Lung parenchymal changes in patients with ankylosing spondylitis

Apical fibrobullous lung disease in ankylosing spondylitis: case report and literature review

Ankylosing spondylitis (AS) is associated with several unique pulmonary manifestations such as apical fibrobullous disease (AFBD), which is a rare extra-spinal complication, predominantly occurring in advanced disease. Infectious complications and differential diagnosis of cavitated lung lesions may be challenging, particularly in patients already submitted to immunosuppression. In this report, we present a low body-mass-index 47-year-old male patient, ex-smoker, with AS and severe joint involvement, medicated in the past with anti-TNF-α therapy, who was diagnosed with AFBD and developed pulmonary tuberculosis and later chronic cavitary pulmonary aspergillosis. The patient died due to lung cavity major bleeding.

Value of HRCT of the chest in evaluation of ankylosing spondylitis: correlation between pleuro-parenchymal abnormalities and disease activity

Background

Ankylosing spondylitis (AS) is a chronic inflammatory disorder primarily involving the sacroiliac joints and spine. It is associated with both articular and extra-articular clinical manifestations. Pulmonary involvement is a well-recognized comorbidity of AS, even among patients with early disease. The availability of high-resolution computed tomography (HRCT) has enabled better visualization of the entire lung parenchyma and earlier identification of lung pathologies, ranging from mild to more severe involvement, which were previously missed on X-rays. The aim of the study is to establish the role of HRCT in the detection of pleuro-parenchymal manifestations of AS and to look for correlations between these findings and AS activity.

Results

Lung CT scans were done for all our patients and 27 patients (90%) had positive HRCT thoracic findings, while the remaining 3 patients (10%) had a normal HRCT thoracic study. Lower lobe fibrotic changes were the most common finding seen in 20 patients (66.7%) followed by bronchial wall thickening in 13 patients (43.3%) and upper and lower fibrotic changes seen in 9 patients (30%). HRCT thoracic findings were more prominent in late AS (disease duration ≥ 10 years) (13 of 13 patients); while 14 of 17 patients with early AS (disease duration < 10 years) had mildly abnormal HRCT findings. The result of statistical analysis showed that there was negative correlation between thoracic findings and disease activity assessed by BASDAI and this correlation was insignificant (p value = 0.5).

Conclusion

HRCT offers an accurate and safe method of assessment of lung disease in patients with AS and without respiratory symptoms. Although there was no correlation between pulmonary findings and AS activity assessed by BASDAI, a positive correlation, albeit insignificant, between pulmonary involvement and disease duration had been found.

Evaluation of the Swallowing and Voice Functions in Ankylosing Spondylitis Patients

This study aimed to evaluate the swallowing and voice functions in patients with ankylosing spondylitis. Thirty patients with ankylosing spondylitis (Group 1) and 30 healthy individuals (Group 2) were included in the study. Following the laryngoscopic evaluation of the patients, the fiberoptic endoscopic evaluation of swallowing was performed, and then, the penetration-aspiration score was determined. The participants were asked to fill the eating assessment tool form. Voice recordings obtained to evaluate sound disorders were measured acoustically and analyzed using the PRAAT program. In terms of swallowing, the penetration-aspiration score obtained as a result of the flexible endoscopic swallowing assessment and eating assessment tool score was found to be higher in Group 1 than in Group 2, and a statistically significant difference was noted (p ≤ 0.001). When analyzing the maximum phonation time (p < 0.001) and fundamental frequency (p = 0.408) values in phonation evaluation, a statistically significant difference was found between the two groups. Group 1 showed a deterioration in terms of jitter (p = 0.040) and shimmer (p = 0.007) compared to Group 2, and a statistically significant difference was noted. There was no statistically significant difference in the harmonic/noise ratio (mean ± standard deviation) between the two groups (p = 0.051). Swallowing and voice functions significantly affect quality of life. Therefore, approaches aimed to improve the associated symptoms have become increasingly important. In patients with ankylosing spondylitis, swallowing quality and phonation ability may be negatively affected. These patients should be monitored for hidden or overt food aspiration.Trial Registry: https://clinicaltrials.gov/ct2/show/NCT04437394.

Rapidly Progressive Pulmonary Apical Fibrosis and Parenchymal Destruction in a Patient with Ankylosing Spondylitis

Pulmonary apical fibrosis is a rare complication of ankylosing spondylitis (AS). The essential characteristics of this lesion are its very slow progression and frequently asymptomatic nature. Herein, we are presenting a patient with AS who rapidly developed pulmonary apical fibrosis in a 3-year period despite decreased musculoskeletal pains. The 60-year-old male applied with complaints of progressively increasing cough in the recent two years, dyspnea, and fatigue. He had no chronic disease except AS. He had no continuous medication except nonsteroid anti-inflammatory drugs for 2-3 days monthly since his musculoskeletal pains decreased in the recent years. His physical examination revealed reduced breath sounds in the upper zones of the right lung. Chest X-ray revealed increased diffuse opacity in the upper zones of the right lung. Thoracic high-resolution computed tomography showed a consolidation accompanied with traction bronchiectases compatible with chronic fibrosis in the upper lobe of the right lung. However, thoracic computed tomography of the patient performed 3 years ago did not reveal pulmonary apical fibrosis and parenchymal destruction. Biopsy revealed no finding of malignancy, granulomatous inflammation, or vasculitis. The results of cultures were negative. So, the patient was diagnosed as pulmonary involvement of AS, which developed in a 3-year period. This case has shown that extra-articular complications may continue to develop in patients with AS even if their musculoskeletal complaints have subsided. So, patients with AS should be followed up regularly with systemic examinations.

Pulmonary high-resolution computed tomography findings in patients with synovitis, acne, pustulosis, hyperostosis and osteitis syndrome

Objective

To characterize the high-resolution computed tomography (HRCT) pulmonary abnormalities in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome.

Methods

Pulmonary HRCT images were reconstructed from whole-spine computed tomography (CT) images of 67 patients with SAPHO syndrome. HRCT images of 58 healthy controls were also obtained and reviewed. Patients with pneumonia and tuberculosis were excluded. Demographic and clinical data such as gender, age, onset age, disease duration, erythrocyte sedimentation rate (ESR), highly sensitive C-reactive protein (hs-CRP) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were collected from the SAPHO syndrome patients. Demographic characteristics, ESR and hs-CRP data from the healthy controls were also recorded. Student’s t test, Mann-Whitney U test, chi-squared test and logistic regression were employed to compare the HRCT findings of the two groups of patients.

Results

The median age of the SAPHO syndrome patients was 47.0 years, interquartile range [38.0–53.0]; that of the healthy controls was 37.0[30.8–53.8]. From the detailed HRCT evaluations, abnormalities were identified in 45 patients. We found irregular linear opacities in 29 (43.3%) patients, opacities in 22 (32.8%), ground-glass opacity in 11 (16.4%), pleural thickening in 9 (13.4%), solitary nodules in 6 (9%), bronchiectasis in 3 (4.5%), pulmonary bulla in 2 (3%), multiple nodules in 1 (1.5%), and reticular patterns in 1 (1.5%). Compared to the healthy controls, the SAPHO syndrome patients had a significantly higher rate of opacities but a significantly lower percentage of nodules (especially multiple nodules), although the overall rates of abnormal HRCT findings were similar in the two groups. According to the multivariate logistic regression analysis, increased age and BASDAI < 4 were significant predictors of abnormal HRCT findings.

Conclusion

Our study is the first to address HRCT pulmonary abnormalities in SAPHO syndrome patients. SAPHO syndrome patients have a significantly higher percentage of opacities and a significantly lower rate of pulmonary nodules than healthy controls. BASDAI and age are possible good predictors of abnormal HRCT pulmonary findings.

Progressive Pulmonary Fibrocystic Changes of Both Upper Lungs in a Patient with Ankylosing Spondylitis

Ankylosing spondylitis is a chronic inflammatory multisystem disease that primarily affects the axial joints. Pleuropulmonary involvement is an uncommon extra-articular manifestation of ankylosing spondylitis. There is a wide spectrum of pulmonary parenchymal changes in ankylosing spondylitis, beginning in the early stages of the disease and increasing over time. The lesions are usually asymptomatic, and not visible on chest radiographs in early stages. We reported a case of advanced ankylosing spondylitis in a 56-year-old man with progressive pulmonary bullous fibrocystic changes on both upper lobes that were misdiagnosed as tuberculosis in the early stages of the disease.