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The predominant clinical feature of nr-axSpA is sacroiliitis, which can manifest as inflammatory back pain (IBP) or alternating buttock pain.1 IBP is characterized by age at onset less than 40 years, insidious onset, improvement with exercise, no improvement with rest, and pain at night with improvement upon getting up.2 Patients with nr-axSpA may also experience extra-spinal manifestations. The most common extra-spinal manifestations in patients with nr-axSpA include enthesitis (up to 44% of patients),3 subclinical bowel inflammation (up to 42% of patients),4 and peripheral arthritis (up to 41% of patients).3 Other extra-spinal manifestations include uveitis (up to 12% of patients),2 psoriasis (up to 11% of patients),5 dactylitis (up to 7% of patients),2 and inflammatory bowel disease (up to 6% of patients) (Figure 9).5
A broad spectrum of diseases and conditions can mimic the extra-spinal manifestations of axSpA, which clinicians consider as part of their differential diagnoses (Table 1).
Figure 9. Prevalence of Extra-spinal Manifestations (ESMs) of nr-axSpA2-5
IBD, inflammatory bowel disease; nr-axSpA, non-radiographic axial spondyloarthritis.
*Prevalence includes all axial and peripheral SpA disease states.
†Prevalence includes all axial and peripheral SpA disease states. Subclinical is defined as relating to or denoting a disease that is not severe enough to present definite or readily observable symptoms.
Table 1. Possible Differential Diagnosis of Extra-spinal Manifestations of nr-axSpA6-12
ESM, extra-spinal manifestations; nr-axSpA, non-radiographic axial spondyloarthritis.
*Anterior uveitis is more commonly associated with axSpA compared with other types of uveitis.
1. van Tubergen A, Weber U. Diagnosis and classification in spondyloarthritis: identifying a chameleon. Nat Rev Rheumatol. 2012;8(5):253-261.
2. Rudwaleit M, van der Heijde D, Landewe R, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009;68(6):777-783.
3. Rudwaleit M, Haibel H, Baraliakos X, et al. The early disease stage in axial spondylarthritis: results from the German Spondyloarthritis Inception Cohort. Arthritis Rheum. 2009;60(3):717-727.
4. Kopylov U, Starr M, Watts C, et al. Detection of Crohn disease in patients with spondyloarthropathy: the SpACE Capsule study. J Rheumatol. 2018;45(4):498-505.
5. Mease PJ, van der Heijde DV, Karki C, et al. Characterization of patients with ankylosing spondylitis and nonradiographic axial spondyloarthritis in the US-Based Corrona Registry. Arthritis Care Res (Hoboken) . 2018;70(11):1661-1670.
6. Alvarez-Nemegyei J, Canoso JJ. Heel pain: diagnosis and treatment, step by step. Cleveland Clin J Med. 2006;73(5):465-471.
7. Gecse KB, Vermeire S. Differential diagnosis of inflammatory bowel disease: imitations and complications. Lancet Gastroenterol Hepatol. 2018;3(9):644-653.
8. Rathinam SR, Babu, M. Algorithmic approach in the diagnosis of uveitis. Indian J Ophthalmol. 2013;61(6):255-262.
9. Pinton PC. Psoriasis differential diagnosis. Clin Derm. 2013;2(2):60-66. Available at: https://www.clinicaldermatology.eu/materiale_cic/697_1_2/6012_psorias/article.htm. Published October 23, 2013. Accessed April 18, 2019.
10. Healy PJ, Helliwell PS. Dactylitis: pathogenesis and clinical considerations. Curr Rheumatol Rep. 2006;8(5):338-341.
11. Venables PJW. Diagnosis and differential diagnosis of rheumatoid arthritis. UpToDate. Available at: https://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of-rheumatoid-arthritis/print. Updated August 23, 2018. Accessed March 22, 2019.
12. Okafor LO, Hewins P, Murray PI, Denniston AK. Tubulointerstitial nephritis and uveitis (TINU) syndrome: a systematic review of its epidemiology, demographics and risk factors. Orphanet J Rare Dis. 2017;12(1):128. doi: 10.1186/s13023-017-0677-2.
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Version: August 2019
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