Working Diagnosis:
HLA-B27 positive Ankylosing Spondylitis that manifested as bilateral sacroiliitis

Treatment:
He was started on non-steroidal anti-inflammatory drugs, completed physical therapy, and started a progressive return to physical activity.
Rheumatology referral was placed for the management of disease progression and disease modifying antirheumatic drugs

Outcome:
Patient had initial improvement with initial trochanteric corticosteroid injection potentially due systemic absorption, or relief from concomitant greater trochanteric pain syndrome. He noted the most improvement from staying active by routinely going to the gym, which also improved his depression. He used non-steroidal anti-inflammatory drugs as needed for pain. However, he developed extraarticular symptoms which were managed by rheumatology with disease modifying antirheumatic drugs.

Author's Comments:
Ankylosing Spondylitis is a chronic inflammatory arthritic condition associated with many symptoms and overlapping presentations. Delays to diagnosis of ankylosing spondylitis are common, with an average delay of 6 years likely due the wide range of symptoms and physician diagnostic biases. It disproportionately affects men younger than 45. Patients often present with low back and sacroiliac joint pain but may have symptoms that involve other organs like the eyes and skin. Radiographic findings in SI joints and vertebrae are common however some patients have no findings. Sacroiliitis is seen on MRI, but 30% of patients develop radiographic changes within 10 years. It is often associated with negative rheumatoid factor and positive HLA-B27

Editor's Comments:
Ankylosing spondylitis is a chronic inflammatory disorder with skeletal and systemic symptoms. The inflammation often starts in the sacroiliac joints and can alternate from one side to the other. The vertebra are also typically involved and can lead to chronic back pain and stiffening. Other musculoskeletal symptoms may include pain at other joints or enthesitis. Some of the most common locations of enthesitis include achilles tendon, plantar fascia, tibial tuberosity, and greater femoral trochanter. Musculoskeletal symptoms are often worse after periods of inactivity and improved with exercise or a hot shower. The pain also improves with non-steroidal anti-inflammatory drugs. Systemic systems that can be affected including eyes (anterior uveitis), cardiovascular (aortitis, aortic insufficiency, conduction disturbances), pulmonary (chest wall rigidity), neurologic (fracture-dislocations, cauda equina syndrome), and gastrointestinal tract (inflammatory bowel disease). Ankylosing spondylitis is a heritable disorder that is strongly associated with the HLA-B27 in many individuals that are symptomatic. Diagnosis can often be difficult due to the insidious onset of symptoms and varied presentations across a variety of ages. Radiographs may be normal early in the disease and thus if suspected non-contrast MRI can be obtained to aid in diagnosis. Early diagnosis allows initiation of treatment which includes nonsteroidal anti-inflammatory drugs, physical therapy, and TNF-blocking agents, which are more effective earlier in the disease. It is important to think about ankylosing spondylitis as a potential diagnosis for patients who present to clinic with signs of back pain and/or sacroiliitis.

References:
Dincer U, Cakar E, Kiralp MZ, Dursun H. Diagnosis delay in patients with ankylosing spondylitis: possible reasons and proposals for new diagnostic criteria. Clin Rheumatol. 2008 Apr;27(4):457-62. doi: 10.1007/s10067-007-0727-6. Epub 2007 Sep 26. PMID: 17899306.
Sieper J, Rudwaleit M, Baraliakos X, et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Annals of the Rheumatic Diseases 2009;68:ii1-ii44.
Bakland, G., Nossent, H.C. Epidemiology of Spondyloarthritis: A Review. Curr Rheumatol Rep 15, 351 (2013). https://doi.org/10.1007/s11926-013-0351-1
Khan, M. A. (2023). Ankylosing spondylitis (1st ed.). Oxford University Press. https://doi.org/10.1093/oso/9780195368079.001.0001

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