Case history
Case history #1
A 20-year-old man presents to his primary care physician with low back pain and stiffness that has persisted for more than 3 months. There is no history of obvious injury but he is an avid sportsman. His back symptoms are worse when he awakes in the morning, and the stiffness lasts more than 1 hour. His back symptoms improve with exercise. He has a desk job and finds that sitting for long periods of time exacerbates his symptoms. He has to get up regularly and move around. His back symptoms also wake him in the second half of the night, after which he can find it difficult to get comfortable. He normally takes an anti-inflammatory drug during the day, and finds his stiffness is worse when he misses a dose. He has had 2 bouts of iritis in the past.
Case history #2
A 17-year-old boy presents with an 18-month history of pain in his right ankle and both heels, with early morning stiffness and fatigue. Walking short distances is proving difficult due to heel pain, and he has given up sport. Examination reveals marked tenderness and swelling over bilateral Achilles tendons.
Other presentations
Spondyloarthropathy is seen in children although less commonly than in adults. It is classified under enthesitis (inflammation of the tendon or ligament attachments to bone)-related arthritis in the classification of juvenile idiopathic arthritis.
There are significant differences in the pattern of onset and course of disease between children and adults. Usual presentation for an adolescent is in the form of asymmetrical oligoarthritis. The joints involved are usually of the lower limbs, including the hips and tarsal joints. Spinal involvement is uncommon in the early course of disease. Sacroiliitis manifesting as low back pain, or enthesitis in association with arthritis can be the presenting symptoms. The calcaneal insertion of the Achilles tendon and plantar fascia, plantar fascia attachments to the base of the fifth metatarsal and the heads of the metatarsals are common sites for enthesitis in children. Although early spinal involvement is uncommon, measurements of lumbosacral mobility using the Schober test are important in detecting it in children with enthesitis-related arthritis.[11] HLA-B27 prevalence is high in children with enthesitis-related arthritis.[12][13] Acute anterior uveitis is seen in 10% to 20% of children with enthesitis-related arthritis, and is usually unilateral.[14][15] In a significant number of adults with ankylosing spondylitis (AS), the disease onset is seen in the juvenile period. There are data to show that juvenile-onset AS is associated with significant delay in diagnosis and worse functional outcomes compared with adult-onset AS.[16]
Some evidence suggests differences in clinical presentation of AS in women, which may explain the under-recognition of the disease in this group. Women tend to have more cervical and peripheral joint pain than men, and may also be more likely to have peripheral arthritis. However, radiographic severity is lower in females. In addition, women report higher degrees of functional impairment for given degrees of radiographically evident damage. These factors may contribute to misdiagnosis in female patients.[17]
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