The Detergents And Disinfectants For Instruments And Surfaces (Hexanios - Surfanios)

• It is the most common inflammatory disease of the axial skeleton.

• It usually starts between the ages of 20-30 and is more common in men.

• It is the SSA type with the highest HLA B27 positivity (85-90%).

Clinical Findings

Joint Findings

• Ankylosis develops due to enthesitis and subsequent new bone formation in the involved joint.

• The most common and earliest involved joint is the sacroiliac joint. Therefore, the disease begins with inflammatory low back pain.

• Later; Intervertebral joints are involved and syndesmophytes develop, in untreated cases this condition progresses as ascending and results in bamboo cane appearance.

• Due to spinal involvement; waist movements are restricted, lumbar lordosis is flattened, thoracic kyphosis increases.

• The most feared complication of spinal disease is spinal fracture. It is most common in the lower cervical vertebrae.

• Chest expansion may be restricted due to costovertebral joint involvement.

• The most frequently involved peripheral joint is the hip.

• Peripheral joint involvement is predominantly in the lower extremities and is asymmetrical, oligoarticular.

• Heel pain may develop as a result of Achilles tendinitis and enthesitis (plantar fasciitis) in the calcaneus.

Extra-articular findings

• Asymptomatic enteric mucosal inflammation findings are detected in 60% of the patients with colonoscopy. Symptomatic inflammatory bowel disease occurs in 5% of patients.

• The most common (40%) extra-articular manifestation is acute anterior uveitis. It is almost always one-sided.

• Heart: Aortic failure, atrioventricular conduction defects

• Lung: Fibrobullous disease in the apical lobes (may be confused with tuberculosis)

• Kidney: IgA nephropathy, secondary amyloidosis

• Neurological deficits due to spinal fractures (eg cauda equina syndrome)

• Vertebral osteoporosis

physical examination

• The most important findings in physical examination are loss of spinal mobility. One of the tests evaluating spinal mobility is the modified Schober test.

• femur in the FABERE test; Flexion, ABduction, Extenal Rotation and Extension are performed. Sacroiliac joint involvement is evaluated.

laboratory findings

• Anemia of chronic disease, increased acute phase response (ESR, CRP) may be seen.

• 85-90% of patients are HLA-B27 positive. It is significant that it is positive in a patient with inflammatory low back pain.

• RF, anti-CCP and ANA are negative.

Radiological examination

• There is no radiographic finding in early disease. The first radiographic finding is sacroiliitis (symmetrical).

• Vertebrae are held sequentially from bottom to top.

• Radiographic changes seen in the vertebrae; squaring in vertebrae, syndesmophyte formation, bamboo cane appearance

• The most sensitive examination in early radiological diagnosis is MRI. In sacroiliitis; indicates early inflammation and bone marrow edema.

Diagnosis

Treatment

• Daily posture and breathing exercises should be recommended because medications alone are not sufficient to maintain posture.

• NSAID;

o They are the drugs of first choice in the treatment of AS.

o Unlike rheumatoid arthritis, it slows down radiographic progression in AS.

• Sulfasalazine

o It is effective in the presence of peripheral involvement.

o In peripheral involvement, sulfasalazine is added in cases unresponsive to NSAIDs.

• Corticosteroids can be used intraarticularly in peripheral arthritis.

• The efficacy of systemic steroids or methotrexate has not been demonstrated in AS.

• Anti-TNF therapy (Infliximab, Etanercept, Adalimumab, Golimumab, certolizumab);

o It is effective in both axial and peripheral involvement. (Given to NSAID and/or sulfasalazine resistant cases.)

o Side effects of TNF alpha inhibitors; increased risk of infection, TB reactivation, infusion reactions (hypersensitivity), psoriasis, SLE, pancytopenia, demyelination, worsening of heart failure, severe liver disease, increased risk of hematological malignancy (the risk of developing solid malignancy was not increased).

o Conditions where TNF alpha inhibitors are contraindicated; presence of active infection or high risk of infection, malignancy or premalignant condition, history of SLE, history of multiple sclerosis. Pregnancy and breastfeeding are no longer contraindications for anti-TNF drugs. Babies should not receive live vaccines for the first 6 months.

• Secukinumab (anti IL17)

It is as effective as anti-TNF drugs. It is used in cases where anti-TNF drugs cannot be tolerated or are insufficient.

o Increases the risk of exacerbation of underlying inflammatory bowel disease.