the Diagnosis of Ankylosing Spondylitis: Key Insights

Q: the Diagnosis of Ankylosing Spondylitis: Key Insights

Hello： At that time, you were suspected of having iritis associated with the HLA-B27 gene, as HLA-B27 positivity is related to iritis. <br>Therefore, your physician requested further testing. <br>The orthopedic doctor may have diagnosed you with spondyloarthritis based on the pos

Diagnosis of Ankylosing Spondylitis

Hello Doctor: I underwent an HLA-B27 test during college due to acute iritis.
At that time, the orthopedic doctor directly told me that I had spondyloarthritis.
Initially, I didn't fully understand it and simply accepted what the doctor said.
Since I have been experiencing discomfort in my back (similar to the symptoms of spondyloarthritis), I attributed the cause to spondyloarthritis.
Later, due to military service, I had a follow-up examination, but the results were inconclusive because the X-ray findings were not clear.
Recently, I visited the hospital again for confirmation and underwent a CT scan, which also did not show any abnormalities.
The doctor mentioned that if I had spondyloarthritis, the joint surfaces would appear serrated.
Given this, can it be concluded that I do not have spondyloarthritis? (HLA-B27 is positive).
In another question, you mentioned the quantitative sacroiliac joint scan (QSS) in nuclear medicine, along with inflammatory markers in the blood (ESR, CRP), and the diagnosis via CT scan.
Which of these would be more definitive? Frankly, I would be quite relieved if it is not spondyloarthritis, as short-term military service is certainly preferable to a lifelong condition.
However, the symptoms of spondyloarthritis persist, so if it is not spondyloarthritis, what could be the cause? I would appreciate your answers to these questions.
Thank you, Doctor!

youngkidd, 20~29 year old female. Ask Date: 2005/05/05

Dr. Lin Xiaoyi reply Orthopedics

Hello: At that time, you were suspected of having iritis associated with the HLA-B27 gene, as HLA-B27 positivity is related to iritis.
Therefore, your physician requested further testing.
The orthopedic doctor may have diagnosed you with spondyloarthritis based on the positive HLA-B27 result and your symptoms of back pain.

To diagnose ankylosing spondylitis clinically, according to current classification criteria, in addition to symptoms, there must be evidence of bilateral grade 2 or higher or unilateral grade 3 or higher sacroiliitis on X-rays.
However, in early ankylosing spondylitis, X-rays may not show abnormalities.
At this stage, some tests can be performed; blood tests for ESR, CRP, and IgA are useful references.
A nuclear medicine quantitative sacroiliac scan (QSS) can reveal inflamed areas, while a CT scan can detect structural changes due to inflammation earlier than X-rays.
MRI typically can identify sacroiliitis earlier than CT scans.
Blood tests are necessary and can serve as diagnostic references.
For imaging, your current first choice should be the nuclear medicine quantitative sacroiliac scan (QSS).
If there is increased uptake in both sacroiliac joints, combined with your HLA-B27 positivity, it is highly likely to be early ankylosing spondylitis.
However, without direct examination, it is not possible to provide a definitive diagnosis.
I recommend that you consult a physician as soon as possible to confirm the diagnosis.
If it is ankylosing spondylitis, it is essential to collaborate closely with your physician for treatment.

Sincerely, Lin Hsiao-Yi, Department of Allergy, Immunology, and Rheumatology, Taipei Veterans General Hospital.

Reply Date: 2005/05/05

More Info

Ankylosing Spondylitis (AS) is a type of inflammatory arthritis that primarily affects the spine and the sacroiliac joints, which are located at the base of the spine where it connects to the pelvis. It is characterized by chronic pain and stiffness, particularly in the lower back and hips, and can lead to the fusion of the vertebrae over time. The condition is often associated with the HLA-B27 antigen, which is found in a significant percentage of individuals with AS. However, not everyone with this antigen will develop the disease, and not everyone with AS will test positive for HLA-B27.

Your experience with acute iritis (an inflammation of the iris) and subsequent testing for HLA-B27 is relevant, as there is a known association between AS and uveitis (which includes iritis). The presence of HLA-B27 can suggest a predisposition to developing AS, especially if you have other symptoms such as chronic back pain, stiffness, or pain in the hips and buttocks, which you have described.

The diagnostic process for AS can be complex. While X-rays are commonly used to assess the sacroiliac joints for changes indicative of AS, early-stage disease may not show significant changes. This is why advanced imaging techniques, such as MRI, can be more effective in detecting early inflammatory changes in the sacroiliac joints and spine. A CT scan can also provide detailed images, but it may not always show early signs of inflammation as clearly as an MRI.

You mentioned that your X-rays did not show clear signs of AS, and your CT scan also did not reveal abnormalities. This does not definitively rule out AS, especially if you have persistent symptoms. The "sawtooth" appearance of the joint surfaces that your doctor referred to is a classic sign of advanced AS, but it may take time for these changes to develop.

In terms of laboratory tests, inflammatory markers such as ESR (Erythrocyte Sedimentation Rate) and CRP (C-Reactive Protein) can help indicate the presence of inflammation in the body, but they are not specific to AS. Elevated levels may suggest an inflammatory process, but they do not confirm AS. The presence of elevated IgA levels can also be associated with AS, particularly in the context of HLA-B27 positivity.

If your symptoms persist and you are not satisfied with the current diagnosis, it may be beneficial to seek a second opinion from a rheumatologist, who specializes in autoimmune and inflammatory diseases. They can provide a more comprehensive evaluation and may consider additional tests or imaging studies to clarify your diagnosis.

In conclusion, while your current tests may not confirm AS, the persistent symptoms you are experiencing warrant further investigation. Conditions such as non-specific inflammatory arthritis, mechanical back pain, or other autoimmune disorders could also be contributing to your symptoms. A thorough evaluation by a specialist can help determine the underlying cause and guide appropriate treatment options. It is essential to address these symptoms, as early intervention can significantly improve quality of life and prevent long-term complications.

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