing spondylitis with subcutaneous nodules. N Eng! J Med 1962;268: 991-994
Clayman
MD, Reinertsen
JL. Ankylosing
spondylitis
with sub-