QD90 - Wrong X - Ray, Wrong Doctor Save
QD Clinic - Lessons from the clinic
Delays in the diagnosis of Ankylosing spondylitis rest with wrong choices
Features Dr. Jack Cush
Transcription
Hi. This is Cush, Cush, brought to you by RheumNow's expanded coverage of virtual ACR twenty twenty. This case is wrong X-ray, wrong doctor, wrong drug. 29 year old fellow comes in to see me with a history of buttock pain. You already know the diagnosis, don't you?
Turns out for the last four years, he's had some low back pain and intermittent buttock pain. The pain is worse at night. He has two to three hours of morning stiffness. He has been going to a bunch of doctors. He started out first with his primary care doctor, who did labs and x rays of his back.
They were normal. Then went to one orthopedist, then another orthopedist, then a physical therapist, then a physiatrist, then another back specialist orthopedist who did an MRI of his lower spine. Luckily enough, the MRI of his lower spine included the pelvis and SI joint, although it wasn't ordered as such. And yes, they found unilateral sacroiliitis. They found bone marrow edema on both sides of the SI joint.
There were no erosions in the SI joint, but bone marrow edema and other inflammatory changes to suggest unilateral sacroiliitis and no other diagnosis. So the story here is we have a young man, 30, who has, inflammatory low back pain. This is sort of the hallmark presentation of someone who has ankylosing spondylitis or a spondyloarthropathy. X rays, we're not done. I ordered those.
We'll see what those come back, but I'm sure there'll be some changes there so that this does, in fact, qualify as axial spondyloarthritis or ankylosing spondylitis. He is HLA B twenty seven positive, never checked before. His labs were actually normal. His SED rate, CRP, chemistries, and blood counts were all normal. The message here is, I think, again, wrong x rays.
Young men, young patients who have, inflammatory back pain should always have an x-ray that includes the, pelvis and SI joints. Problem is they always get LS spine films and will often miss this diagnosis. Wrong doctors flopping around between PM and R, PCPs and ortho didn't do very well here. And of course, he was treated with the wrong drug. He was taking Tylenol over the counter medicines, given an occasional prescription for a nonsteroidal that he didn't know that he should take on a regular basis.
So the fellow has been in pain for quite some time. This is a big problem. As you may know, there are substantial delays in the diagnosis of ankylosing spondylitis. On average, seven to eight years. It is amazing in this day and age with all the notice that spondylitis has gotten over the years, all the drugs being approved for spondylitis, you know, perpetuating the story, the presentation, the evaluation, and the new therapies, that this really hasn't changed very much.
In fact, most patients diagnosed with ankylosing spondylitis are not diagnosed by rheumatologists. It takes many years to get to the rheumatologist. In fact, that number I mentioned earlier, seven, eight years, that might be the number it takes. So maybe you have to fail three, four, five doctors before you finally get referred to the rheumatologist. Rheumatologist.
I think we as the teachers of the masses, not just patients, but also other clinicians need to perpetuate this story that inflammatory back pain in someone, you know, under the age of 30, under the age of 40 should always prompt the B27 and pelvic x rays. In that instance, this man would have at least been able to avert four years of pain and disability. And now he's going to go bungee jumping and join the Marines now that he's been started on, effective biologic therapy. So again, wrong x rays, wrong doctors, wrong drugs usually don't speak well for the patients, but thank God the rheumatologist is here to save the day. Be sure to check out RheumNow's expanded coverage of ACR twenty twenty, the virtual meeting.
We've got a lot of new exciting things coming up. It's a new way to learn. It's a grand new world. Aren't we enjoying it?
Turns out for the last four years, he's had some low back pain and intermittent buttock pain. The pain is worse at night. He has two to three hours of morning stiffness. He has been going to a bunch of doctors. He started out first with his primary care doctor, who did labs and x rays of his back.
They were normal. Then went to one orthopedist, then another orthopedist, then a physical therapist, then a physiatrist, then another back specialist orthopedist who did an MRI of his lower spine. Luckily enough, the MRI of his lower spine included the pelvis and SI joint, although it wasn't ordered as such. And yes, they found unilateral sacroiliitis. They found bone marrow edema on both sides of the SI joint.
There were no erosions in the SI joint, but bone marrow edema and other inflammatory changes to suggest unilateral sacroiliitis and no other diagnosis. So the story here is we have a young man, 30, who has, inflammatory low back pain. This is sort of the hallmark presentation of someone who has ankylosing spondylitis or a spondyloarthropathy. X rays, we're not done. I ordered those.
We'll see what those come back, but I'm sure there'll be some changes there so that this does, in fact, qualify as axial spondyloarthritis or ankylosing spondylitis. He is HLA B twenty seven positive, never checked before. His labs were actually normal. His SED rate, CRP, chemistries, and blood counts were all normal. The message here is, I think, again, wrong x rays.
Young men, young patients who have, inflammatory back pain should always have an x-ray that includes the, pelvis and SI joints. Problem is they always get LS spine films and will often miss this diagnosis. Wrong doctors flopping around between PM and R, PCPs and ortho didn't do very well here. And of course, he was treated with the wrong drug. He was taking Tylenol over the counter medicines, given an occasional prescription for a nonsteroidal that he didn't know that he should take on a regular basis.
So the fellow has been in pain for quite some time. This is a big problem. As you may know, there are substantial delays in the diagnosis of ankylosing spondylitis. On average, seven to eight years. It is amazing in this day and age with all the notice that spondylitis has gotten over the years, all the drugs being approved for spondylitis, you know, perpetuating the story, the presentation, the evaluation, and the new therapies, that this really hasn't changed very much.
In fact, most patients diagnosed with ankylosing spondylitis are not diagnosed by rheumatologists. It takes many years to get to the rheumatologist. In fact, that number I mentioned earlier, seven, eight years, that might be the number it takes. So maybe you have to fail three, four, five doctors before you finally get referred to the rheumatologist. Rheumatologist.
I think we as the teachers of the masses, not just patients, but also other clinicians need to perpetuate this story that inflammatory back pain in someone, you know, under the age of 30, under the age of 40 should always prompt the B27 and pelvic x rays. In that instance, this man would have at least been able to avert four years of pain and disability. And now he's going to go bungee jumping and join the Marines now that he's been started on, effective biologic therapy. So again, wrong x rays, wrong doctors, wrong drugs usually don't speak well for the patients, but thank God the rheumatologist is here to save the day. Be sure to check out RheumNow's expanded coverage of ACR twenty twenty, the virtual meeting.
We've got a lot of new exciting things coming up. It's a new way to learn. It's a grand new world. Aren't we enjoying it?
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