1076

Coexisting Spondylitis
Paul Major,1 Philip Kline3 Donald

Rheumatoid
Resnick,1 Murray Dalinka,2

Arthritis
and

and Ankylosing

Rheumatoid sidered

arthritis

and and

ankybosing unrelated

spondylitis diseases,

are readily

condif-

agnosed,
and 5).

with characteristic
A severe peripheral

spinal
arthritis

and sacroiliac
involving the

changes
hands,

(figs.
wrists,

to be separate

farentiatad
sionally disease both examples literature. that other. the

in most

cases.

Diagnostic

confusion
symptoms or, more patient.

may occaof the one rarely, when There are language indicate of either 21

arise when the signs and overlap those of the other entities coexist within the same in from of the batter The cumulative clinical Thus, and diagnostic detailed data

elbows, began.
rheumatoid

ankles, and feet developed Representative films of the

changes with ulnar deviation

1 4 years after the back pain hands (fig. 6) demonstrated

of the digits, symmetrically

the English these reports manifestations

distributed erosions, and symmetrical joint space narrowing. There were no subcutaneous nodules. Thepatient was HLA-B27 positive. Rheumatoid factor was present in high titer. The diagnosis was
coexisting rheumatoid arthritis and ankylosing spondylitis.

radiographic

disease

are apparently

unmodified
precision

by the presence
can be achieved

of the
by an

awareness of this potential association. We report two more cases of coexisting rheumatoid arthritis and ankybosing
spondylitis, literature. the first to our knowledge in the radiobogic

Case
Case

Reports
1

M. L. , a 64-year-old white man, had a 36 year history of chronic back pain. Peripheral joint symptoms involving the metacarpophalangeal joints of both hands, wrists, elbows, knees, and ankles first appeared 1 0 years before his most recant admission. Cutaneous nodules were present. The rheumatoid factor was positive, the titer measuring 1 /1 280. HLA-B27 had been positive on two occasions. Radiographs of the lumbar spine (fig. 1) and pelvis (fig. 2) on
admission joint fusion. demonstrated Radiographs syndesmophytes of the hands (fig. and bilateral sacroiliac symmetri3) revealed

cally distributed erosive changes in the metacarpal heads, carpals, ubnar styboid processes, and distal radii associated with carpal subluxations, symmetrical metacarpophalangeal joint space narrowing, and ulnar deviation of the digits. On the basis of clinical, laboratory, and radiographic findings, the diagnosis was coexisting rheumatoid arthritis and ankylosing spondylitis.

Case

2 man developed spinal immobility. low back pain which eventually Ankylosing spondylitis was diFig. 1 -Case 1 . Antenoposterior

A 61 -year-old caused complete

racolumbar

junction;

bilateral

sacroiliac

lumbar spine. Syndesmophytes joint bony fusion.

at tho-

Received
Department

June address: address:

5, 1 979;

accepted
Veterans

after

revision

November
Medical

27, 1979.
Center, 3350 La Jolla Village Dr., San Diego, CA 921 61
.

of Radiology,

Administration

Address

reprint

requests

to D. Resnick.

2Present 3Present
AJR

Department Department
May

of Radiology, of Radiology, 1980

University of Pennsylvania, Baptist Memorial Hospital, 345-1 076 $00.00

Philadelphia, San Antonio, American

PA 19104. TX 78286. Roentgen Ray Society

134:1076-1079,

0361 -803X/80/1

AJR:134,

May 1980

CASE

REPORTS

1077

Fig.

2.-Case

and nonarticulating

Anteropostenior pelvis. Ankylosis aspects of sacroiliac spaces.

.

involves

articulating

Fig. 4.-Case sive ligamentous

2. Anteroposterior and lateral views of lumbar spine. calcification with ankylosis of apophyseal joints.

Exten-

Fig. 3.-Case 1 . Posteroantenior views of hands. Symmetrically erosions in metacarpal heads, carpals, ulnar styloid processes,
radii with symmetrical joint space narrowing in metacarpophalangeal,

distributed and distal

inter-

carpal,

and radiocarpal

joints.

Discussion
Ankybosing rheumatoid spondylitis, formerly considered a variant of arthritis, is now regarded as a separate and
,

distinct entity [1 2]. The two diseases are readily tiated in most cases on the basis of characteristic
laboratory, and radiographic manifestations. Briefly,

diffaren-

clinical,
the arFig. 5.-Case 2. AnteroposteriOr
aspects of sacroiliac

thritis of anklyosing spondylitis is characterized by genetic predisposition [3], earlier onset, male predominance, and axial distribution [4]. The radiographic finding of bilaterally

pelvis.
space

Ankylosis
with marked

of articulating
bilateral

and

nonarticulating defects.

protruslo

1078

CASE

REPORTS

AJR:134,

May

1980

persons
purely

[20]. reported
clinical who

General [20-29];
picture

opinion
Including

regards
our two,

the association
23 such the typical cases

as
have

coincidence.

been
acteristic a man

from
has

the cumulative
emerged; ankylosing

data,

a charpatient at about is

initially

develops

spondylitis

age 34 years, and develops rheumatoid arthritis about 15 years later [22]. There is no evidence to suggest that the manifestations of either disease are modified in the presence of the other. An accurate diagnosis is therefore possible when the characteristic changes of both diseases are presant. Thus, the majority of coexisting rheumatoid
have fulfilled the following

of the generally accepted arthritis and ankylosing

diagnostic criteria:

examples spondylitis
individ-

these

uals
axial

are

HLA-B27 high serum

positive titer

with

the

classic
with

radiographic
subcutaneous

changes

of ankybosing symmetrical

spondylitis,

nodules,
peripheral,
Fig. deviation

of rheumatoid
arthropathy

factor,

and

the

erosive

of rheumatoid

6.-case
of wrists;

2. Posteroanterior
symmetrically

hands.
distributed

Ulnar

deviation and joint

radiocarpal

of hands; space
joints.

radial
heads,

arthritis.

erosions and

in metacarpal

The
arthritis

paucity
and

of reported
ankybosing

cases
spondylitis

of coexisting
is probably

rheumatoid
due to (1) (2) a to

carpals,
involving

distal

radii,

and ulnar

styloid

processes;

narrowing

metacarpophalangeal,

intercarpal,

lack of awareness natural tendency a single disease

of this potential association, and to attribute the observed abnormalities process. differentiating It is likely

fused sacroiliac joints with pathognomic [5]. In contrast, established predominance,

graphic

bamboo rheumatoid

spine is virtually arthritis has no

coexisting entity
basis

rheumatoid Either

arthritis disease

and

that in many cases of ankybosing spondylitis,

of one or the other

the characteristic

features

genetic and

susceptibility a peripheral
of rheumatoid

[6], a later onset, female distribution [4]. The radioarthritis are periarticubar

are lacking.
of the dominant

is than
We

diagnosed
recommend

on the
that in with process methods

abnormalities.

hallmarks

cases and

of rheumatoid

arthritis

or ankylosing

spondylitis

demineralization, marginal articubar cabby distributed

symmetrical erosions; in a mirror-image

joint these

space abnormalities symmetrical

narrowing, are pattern

classi[7].

atypical features be entertained, be periodically toid arthritis and

that the possibility of a coexisting and that the pertinent diagnostic

reviewed.

Although

coexistence can

of rheurnabe strongly

An extremely
two ing factor
ant in

useful
is the [8,

clinical
rarity 9].
normal

point

of distinction
nodules and they and HLA-B27 markers,

between
rheumatoid may

the

ankybosing

spondylitis

diseases spondylitis provide

apparently

of rheumatoid disease

in ankybosbe presdisease ankybosing

Although

suspected requires
laboratory

on radiographic logical integration

data.

findings alone, a firm diagnosis of radiographic, clinical, and

sensitive

individuals

in other and

states

[1 0-1 4], and are therefore

varieties of rheumatoid diagnostic arthritis arthropathy may create rheumatoid a peripheral [1 7]. in otherwise mentioned, stigmata other

nonspecific.
arthritis confusion; in 20% of is present or HLA-B27 of these in individuals Radiography examples identified disease. sacroiliitis patients [15, in 50% may diseases who is of be

Atypical spondybitis complicates

1 6],

REFERENCES
1 . McEwen C, Ziff M, Carmel P, Ditata D, Tanner M. The relationship to rheumatoid arthritis of its so called variants. Arthritis Rheum 1 958; 1:481-496 2. Graham W. Is rheumatoid spondylitis a separate entity? Arthritis Rheum 1960;3:88-9O

and

spondylitics undetected have no or, as previously

Rheumatoid classic are

factor

3.

of either

especially useful in such atypical cases, since subtle, but distinctive differences exist between the two entities in their appearance and distribution. Thus, a chronic, erosive peripherab arthritis is rarely seen with ankybosing spondylitis;
if present, it occurs in an asymmetrical distribution and is

Emery AEH, Lawrence JS. Genetics of ankylosing spondylitis. J Med Genet 1 967;4 : 239-244 4. Copeman WSC. In: Scott JT, ad. Copeman s textbook of the rheumatic diseases. Edinburgh: Churchill Livingstone, 1978 5. McEwan C, Ditata D, Lingg C, Porini A, Good A, Rankin T. Ankylosing spondylitis and spondylitis accompanying ulcarativa colitis, regional enteritis, psoriasis and Raiters disease: a

associated with proliferative bony changes [1 8]. Sacroiliitis is rarely the initial manifestation of rheumatoid arthritis, and
lumbar distinctly involvement unusual [19]. eventuating in extensive ankybosis is

Another
both diseases

possible
coexist

source
in the

of diagnostic
same patient.

error
On

arises
the

when
of

basis

prevalence
spondybitis

rates
in the

of rheumatoid
general population,

arthritis
such

and

ankylosing

an association

has

been

conservatively

estimated

to occur

in 1 :100,000

comparative study. Arthritis Rheum 1 971 ;1 4:291-318 6. Meyorwitz 5, Jacox RF, Hess DW. Monozygotic twins discordant for rheumatoid arthritis: a genetic, clinical and psychological study of 8 sets. Arthritis Rheum 1968;1 1 : 1 -21 7. Bywatars EGL. The early radiological signs of rheumatoid arthritis. Bull Rheum Dis 1960;1 1 :231-232 8. Simpson NRW, Stevenson CJ. Analysis of 200 cases of ankylosing spondylitis. Br Med J 1949;1 :214-216 9. Forbech V. Do mutual features really dominate separating features in rheumatoid arthritis and rhamatoid spondylitis? Acta Med Scand 1 958; 1 62 : 43-46

AJR:134,

May

1980

CASE

REPORTS

1079

WaIler M, Toone EC, Vaughan E. Study of rheumatoid factor in a normal population. Arthritis Rheum 1 964;7 :513-520 1 1 . Bartfield H. Distribution of rheumatoid factory activity in nonrheumatoid states. Ann NY Acad Sci 1 969;1 68 : 30-40 1 2. Cohen LM, Mittal KM, Schmid FR. Increased risk for spondylitis stigmata in apparently healthy HA-AW27 men. Ann Intern Med 1976;84:1 -7 1 3. Brewerton DA, Nicholls A, Caffrey M, Walters D. HL-A27 and arthropathies associated with ulcerative colitis and psoriasis. Lancet 1974;1 :956-958 1 4. Brewerton DA, Nicholls A, Caffrey M, Oates JK, Walters D, James DCO. Aeiters disease and HL-A27. Lancet 1973;2:
996-998

1 0.

sequent

development
rheumatoid

of rheumatoid
vasculitis.

nodules,
Arthritis

Sjogrens

syn-

drome and 383-388

Rheum

1978;21:

21

Falbet GH, Mason M, Barry H, Mowat AG, Boussina JC. Rheumatoid arthritis and ankylosing spondylitis

I, Gerster occurring

22.

23.

together. Br Med J 1976;1 :804-807 Good AE, Hyla JF, Rapp A. Ankylosing spondylitis with rheumatoid arthritis and subcutaneous nodule (letter). Arthritis Rheum 1977;20: 1434-1437 Luthra HS, Ferguson RH, Conn DL. Coexistence of ankylosing spondylitis and rheumatoid arthritis. Arthritis Rheum I 976;1 9:
111-114

24.

Wilkinson

M, Bywaters

1 5. 1 6.

1 7. 1 8. 1 9.

Martel W, Duff I. Pelvo-spondylitis in rheumatoid arthritis. Radiology 1961 :77:754-756 Dixon AS, Lience E. Sacro-iliac joint in adult rheumatoid arthritis and psoriatic arthropathy. Ann Rheum Dis 196120: 247-257 Polley H. The diagnosis and treatment of rheumatoid spondylitis. Med Clin North Am 1955;39:509-528 Resnick D. Patterns of peripheral joint disease in ankylosing spondylitis. Radiology 1974;1 1 0 : 523-532 Dilsen N, McEwen C, Poppel M, Gersh WJ, Ditata D, Carmel
0. A comparative roentgenologic study of rheumatoid Arthritis arthritis Rheum

25.
26.

ankylosing Rosenthal

spondylitis. SH, Lidsky

EGL. Clinical features and course Ann Rheum Dis 1 958;1 7 : 209-228

of

MD, Sharp JT,. Arrthritis

with nodules

27.

28. 29.

and 20.

rheumatoid
-368

(ankylosing)

spondylitis.

1962;5:341

following ankylosing spondylitis. JAMA 1968;206 :2893-2894 Espinoza LA, Dove FB, Osterland CK. Co-existence of ankylosing spondylitis and rheumatoid arthritis in a single family (letter). Arthritis Rheum 1979;22 : 203-204 Fallet GH, Mason M, Berry H, Mowat A, Boussina I, Gerster JC. Co-existence of rheumatoid arthritis and ankylosing spondylitis. J Rheum 1 977;4 [suppl 3]: 70-73 Huskisson EC. Ankylosing spondylitis and rheumatoid arthritis. Proc R Soc Med 1970;63:620 London MG, Bland JH. Ankylosing spondylitis with subcutaneous nodules. N Eng! J Med 1962;268: 991-994

Clayman

MD, Reinertsen

JL. Ankylosing

spondylitis

with sub-