gms | German Medical Science

History: A 35-year-old male with migration background presented to a peripheral hospital with weakness in the left arm and chest pain. The neurological examination showed a left-sided paresis. A CT-Scan showed ischemic white matter lesions possibly caused by an embolism. Further diagnostic showed a significantly reduced ejection fraction and thrombosis in the apex of the heart. A coronary intervention showed multi-vessel coronary artery disease; stents were placed and medical therapy for heart failure was initiated. The cardiac problems were seen as secondary to alcoholism. Several months later, the patient presented to the same hospital with knee pain.

Leading symptom during disease manifestation: Following transfer to our clinic the patient presented with extensive knee pain and swelling; incidentally, the patient showed an extensive kyphosis of the thorax.

Diagnostics: The mobility of the spinal column was significantly reduced. When lying down the patient could not place his head on the bed. A systolic murmur was auscultated. Laboratory tests showed an elevated CRP (89 mg/L) and ProBNP (1.966 pg/ml). A joint aspiration showed an increased number (13,500/µl) of predominantly granulocytic leucocytes (88%). Examination for crystals and bacteria was unremarkable. X-rays of the sacroiliac joints and spinal column showed significant ankylosis as well as syndesmophytes, respectively. Occiput to wall distance was 30 cm. Pain was 6/10 on VAS (however, ambulation due to pain was severely restricted). The patient history was notable for significant back pain since adolescence. Ankylosing spondylitis was diagnosed.

Therapy: Due to the advanced disease a TNF-inhibitor (Adalimumab) with low-dose prednisone (10 mg/day) because of the peripheral arthritis were initiated.

Further course: After beginning therapy the pain improved significantly. Looking back, (as a rheumatologist) the diagnosis of ankylosing spondylitis is obvious; yet how could the disease progress so far? As a member of an ethnic minority (as well alcoholism), the patient belongs to two marginalized groups. Studies have shown such patient groups frequently receive substandard care. We interpret the cardiac symptoms as an extraarticular manifestation of ankylosing spondylitis. The patient’s alcohol abuse may have stopped the further search for an explanation of his symptoms through anchoring bias. This case highlights how even currently, advanced disease with life-threatening manifestation can develop.