"A clinical case of lung damage in ankylosing spondylitis"


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Abstract

Ankylosing spondylitis (AS) is a chronic inflammatory disease from the group of spondyloarthritis characterized by obligatory damage to the sacroiliac joints and/or spine with their potential outcome in ankylosis, with frequent involvement of entheses and peripheral joints in the pathological process. Cardiac dysfunction and lung damage are well-known and common extraarticular manifestations associated with AS. This review presents a clinical case of a 56-year-old patient with lung damage in AS. The purpose of the study was to describe a clinical case to improve the effectiveness of medical care. Materials and methods. The material of the study was the medical history of this patient, who underwent examination and treatment at the Higher Medical School of the Russian Academy of Medical Sciences No. 1. Results. A clinical case of the development of pulmonary manifestations on the background of ankylosing spondylitis is described. Upon admission to the hospital, the patient complained of shortness of breath with minimal physical exertion, swelling of the feet and shins, pain in the hands, feet, and lower back. It is known from her medical history that since 2003 she has been seen by a rheumatologist at the Higher School of Medicine No. 20 with a diagnosis of Ankylosing spondylitis, and also periodically consulted at the rheumatology center at the Higher School of Medicine No. 1. In recent years, there has been no dynamics from NSAID treatment. In November 2024, she was hospitalized in the cardiology department at the VGKBSMP No. 1 with the above complaints. Lung damage was mistakenly interpreted as chronic heart failure and the patient was prescribed appropriate therapy for heart failure. During a comprehensive examination by cardiologists and staff of the Department of Faculty Therapy at N.N. Burdenko VSMU, pulmonary manifestations were suspected against the background of AS, and the patient was referred to the MRC.Moscow, where this relationship was confirmed and treatment with methotrexate was prescribed. Conclusion. AS is a dangerous disabling disease with a variety of clinical manifestations and requires a multidisciplinary approach not only by rheumatologists, but also by specialists in other specialties. The presented clinical case demonstrates the lack of awareness of doctors about possible pulmonary manifestations of systemic connective tissue diseases, which subsequently causes an incorrect diagnosis. Thus, it is necessary to raise doctors' awareness of extra-articular manifestations of systemic connective tissue diseases for timely diagnosis, differential diagnosis and appropriate treatment.

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Introduction. Ankylosing spondylitis (AS) is a chronic inflammatory disease from the group of spondyloarthritis characterized by obligatory damage to the sacroiliac joints and/or spine with their potential outcome in ankylosis, with frequent involvement of entheses and peripheral joints in the pathological process [1]. Cardiac dysfunction and lung damage are well-known and frequently reported extraarticular manifestations associated with AS. Pulmonary manifestations of this disease include fibrosis of the upper lobes, interstitial lung disease, impaired ventilation due to limited chest movements, sleep apnea, spontaneous pneumothorax. Currently, there are no clear recommendations for a step-by-step approach to screening these patients for cardiovascular and pulmonary complications [2]. However, despite the rare occurrence of pulmonary manifestations of Ankylosing spondylitis, there is a lack of awareness among doctors and untimely diagnosis.The purpose of the work. The aim of the study was to describe a clinical case of lung damage in a patient with AS in order to improve the effectiveness of medical care.Materials and methods of research. The material of the study was the medical history of a patient undergoing examination and treatment at the Higher Medical School of the Russian Academy of Medical Sciences No. 1.The results of the study. Patient B., 56 years old, was hospitalized in November 2024 with a diagnosis of "Chronic heart failure with preserved ejection fraction, stage I, FC 3. CHD. Paroxysmal form of atrial fibrillation. CHA2DS2VASc- 3 points, HAS-BLED-1 point. Stage III hypertension, the target blood pressure level has been reached, the risk of CCO4" in the Higher School of Medicine No. 1. Of the complaints, she noted shortness of breath with minimal physical exertion, swelling of the feet and shins, pain in the hands and feet.For a long time she was observed in a polyclinic with a paroxysmal form of atrial fibrillation and hypertension.It is also known from the anamnesis that since 2003, a rheumatologist has been seeing a patient with a diagnosis of Ankylosing spondylitis at the Higher Medical School No. 20. She also periodically consulted at the rheumatology center of the Higher Medical School No. 1. In recent years, previously prescribed therapy with NSAIDs and GCS has had no pronounced positive dynamics.During a comprehensive examination at the VGBSMP No. 1 by cardiologists and staff of the Department of Faculty Therapy at the N.N. Burdenko VSMU, a relationship between pulmonary manifestations and AS was suspected, and the patient was referred to the MRC.Moscow, where this assumption was confirmed and methotrexate therapy was prescribed.Objectively: Height 156 cm, weight 62 kg. BMI is 25.4 kg/m2. During auscultation of the lungs, hard breathing occurs in all pulmonary fields, crepitating wheezing of the "cellophane crackle" type. The respiratory rate is 22 beats/min. During cardiac auscultation, the heart tones are muted and rhythmic. Pulse rate-76 beats/min. Blood pressure is 120/80 mmHg. Swelling of the feet and shins. Severe soreness on palpation of the sacroiliac joints on both sides. Soreness of the paravertebral points along the spine, muscle defiance.  From other organs and systems without special features.A clinical, laboratory and instrumental examination was performed.The total blood count showed a decrease in hemoglobin to 113 g/l.A biochemical blood test showed an increase in total cholesterol to 4.8 mmol/L, HDL cholesterol to 2.1 mmol/L.NT-proBNP is normal.ECG: Sinus rhythm. Deviation of the EOS to the left.Transthoracic echocardiography without significant pathology.SpO2- 92 %.Prescribed treatment with diuretics (furosemide 4 ml in a jet, spironolactone 50 mg), ACE inhibitor- fosinopril 20 mg / day. and bisoprolol 2.5 mg / day with no effect other than normalization of blood pressure and pulse.According to CT scans of the chest organs, there is a picture of widespread bilateral pulmosclerosis with elements of fibrosis. Radiography of the spine shows signs of osteochondrosis, spondylosis of the thoracic spine, and signs of ankylosing spondylitis.Neurologist's consultation: Deforming dorsopathy. Common osteochondrosis. Chronic lumbalgia.CVB. Dyscirculatory encephalopathy. Cerebral atherosclerosis.Consultation of a pulmonologist in December 2024 at the Hospital No. 1: Interstitial lung disease. DAY 2.Hospitalization in the MRC Moscow in December 2024: Lung damage in AS. Bilateral sacroiliitis, art.3-4. Late stage. Moderate activity. Dactylitis of the foot. Severe pain syndrome FN 2.Methotrexate was prescribed 15 mg per week intramuscularly with positive dynamics.Conclusion. Ankylosing spondylitis is a dangerous disabling disease with a variety of clinical manifestations and requires a common approach not only from rheumatologists, but also from specialists in other fields.  The example of the presented clinical case demonstrates the lack of awareness of the majority of doctors about possible pulmonary manifestations of systemic connective tissue diseases, which subsequently causes an incorrect diagnosis and, accordingly, incorrectly selected therapy. This disease is not deadly, and with early detection and timely treatment, it can ensure a long life expectancy.

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About the authors

Andrey Valerievich Budnevsky

Voronezh State Medical University named after N.N.Burdenko

Email: budnev@list.ru
ORCID iD: 0000-0002-1171-2746

MD, Professor, Head of the Department of Faculty Therapy

Russian Federation, 10 Studencheskaya str., Voronezh, 394036, Russia

Evgeniy Sergeevich Ovsyannikov

Voronezh State Medical University named after N.N.Burdenko

Email: ovses@yandex.ru
ORCID iD: 0000-0002-8545-6255

Doctor of Medical Sciences, Professor of the Faculty Therapy Department

Russian Federation, 394036, Россия, Воронеж, ул.Студенческая, 10.

Karina Valerievna Vostrikova

Voronezh State Medical University named after N.N.Burdenko

Author for correspondence.
Email: prudnikova.2012@inbox.ru
ORCID iD: 0000-0003-2103-5328

Assistant Professor of Faculty Therapy

Russian Federation, 10 Studencheskaya str., Voronezh, 394036, Russia.

Elena Nikolaevna Alferova

Voronezh Region Budgetary Healthcare Institution Voronezh City Clinical Emergency Hospital No. 1

Email: help@medrocket.ru

Заведующая 2 кардиологическим отделением

Russian Federation, 10 Studencheskaya str., Voronezh, 394035, Russia

Irina Petrovna Alferova

Voronezh State Medical University named after N.N.Burdenko

Email: help@medrocket.ru

5th year student of the Faculty of Medicine

Russian Federation, 10 Studencheskaya str., Voronezh, 394036, Russia.

References

  1. Федеральные клинические рекомендации: Анкилозирующий спондилит. Пересмотр: 2018 год. https://library.mededtech.ru/rest/documents/cr_175/?ysclid=m78uckx0wb558554812
  2. Momeni M. Taylor N. Tehrani M. Cardiopulmonary manifestations of ankylosing spondylitis //International journal of rheumatology. 2011. 172847: 1. https://doi.org/10.1155/2011/728471
  3. Mercieca C. Van der Horst-Bruinsma I. E. Borg A. A. Pulmonary, renal and neurological comorbidities in patients with ankylosing spondylitis; implications for clinical practice //Current rheumatology reports. 2014. 16: 1-10. https://doi.org/10.1007/s11926-014-0434

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