Persistent enthesitis and spondyloarhtropathy: A case series of 71 Bangladeshi people

BACKGROUND:\ud Enthesitis is a prominent feature of spondyloarthropathy (SpA) and persisting enthesitis may be a presenting symptom either alone or in combination with peripheral synovitis and/or inflammatory back pain.\ud \ud OBJECTIVE:\ud To describe a series of SpA patients with persistent enthesitis as first manifestation.\ud \ud METHODS:\ud This is a cross-sectional study. All SpA patients visiting the rheumatology and rehabilitation clinic, of Chittagong Medical College Hospital, between May 2007 and December 2008, were studied and those with chronic enthesitis as presenting symptom were included. Patients were classified with European Spondyloarthropathy Study Group (ESSG) classification criteria for SpA. Demographic data were collected and routine lab tests performed, including HLA-B-27 testing. In all patients X-ray of spinal segments, sacroiliac joints and pelvis were performed. Collected data were analyzed using SPSS package program (version 12.0) and multivariate analysis was done.\ud \ud RESULTS:\ud A total of 71 SpA patients could be included with initial presentation with chronic enthesitis. Of these patients 20 gave a history of disease onset before their 16th birthday and in 51 cases it was after their sixteenth. The mean age at presentation was respectively 12.5 ± 2.5 and 23.3 ± 6.4 years in juvenile and adult cases. Enthesitis was defined by history, clinical examination, and radio-imaging at accessible sites (X-ray pelvis/foot). Enthesitis presenting in the heel was the most common site (n= 51), but it was also seen in other locations in another 20 patients. The mean duration between presenting enthesitis and other features of SpA was 7.7 ± 3.2 and 8.5 ± 2.2 months in juvenile and adult cases respectively. All patients had raised ESR at disease onset and HLA-B27 was found to be positive in 58 cases. Ankylosing spondylitis (AS) was diagnosed in 49 cases and GradeI-II, Grade-III, and Grade-IV sacroiliitis was documented in 31, 5, and 13 patients respectively.\ud \ud CONCLUSION:\ud Persistent enthesitis is one of the most common clinical presentation of SpA usually associated with high ESR, HLA-B27 positivity. Definition and classification of enthesitis is important in early diagnosis of this rheumatologic condition

Extra-spinal sciatica and sciatica mimics: a scoping review

Not all sciatica-like manifestations are of lumbar spine origin. Some of them are caused at points along the extra-spinal course of the sciatic nerve, making diagnosis difficult for the treating physician and delaying adequate treatment. While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics. Examples of benign extra-spinal sciatica are: piriformis syndrome, walletosis, quadratus lumborum myofascial pain syndrome, cluneal nerve disorder, and osteitis condensans ilii. In some cases, extra-spinal sciatica may have a catastrophic course when the sciatic nerve is involved in cyclical sciatica, or the piriformis muscle in piriformis pyomyositis. In addition to cases of sciatica with clear spinal or extra-spinal origin, some cases can be a product of both origins; the same could be true for pseudo-sciatica or sciatica mimics, we simply don’t know how prevalent extra-spinal sciatica is among total sciatica cases. As treatment regimens differ for spinal, extra-spinal sciatica, and sciatica-mimics, their precise diagnosis will help physicians to make a targeted treatment plan. As published works regarding extra-spinal sciatica and sciatica mimics include only a few case reports and case series, and systematic reviews addressing them are hardly feasible at this stage, a scoping review in the field can be an eye-opener for the scientific community to do larger-scale prospective research