Ankylosing spondylitis

Synonyms in a broader sense

Ankylosing spondylitis (AS), ankylosing spondylitis, spondylarthropathyrheumatism, rheumatoid arthritis, psoriatic arthritis, methotrexate English: Ankylosing spondylitis

Definition

Bekhterev’s disease is one of the most common inflammatory rheumatic diseases. It belongs to the group of so-called spondylarthropathies, which also includes psoriatic arthritis, arthritis in chronic inflammatory bowel diseases, Lyme arthritis (borreliosis), rheumatic fever and reactive post-streptococcal arthritis. The inflammatory changes are mainly found in the area of the spinal column and the sacroiliac joints (ISG joints). In 20-50% of patients, other joints (e.g. hip joint and knee joint) are also affected in the course of the disease. 20% of patients also suffer from inflammation of:

Tendon insertions (enthesiopathy)
Eye
Gut
Heart
Kidney and
Lung.

History

The disease was first described in 1884 by Adolf from Leipzig on the basis of two patients with a complete stiffening of the spine and joints. Further reports followed from Vladimir von Bechterew (1886-1927) from St. Petersburg and Pierre Marie from Paris.

Cause

The cause of Bekhterev’s disease is unknown. The association of the disease with genetic characteristics, in particular with the human leukocyte antigen HLA-B27, is known. More than 90% of patients are HLA-B27 positive.

In Germany about 8% of the population are HLA-B27 positive, 2-5% of which are infected with Mb. Bechterew’s disease, i.e. over 90% of HLA-B27 positive people remain healthy. In case of 1st degree relatives the risk of Mb.

Bekhterev’s disease is 20%, in identical twins 60%. In Germany there are about 800,000 patients suffering from Bekhterev’s disease. As with other inflammatory rheumatic diseases, certain bacterial infections are discussed as triggers. At the onset of the disease, patients are on average 26 years old. Men are affected two to three times more frequently than women.

Symptoms / Complaints

In about 75% of the patients a deep-seated back pain is the first symptom. The onset is usually gradual and is before the age of 40. Characteristic are persistent complaints over three months, occurrence of the complaints especially in the second half of the night, in the morning and after a longer rest.

The symptoms typically improve with exercise and respond well to non-steroidal anti-inflammatory drugs (NSAIDs). Besides the sacroiliac joints, the transition from the thoracic spine to the lumbar spine (Th8-L2) is most frequently affected. In the course of the disease, the mobility of the spinal column is increasingly restricted until complete stiffening occurs.

In extreme cases, in the late stages of the disease, the patient can no longer raise the visual axis above the horizontal by blocking the thoracic vertebrae in a flexed position and stretching the cervical spine. Involvement of the rib-vertebral joints can lead to restriction of the respiratory movement. Pain in the area of the anterior chest wall can be triggered by inflammatory changes in the sternoclavicular joints, the sternum (synochondrosis manubrio-sternalis) and the rib cartilage (enthesitis).

In 20% of patients, the disease first appears in the form of an inflammation of a peripheral joint (arthritis), typically in one or a few joints (mono- or oligoarthritis) in the leg region. The inflammatory changes also lead to changes in tendon attachments. Due to the particular strain and prominence, these appear in about 20% of patients in the form of heel pain, sometimes also in the area of the major trochanter, the ischium or the iliac crest.

Outside the locomotor system, Bekhterev’s disease can also become symptomatic as an inflammation of the eye (iridocyclitis). Acute onset of pain in one eye, sensitivity to light and limitation of visual acuity occur. Further manifestations can occur in the area of the heart and blood vessels in the form of aortic valve insufficiency and cardiac arrhythmia and in the area of the intestine in the form of ileitis or colitis.

Rare are involvement of the lung (bilateral apical pulmonary fibrosis) and kidney (IgA nephropathy). A complication after many years of high inflammatory activity may be a so-called amyloidosis (deposition of proteins in internal organs with subsequent disturbance of organ function). A further complication in later stages of the disease is the increased risk of bone fractures, especially in the area of the spine. Stiffening can lead to bone fractures even with minor trauma, as the bone has lost its elasticity.