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Abstract
Ankylosing spondylitis is a disease that shows a young age of onset (less than 40 years old), inflammatory back pain, sacroiliitis and a strong association with HLA-B27. Yet some recently reported cases have presented with a late age of onset (more than 55 years old), atypical clinical presentations and a low response to NSAIDs, and this has also been named late onset spondyloarthropathy (LOSPA). As compared with early onset spondyloarthropathy (EOSPA), the LOSPA patients more frequently suffer with combined peripheral arthritis and inflammatory systemic symptoms and a high ESR and CRP level, but they lack the typical axial symptoms. Yet there have been few reports about late onset ankylosing spondylitis (LOAS). The previous cases of LOSPA and LOAS were managed with NSAIDs, steroids, methotrexate and sulfasalazine, but none were managed with TNF antagonists. LOAS is rare and difficult for management because of the patients' older age and the lack of experiences with this malady, so we report here on the four cases of LOAS that were successfully treated by TNF antagonists.
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Fig. 1.
Case 1. (A) The sacroiliac joint series: both SI joints are widened with erosions and subchondral sclerosis, and this is compatible with bilateral sacroiliitis, grade 3. (B) The whole body bone scan: note the focal increased uptake in the bilateral SI joints, the body portions at the T7 T11 levels, the right sternoclavicular joint, the superior portion of the right patella, the medical aspect of the left ankle, the bilateral proximal tibiofibular joint areas and the bilateral shoulders, and all this is compatible with ankylosing spondylitis with accompanying enthesopathy.
Fig. 2.
Case 2. The sacrum 3D-CT revealed the irregularity of the articular surface of the left SI joint with erosions and pseudowidening of the joint surface and the mild subchondral sclerosis of the right SI joint, and all this compatible with sacroiliitis (right: grade 2 and left: grade 3).
Fig. 3.
Case 3. (A) The sacroiliac joint series revealed ill-defined irregular articular surfaces with erosions and subchondral sclerosis with focal narrowing of the joint spaces of both SI joints, and all this is compatible with bilateral sacroiliitis, grade 3. (B) The sacrum CT revealed ill-defined irregular articular surfaces with erosions and subchondral sclerosis with alteration of the joint space width bilaterally, and all this is compatible with bilateral sacroiliitis, grade 3.
Fig. 4.
Case 4. (A) The sacroiliac joint series revealed focal subchondral sclerosis at about the upper portion of the bilateral SI joints, and this compatible with bilateral sacroiliitis, grade 3. (B) The sacrum CT revealed irregularity of the articular surface of the lower portion of the left SI joint with possible erosions and pseudo-widening of the joint space, and all this is compatible with left sacroiliitis, grade 3.
Table 1.
Cases of elderly onset ankylosing spondylitis
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