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

BACKGROUND: 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. OBJECTIVE: To describe a series of SpA patients with persistent enthesitis as first manifestation. METHODS: 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. RESULTS: 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. CONCLUSION: 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.