Quantitative Radio-Isotope Scanning of the Sacroiliac Joints in Ankylosing Spondylitis
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Abstract:
A method for applying 99mTc-MDP for dynamic and static quantitative radioisotope scanning (QRS) of the sacroiliac joints (SI) in early progressive sacroiliitis in ankylosing spondylitis (AS) is described. In a prospective study, 2 groups of male AS patients were investigated, one with increased elevated erythrocytic sedimentation rate (ESR) (group A, n = 7) and one with normal ESR (group B, n = 8). In both groups an increased uptake of the radiotracer was found in the static part of the study versus a control group C (n = 9). An increased uptake versus group C was also found for group A in the dynamic part of the study (p = 0.01) while there was no significant difference dynamically between groups B and C. The results of the dynamic study in group A indicate ESR to be a parameter of inflammatory activity in the SI joints. The study also seems to indicate QRS to be a valuable diagnostic method in early AS without definite radiographic changes in the SI joints.Keywords:
Erythrocyte sedimentation rate
Sacroiliac joint
Spondylitis
Aim: The 14-3-3η (eta) protein has been associated with the severity of the disease and joint destruction in patients with rheumatoid arthritis (RA). It has also been shown to be likely to be effective in inflammatory events. We aimed to investigate whether eta levels could be a potential biomarker in the diagnosis of ankylosing spondylitis (AS) and in the determination of disease activity in patients with AS.Methods: This study included 51 patients diagnosed with AS and 49 healthy controls aged 20-65 years. The routine hemogram, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels were measured and the neutrophil/lymphocyte ratio (NLR) was calculated in the patients. The serum eta levels were also measured in the patient and healthy control groups. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Disease Activity Score (ASDAS) were used to assess disease activity. Sacroiliac joint radiographs of the patients were evaluated and the sacroiliitis was graded.Results: There was no statistically significant correlation between the degree of sacroiliitis, disease activity indices, and eta levels. There was no statistically significant correlation between eta levels and hematological parameters except for CRP. There was a negative, weak, and statistically significant relationship between the patients’ eta levels and CRP (r=-0.277; p=0.049). We could not find any correlation between the degree of sacroiliitis, disease activity indexes, and serum eta levels in AS patients.Conclusion: Serum eta levels are not a good biomarker for detecting disease activity in patients with ankylosing spondylitis. The 14-3-3η protein may play a more active role in rheumatic diseases where peripheral joint involvement is prominent.
Erythrocyte sedimentation rate
Spondylitis
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We present two cases of accessory sacroiliac joint mimicking focal erosive sacroiliitis on plain radiographs. Two women presented with symptoms of chronic lower back pain. They were initially diagnosed as focal erosive sacroiliitis on plain radiographs. Further CT images of sacroiliac joints found accessory sacroiliac joints.
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The incidence of B27 in patients with ankylosing spondylitis associated with regional enteritis was significantly lower than in ankylosing spondylitis without inflammatory bowel disease. It was significantly higher, however, than in a control group of blood donors. The incidence of B27 was found to be nil in patients with regional entertitis without ankylosing spondylitis, as well as in patients with regional enteritis and asymptomatic radiographic sacroilitis. Conversely, all patients with regional enteritis, positive for B27, developed ankylosing spondylitis.
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In a family study, sacroiliitis was found in 15 (25%) out of 61 HLA-B27 positive first-degree relatives (FDR) of 20 randomly chosen HLA-B27 positive ankylosing spondylitis (AS) patients and never in 41 HLA-B27 negative FDR. Eight (53%) of the 15 FDR with sacroiliitis fulfilled the New York criteria for AS. In the population study the prevalence of HLA-B27 positive AS was found to be 0.1%. AS will develop in 1.3% of all HLA-B27 positive individuals belonging to the general population.
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In order to reduce the subjective factor in evaluating sacroiliac joint radiographs we further evaluated changes seen on standard plain films of patients suffering from Behcçet's syndrome (BS) by using computed tomography (CT). Sacroiliac joint films of 20 consecutive patients with BS were mixed with those of 20 consecutive control patients and read blindly and independently by two observers. Six patients with BS met the New York criteria for sacroiliitis. Of the control patients, one had monolateral grade 1 sacroiliitis and two revealed findings consistent with osteitis condensans ilii. CT confirmed the diagnosis of sacroiliitis in patients with BS showing a high degree in at least one joint. The results of the present study suggest that the use of CT for BS patients showing sacroiliac joint changes on pelvic plain films may limit the confusion which exists about this finding in BS.
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In a population survey of ankylosing spondylitis (AS) seven subjects, six males and one female, had x-ray changes in the lumbar spine typical of AS but without concomitant roentgenological sacroiliitis. The overall prevalence of such cases in the population studied was 0.37%. Four out of these seven subjects carried the tissue antigen HLA-B27 (57%). The clinical and roentgenological features of these subjects are described and it is suggested that the x-ray findings represent a mild and variant form of primary or definite AS.
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"HLA-B27 positive, low back pain and sacroiliitis" represent a cluster of signs and symptoms often misinterpreted as "ankylosing spondylitis". Compared to ankylosing spondylitis persistent bilateral isolated sacroiliitis shows a considerably different potential of prognosis, concerning planning and quality of life (private, profession), medical and physiotherapeutic regimens and last but not least the general costs of treatment. Problems of nomenclature, advantage and disadvantage of existing diagnostic criteria (Rome, New York, modified New York) are discussed. These criteria perpetuate a specific clinical appearance traditionally - often wrongly - regarded as typical of ankylosing spondylitis and dont allow differentiation to persistent bilateral isolated sacroiliitis. The frequency of low back pain combined with population-specific frequency of HLA-B27 on one side - prevalence of white hospitalized patients with ankylosing spondylitis (0.05-0.25%) compared to the prevalence of bilateral isolated sacroiliitis in population studies (1-1.7%) or in AS-collectives (≥4.5% after a disease course of appr. 5 years) on the other side are convincing arguments for a disease (persistent) "bilateral isolated sacroiliitis". This disease has to be differentiated from ankylosing spondylitis and diseases related to ankylosing spondylitis. Still not clear and subject to further examination is the amount of time until the bilateral isolated sacroiliitis will take over from the diagnosis ankylosing spondylitis.
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Summary and ConclusionsFollow-up information is presented for a series of 47 cases of Reiter's disease. During the acute episodes observed, pain consistent with sacroiliitis or spondylitis was present in 40 cases (85 %). Of 35 patients with radiographs 2 or more years after onset, 20 (57%) had definite bilateral sacro-iliac disease. Ankylosing spondylitis has been diagnosed in 12 patients, several of whom have followed a progressive course typical for that of severe ankylosing spondylitis. Rheumatoid arthritis has not been documented in our series. Our data and other accumulating evidence appear to link Reiter's disease closely with ankylosing spondylitis.
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