Dados do Trabalho

Title

NON-RADIOGRAPHIC ANKYLOSING SPONDYLITIS MANIFESTED BY ENTHESITIS OF STERNAL-MANUBRIUM JOINT: CASE REPORT

Background

Ankylosing spondylitis (AS) has an inflammatory character, presents predominantly in the vertebral column and may evolve the function of the axial skeleton. The epidemiology starts in the white young adult male. The patient's main mission is low back pain, which is the most common joint involvement. Peripheral joint involvement is due to the presence of arthritis and enthesitis. Arthritis predominates in large lower limb joints. The enthesitis preferentially affect the insertion of Achilles tendon and the plantar fascia. As for extra-articular manifestations, the most frequent is uveitis, which can be observed in up to 40% of patients, usually associated with Human leukocyte antigen (HLA) B27 positive. Radiological examinations, such as computed tomography or magnetic resonance imaging, the most common finding is bilateral sacroiliitis. The diagnosis is made by the proven sacroiliitis plus a suggestive finding of AS or HLA-B27 positive plus two findings suggestive of AS. Finally, the treatment is done with nonsteroidal anti-inflammatory drugs (NSAIDs) and / or priority with tumor necrosis factor (TNF) blockers. The aim of this study was to describe a case that has as main complaint an atypical and abrupt onset symptom.

Case report

A 22-year-old white male patient complained of severe chest pain two years ago, that started abruptly without any previous clinical symptoms. He was taken to the emergency room, where he administered intravenous analgesics, which resulted in minimal relief, but without improvement of the condition. After this episode, patient reports having been consulted by a cardiologist and four orthopedists, cardiographic tests showed no change and was diagnosed with Tietze syndrome. NSAIDs were prescribed, but they did not respond well. After 4 months without resolution of the condition, the patient consulted with a rheumatologist who suspected AS, due to the clinical and epidemiological profile of the patient, which was manifested by enthesitis of the manubrium-sternal joint and requested laboratory and radiological examinations.The results showed increased inflammatory evidence (CRP and ESR), HLA-B27 positive and without alterations of the vertebral column or sacroiliac joint to magnetic resonance, evidencing a non-radiographic AS. And the treatment did not respond with NSAIDs, corticosteroids and sulfasalazine, only with Adalimumab (TNF blocker).

Conclusion

This report shows the importance of early diagnosis of AS for an effective treatment, recognizing atypical symptoms as the main complaint.