Teng Huang1,Linfeng Li1,Bin Hao2*,Zhiyong Zhao2,Shu ling Zhao2

1Hebei university,Baoding,Hebei,China.2Chinese people's liberation Army 252 Hosptital,Baoding,Hebei,China.

Abstract Ankylosing spondylitis(AS)and rheumatoid arthritis(RA)are two different rheumatoid immune diseases.It is not common that the two diseases occur simultaneously in the same patient in clinical practice.Here,we reported a case of meeting the diagnostic criteria for both AS and RA,who was treated with integrated traditional Chineseand Western medicineand received apparent improvement.

Keywords:ankylosing spondylitis;rheumatoid arthritis;integrated Chinese and Western Medicine

Introduction

At present, modern rheumatologists generally acknowledge that ankylosing spondylitis(AS)and rheumatoid arthritis(RA)are two independent diseases,which differ in etiology, pathogenesis, clinical symptoms and imaging data.RA is characterized by synovitis,while ASis characterized by inflammation at the tendon tip.However,the same patient can also suffer from the two diseases simultaneously in clinic.Now we report the diagnosis and treatment of a patient with ASand RA in our department as follows,in order to provide better diagnostic basis and treatment ideas for clinic,prevent missed diagnosis to delay the condition,and preparefor better treatment in advance.

Casepresentation

Case history

Ms.Liu,a 28-year-old female,complained of lumbosacral pain without obvious inducement 9 years ago,and followed by the neck,back,sternum,knees and lower limbs pain intermittently two weeks later,with limited waist activity and morning stiffness.These symptoms are more pronounced in morning and night,and relieved after activity.There was no history of fever, cough, ophthalmitis and hematuria.No other joint symmetric and migratory pain,no joint deformity,no numbness of lower limbs.On July 18,2011,she was diagnosed with ASin our hospital.

According to the New York diagnostic criteria revised in 1984,patients with one or more clinical criteria and radiological criteria can be diagnosed as AS.According to the corresponding clinical manifestations of low back pain,stiffness,and other related medical history,imaging,laboratory examination results distinguished from fractures,infections,trauma,RA and other diseases.The detailed situation of the patient at the time of the first admission is shown in Table 1.

After hospitalization,she received the NSAIDs,calcium supplement,protective agents of gastric mucosa, neurotrophic drugs, biological preparations,immunosuppressant treatment.Then she was discharged with improved symptoms.After discharge,she took medication regularly:diclofenac sodium enteric-coated tablets,100 mg orally twice daily;sulfasalazine,0.75g orally twice daily;omeprazole,20 mg orally twice daily.Untill to readmission,her condition was relativelystable[regular review;blood routine,erythrocyte sedimentation rate(ESR),C-reactive protein(CRP),liver and kidney function were normal].

Table 1 Clinical symptomsand examination resultsof the patient at the timeof the first admission

In the past month,the above symptoms of the patient have worsened.Finger joints often appear ache accompanied with morning stiffness and deformation(Figure 1).So she came to our hospital for further treatment on January 20,2019.Outpatient examination showed high ESR,CRP and platelet count levels.The patients were admitted to our department with the diagnosisof AS.

Physical examination

No redness and swelling in the skin of neck and lumbar vertebra spine.Cervical vertebra mobility:forward flexion 20°,backward extension 20°,left flexion 20°,right flexion 20°,left rotation 30°,right rotation 30°.Lumbar vertebra mobility:forward flexion 60°,backward extension 0°,left flexion 10°,right flexion 10°,left rotation 20°,right rotation 20°.Tenderness exist in spinal joints and bilateral sacroiliac joints.Bilateral straight leg elevation tests were all 70°,and bilateral negative results were found in strengthened tests.Bilateral hip joints had normal range of motion,no tenderness,and negative resluts in bilateral"4"test.The pillow-wall distance is 0 cm.The degree of thoracic motion in the fourth intercostal space level was 1.0 cm.The proximal finger joints of both hands showed mild spindle swelling,especially in the right little finger,companied with tenderness.The patient hasno deformities in limbs,no swelling,tenderness and activity limitation in other joints.There was no edema in both lower limbs.The muscle strength of the limbs was grade V,and the muscle tension was moderate.Bilateral brachial biceps and triceps tendon reflex,knee reflex and Achilles tendon reflex werepresent.

Auxiliary examination

Blood routine:leucocyte 6.37x10^9/L,erythrocyte 4.94x10^12/L,hemoglobin 121.0 g/l,platelet 437x10^9/L;ESR 92 mm/h;CRP 66.10mg/l;renal and hepatic function tests were normal.

Rheumatoid factor(RF)103.0 IU/ml;anticyclic citrullinated peptide antibody(anti-CCP)686.0RU/ml;urine routine,blood sugar and coagulation function were normal.Anti-chain"O",anti-tuberculosis antibody,blood-borne four items and influenza A virusantigen wereall negative.

Sacroiliac joint CT (2019.01.21):sacroiliac joints had inflammatory changes(Figure 2),and therewasno abnormality in both hip joints.

Figure 1 Spindle changes of finger joints

Figure2 X-ray results of sacroiliac joints

Cervical vertebra CR(2019.01.21):cervical vertebra physiological curvature straightened (Figure 3);thoracic vertebra CRbone had no abnormality;

Thoracic CT(2019.01.21):bilateral lower lobes of the lungsshowed rope-like pathological changes.

The comparison of auxiliary examination in different stages are shown in Table 2.The detailed results of radiographic measurements after illness are compared in Table 3.

Diagonosis and treatment

According to the patient's condition and examination results,and referring to the diagnostic criteria of RA established by ACR conference in 2009,there were 3 facet joints involvement(2 points),RFand high titer of anti-CCPantibody(3 points),and symptoms persisted for more than 6 weeks(1 point)in patient.Taking into account,the total score is 6,which can be diagnosed as RA.Final diagnosis:ASwith RA.

The patient was treated with integrated traditional Chinese and Western medicine.Western medicine treatment:celecoxib capsule 0.2g orally twice daily;sulfasalazine tablet 0.75g orally twice daily;methotrexate tablet 10 mg orally every Tuesday;folic acid tablet 10 mg orally every Wednesday;omeprazole enteric-coated tablet 20 mg oral once daily;recombinant human type II tumor necrosis factor 50 mg subcutaneous injection once a week,and the dosage was gradually reduced after 3 months.Meanwhile,patients was asked to check blood routine,liver and kidney function regularly.The modern medical treatment in different stages was compared in Table 4.

According to the tongue(Figure 4)and pulse condition(gloomy tongue,less fur,deep thready pulse),doctors dialectically called it"deficiency of liver and kidney"and gave the patient Chinese medicine decoction treatment of"tonifying liver and kidney,promoting blood circulation and dredging collaterals".The prescriptions were as follows:Peach Kernel 10g,Safflower 6g,Angelica 15g,Wild Rehmannia 15g,Rhizoma cibotii10g,Eucommia Ulmoides 10g, Chuanduan 10g,Weilingxian 10g, Achyranthes Bidentata 10g,Astragalus 20g,Cinnamon Branch 6g,Qianghuo 10g,Gancao 6g.All medicines were decocted with water and taken orally twice a day for 7 days.During the treatment,the patient's joint pain symptoms gradually eased.After discharge,the oral dose of Western medicine was maintained.Chinese medicine was taken continuously for two weeks.After two weeks,the outpatient department will review and adjust the medicine according to thechange of the condition.

Figure 3 X-ray result of cervical spine joints

Table 2 Clinical comparison of auxiliary examination at different stages

Table 3 Radiographic measurements after illness

Table 4 Modern medical treatment

Figure4 Tonguepicture of the patient

Discussion

AS is a chronic inflammatory disease,which mainly invades sacroiliac joints,paravertebral soft tissue and peripheral joints, accompanied by extraarticular manifestations.In severe cases,spinal deformity and ankylosis may occur.The male to female ratio of ASis about 2-3:1,and the peak age of onset is 20-30 years old.RA is a systemic autoimmune disease characterized by erosive arthritis.The disease is more common in women and the ratio of male to female is about 1:3.The main clinical manifestations of RA are symmetrical and persistent polyarthritis involving facet joints such as hands and wrists,which can eventually lead to joint deformity and loss of physiological function[1].

Huskisson first proposed that ASand RA co-occur in the same patient,rather than the possible diagnosis of"rheumatoid spondylitis"in the past.In 1976,the medical scientist Fallet[2]reported such cases and described their characteristics in detail.In this case of AScomplicated with RA,pain and bone destruction of lumbosacral joint were the main causes at onset,and then bone changes of both hands' joints and polyarthritis of the whole body gradually appeared.The prevalence of RA in China mainland is about 0.2-0.4%[1]and that of AS is about 0.3%[3].According to the same theory,the probability of overlap of RA and AS in the same patient is about 1.2/100000[4].Modern medicine for such complications is mainly treated with anti-rheumatic drugs (DMARDs)combined with non-steroidal anti-inflammatory drugs(NSAIDs).Sulfasalazine has obvious curative effect on AS and RA,and low-dose hormones can be given to patients with severe symptoms and other systemic involvement for ashort time.

In traditional Chinese medicine,clinical symptoms of AS and RA are classified into“bi zheng".Every physician has his own understanding of the etiology and pathogenesis of arthralgia,but it is agreed that the etiology and pathogenesis of arthralgia are closely related to the liver and kidney.The liver stores blood,which dominates the stretching of muscles and veins in the body;the kidney stores essence,which dominates the growth of bone and bone marrow.If the sperm and blood are insufficient,the bones and muscles will lose nourishment.Then patients may experience joint pain,muscle tension,poor flexion and extension of limbs,or even limited movement in severe cases.Most of RA patients are middleaged women and most of AS patients are young men,which is similar to the concept of liver-based for women and kidney-based for men in traditional Chinese medicine theory.Moreover,the inheritance of susceptibility gene HLA-B27 and HIA-DR4 identified by modern medicine coincides with the congenital deficiency of liver and kidney in traditional Chinese medicine.In clinical treatment,physicians should realize that the congenital deficiency of liver and kidney is the root of arthralgia,the inducement and product of repeated attacks of the disease,and the intrinsic factor of the invasion of pathogenic factor.Tonifying liver and benefiting kidney plays a key role in the active and remission stages of the disease.Therefore,physicians can consider the use of Rehmannia,Rhizoma Cibotii,Chuanduan,

Eucommia Ulmoides and other drugs in the prescription to tonify the liver and kidney,strengthen muscles and bones.

In addition,according to the thought of"chronic diseases transforming to collaterals"and"chronic pain transforming to collaterals"put forward by the Qing dynasty physician Tian-shi Ye,and the theory of“initially,the Qi was blocked in the meridians.For a long time,blood will bruise into the collaterals”,physicians should consider that the disease will gradually damage the collaterals with the course prolonging,resulting in blood stasis of the collaterals.Therefore,prescription should be added the products of nourishing blood and promoting blood circulation,removing blood stasis and dredging collaterals,such as Peach Kernels,Safflower,Angelica.Cinnamon Twig and Qianghuo dispel dampness evil,also clear tendons and veins.Finally,add Astragalus Membranaceus in the prescription to improve immunity.

In summary,AS causes peripheral joint involvement,especially symmetry changes of interphalangeal joints,metacarpophalangeal joints and wrist joints.The physicians should inquire the patient's condition in detail and give a definite diagnosis.At the same time,the symptoms and signs of RA patients are more serious,and those with lower back pain should not ignore the possibility of central axis joint involvement.It is necessary and timely to carry out sacroiliac joint and lumbar motion examination, especially sacroiliac joint radiographic examination,to prevent missed diagnosis and misdiagnosis,so asto take timely treatment measures to control disease activity and reduce disability rate.