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DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS (DISH) AS A DIFFERENTIAL DIAGNOSIS OF ANKYLOSING SPONDYLITIS (AS)
Ankylosing Spondylitis (AS) is a chronic inflammatory disease that affects predominantly the axial skeleton, vertebral spine, entheses, as well as the sacroiliac and peripheral joints. Therefore, its diagnosis and preemptive treatment are essential in preventing further lesions, many of which can be limiting and irreparable. Because of phenotypic similarities, during inspection, AS may be conflated with an advanced case of DISH or others, though their pathophysiology differ.
A 59-year-old male patient, asian descent, former smoker, pre-diabetic, presents with proto kinetic and inflammatory pain, coincidental with movement limitation of both the cervical and lumbar spines, for the past 5 years. The pain worsened progressively, impairing movements of rotation, flexion and extension of the cervical spine, as well as lumbar flexion; substantial rectification of the cervical (fig.1) and lumbar lordosis is observed.
In order to perform daily activities, such as getting off the bed or dressing up, the patient requires assistance. Upon physical examination, a block gait is observed, as well as a decreased range of motion in the cervical and lumbar spines, with a Tragus-to-Wall test of 8,6 inches and Modified Schober test of 0,59 inches. During mobilization the patient felt pain diffusely, concomitant to paravertebral contracture.
Following orthopedic examination, a spinal CT scan was performed, demonstrating gross calcifications of the anterior longitudinal ligament in both the cervical and lumbar regions, affecting at least 4 vertebrae in each segment (fig. 2).
The patient also brought laboratorial results as follows: Triglycerides 505 mg/dL, HDL 37 mg/dL, HbA1c 7,1% and HLA-B27 negative.
The initial diagnostic hypothesis was DISH and the patient's metabolic imbalance was treated. The therapeutic measures included non-steroidal anti-inflammatory and kinesiotherapy.
This case report comes to show how important are the clinical history and anamnesis in assessing differential diagnoses of AS and other spondyloarthritis. It's crucial to evaluate possible influencing factors, such as onset of symptoms, characteristics of the pain and comorbidities associated; since the DISH patient, once limitations are established, may maintain pathological postures such as those of long term AS patients, it’s crucial to properly diagnose and manage these ailments, whenever suspected.
CAROLINA YUME ARAZAWA, RENATO FURTADO TAVARES, DEBORA TOBALDINI RUSSO DORETO, QUEROLAI GOMES GRADELHA, LEONARDO PERERA WON MUHLEN