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Chronic low backache in young adults, generally worst in the morning Progressive limitation of back motion and of chest expansion Transient (50%) or permanent (25%) peripheral arthritis Anterior uveitis in 20 25% Diagnostic radiographic changes in sacroiliac joints Elevated ESR and negative serologic tests for rheumatoid factor HLA-B27 testing is most helpful when there is an indeterminate probability of disease
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LIVEDO RETICULARIS
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Livedo reticularis produces a mottled, purplish discoloration of the skin with reticulated cyanotic areas surrounding paler central cores This distinctive fishnet pattern is caused by spasm or obstruction of perpendicular arterioles, combined with pooling of blood in surrounding venous plexuses Livedo reticularis can be idiopathic or a manifestation of a serious underlying condition Idiopathic livedo reticularis is a benign condition that worsens with cold exposure, improves with warming, and primarily affects the extremities Apart from cosmetic concerns, it is usually asymptomatic The presence of systemic symptoms or the development of cutaneous ulcerations points to the presence of an underlying disease Secondary livedo reticularis occurs in association with a variety of diseases that cause vascular obstruction or inflammation Of particular importance is the link with antiphospholipid antibody syndrome Livedo reticularis is the presenting manifestation of 25% of patients with antiphospholipid antibody syndrome and is strongly associated with the subgroup that has arterial thromboses, including those with Sneddon s syndrome (livedo reticularis and cerebrovascular events) Other underlying causes of livedo retic-
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Ankylosing spondylitis is a chronic inflammatory disease of the joints of the axial skeleton, manifested clinically by pain and progressive stiffening of the spine The age at onset is usually in the late teens or early 20s The incidence is greater in males than in females, and symptoms are more
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Arthritis & Musculoskeletal Disorders
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prominent in men, with ascending involvement of the spine more likely to occur
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Clinical Findings
A Symptoms and Signs
The onset is usually gradual, with intermittent bouts of back pain that may radiate down the thighs As the disease advances, symptoms progress in a cephalad direction and back motion becomes limited, with the normal lumbar curve flattened and the thoracic curvature exaggerated Chest expansion is often limited as a consequence of costovertebral joint involvement Radicular symptoms due to cauda equina fibrosis may occur years after onset of the disease In advanced cases, the entire spine becomes fused, allowing no motion in any direction Transient acute arthritis of the peripheral joints occurs in about 50% of cases, and permanent changes in the peripheral joints most commonly the hips, shoulders, and knees are seen in about 25% Enthesopathy, a hallmark of the spondyloarthropathies, can manifest as swelling of the Achilles tendon, plantar fasciitis (producing heel pain), or sausage swelling of a finger or toe (less common in ankylosing spondylitis than in psoriatic arthritis) Spondylitic heart disease, characterized chiefly by atrioventricular conduction defects and aortic insufficiency, occurs in 3 5% of patients with long-standing severe disease Anterior uveitis is associated in as many as 25% of cases and may be a presenting feature Pulmonary fibrosis of the upper lobes, with progression to cavitation and bronchiectasis mimicking tuberculosis, may occur, characteristically long after the onset of skeletal symptoms Constitutional symptoms similar to those of rheumatoid arthritis are absent in most patients
sternomanubrial joint similar to those of the sacroiliacs Radiologic changes in peripheral joints, when present, tend to be asymmetric and lack the demineralization and erosions seen in rheumatoid arthritis
Differential Diagnosis
In contrast to ankylosing spondylitis, rheumatoid arthritis predominantly affects multiple, small, peripheral joints of the hands and feet Rheumatoid arthritis also spares the sacroiliac joints, and has little effect on the rest of the spine except for C1 C2 Finally, rheumatoid arthritis is often associated with rheumatoid nodules and with rheumatoid factor, not with HLA-B27 The history and physical findings of ankylosing spondylitis serve to distinguish this disorder from other causes of low back pain such as disk disease, osteoporosis, soft tissue trauma, and tumors The most valuable distinguishing radiologic sign of ankylosing spondylitis is the appearance of the sacroiliac joints, although a similar pattern may be seen in Reiter s syndrome and in the arthritis associated with inflammatory intestinal diseases and psoriasis In ankylosing hyperostosis (diffuse idiopathic skeletal hyperostosis [DISH], Forestier s disease), there is exuberant osteophyte formation The osteophytes are thicker and more anterior than the syndesmophytes of ankylosing spondylitis, and the sacroiliac joints are not affected The radiographic appearance of the sacroiliac joints in spondylitis should be distinguished from that in osteitis condensans ilii
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