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  • Sue Gurden; AS Case Study for Astretch 2012. Introduction Mrs M D.O.B. 1/4/1946 Longstanding Disease First contact Physiotherapy AS Clinic 2002 Sue Gurden;
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Presentation and Discussion of a case study of a female patient with longstanding “atypical disease” Sue Gurden; AS Case Study for Astretch 2012

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  • Slide 1
  • Sue Gurden; AS Case Study for Astretch 2012
  • Slide 2
  • Introduction Mrs M D.O.B. 1/4/1946 Longstanding Disease First contact Physiotherapy AS Clinic 2002 Sue Gurden; AS Case Study for AStretch 2012
  • Slide 3
  • History 1961; age 16 years; generally unwell, swollen knees and ankles Admitted to hospital for 8 weeks Diagnosed Rheumatic Fever Treated with IM steroids and high dose Aspirin Complete recovery Sue Gurden; AS Case Study for AStretch 2012
  • Slide 4
  • History 1965-6 LBP following childbirth Treated conservatively no improvement MUA x2 Traction and 3 week plaster cast Physiotherapy Ongoing intermittent pain Relevant Investigations?? Sue Gurden; AS Case Study 2012
  • Slide 5
  • History 1970, birth 2 nd child Developed chest pain and multiple joint pain Felt she was being ignored Requested to see Psychiatrist Sue Gurden; AS Case Study for AStretch 2012
  • Slide 6
  • History 1973 admitted to hospital Prescribed Indocid They were wonderful Complete recovery mild episodic flares until 1978 Domiciliary visit from Orthopaedic Surgeon Manipulation Mortal Agony, never felt such severe pain Sue Gurden; AS Case Study for AStretch 2012
  • Slide 7
  • Reasoning With the benefit of hindsight, thoughts so far? Any medical concerns? Any further questions you would have asked? What is pattern of symptoms telling us? What would you do? Questions? Sue Gurden; AS Case Study for AStretch 2012
  • Slide 8
  • Pattern of Symptoms Insidious onset Age of onset Flares following childbirth Inflammatory Arthritis Intermittent worsening episodes Possible enthesitis Good response to NSAIDs Sue Gurden; AS Case Study for AStretch 2012
  • Slide 9
  • Rheumatology History 1979 Referred to Rheumatologist Diagnosed Ankylosing Spondylitis Told would probably end up in a wheelchair and become incontinent My world fell apart- husband, 2 children and a job---- ---however secretly I was relieved to have a diagnosis; not all in the mind Sue Gurden; AS Case Study for AStretch 2012
  • Slide 10
  • Reasoning What happened in 1973? What mechanisms are brought into play now? What do you think this Rheumatologist should have done? Sue Gurden; AS Case Study AStretch 2012
  • Slide 11
  • Other stuff Around this time experiencing severe lateral trunk/back pain Dismissed by herself and medical team as part of her AS Tried various pain relieving methods Acupuncture TENS Various NSAIDs This pain actually turned out be a combination of ovarian cyst and endometriosis 1981 Hysterctomy Sue Gurden; AS Case Study AStretch 2012
  • Slide 12
  • Summary so far Working Mum with 2 children Intermittent severe and debilitating pain and stiffness 18 years from first onset to diagnosis Poorly managed disease Bizarre treatments!!! Sue Gurden; AS Case Study AStretch 2012
  • Slide 13
  • LESSONS Taking things at face value Never assume Education?? Specialist Physio??? Adequate management??? Could we have yellow Flags already emerging through previous treatments impact and style of diagnosis? Sue Gurden; AS Case Study AStretch 2012
  • Slide 14
  • Moving on 1981-1994 Increasing fatigue and pain Treated with IM steroid injections when desperate Sold house and moved to a smaller one to help her to cope Struggling to keep working (her GP was also her employer 1994 One morning the car would not start decided to retire (48years) Sue Gurden; AS Case Study for AStretch 2012
  • Slide 15
  • Bath Referred to bath 1995 Several scans Isotope bone scan followed by MRI Metastasis Spine I was told that I had cancer and had a short time to live Multiple scans; no primary tumour found Assumption made that this was Atypical AS Sue Gurden; AS Case for AStretch Study 2012
  • Slide 16
  • Evidence Destructive diskovertebral lesions in ankylosing spondylitis: appearance on magnetic resonance imaging. Kurugoglu SKurugoglu S, Mihmanli I, Kanberoglu K, Kanberoglu A.Mihmanli IKanberoglu KKanberoglu A Neuroradiology. 2001 Dec;43(12):1098-101.PMID: 11792053 [PubMed - indexed for MEDLINE] We report magnetic resonance imaging findings of diskovertebral lesions in a case of ankylosing spondylitis mimicking metastatic and/or infectious disease. Multiple hypointense areas were seen on T1- weighted images corresponding to hyperintense areas on T2-weighted images in dorsal, lumbar, and sacral vertebral bodies and the manubriosternal joint, with accompanying soft tissue masses. Diagnosis was achieved through biopsy, regression of the paravertebral soft tissue masses, later detection of bilateral sacroiliitis on computed tomography, and presence of histocompatibility antigen HLA-B27.and/or Sue Gurden; AS Case Study for AStretch 2012
  • Slide 17
  • Moving on again! Services Change 1999 Consultant input from Bath Gwent Rheumatology Service Felt that everything I told him he listened pain did not change but I felt better Referred to Orthopaedics (L.THR1999 R. THR 2000)* Joined local newly formed NASS group Sue Gurden; AS Case Study for AStretch 2012
  • Slide 18
  • Reasoning Women have a significantly earlier age of disease onset and worse functional outcomes despite more radiographic severity in men 1D There is suggestion that women have more peripheral arthritis 1E A greater proportion of first degree relatives have a history of the disease 1C In women, the symptoms of ankylosing spondylitis often first present during or post PREGNANCY Lee, K et al. Are there gender differences in severity of ankylosing spondylitis? Results from the PSOAS cohort. Ann Rheum Dis 2007;66(5):633-638 Sue Gurden; AS Case Study for AStretch 2012
  • Slide 19
  • Hip Joint involvement The hip joint space is narrowed uniformly. 2a Axial migration of the femoral head occurs, and a collar of osteophytes may be seen at the femoral head-neck junction 2b Sue Gurden; AS Case Study for AStretch 2012 2. Imaging In Ankylosing Spondylitis; Wilfred C.G. et al. Medscape Reference (2011) (last accessed July 2012)
  • Slide 20
  • Hip Joint involvement Typically is bilateral and symmetrical. 2c Non destructive ankylosing form in young patients. 3a Secondly, a slower unilaterally destructive process in older individuals. 3b Hip disease suggests a more aggressive disease. 3c Sue Gurden; AS Case Study for AStretch 2012 3. Hip involvement in ankylosing spondylitis: epidemiology and risk factors associated with hip replacement surgery; Bert Vander Cruyssen et al. Rheumatology Volume 49, Issue 1 Pp. 73-81 (2010)Bert Vander CruyssenRheumatologyVolume 49, Issue 1
  • Slide 21
  • Physiotherapy Service (2001-2003) Increasingly reduced function Increasing pain particularly Thoracic spine Chronic Migraine Fatigue Poor sleep pattern Not responsive to physical treatment Increasing disease activity, marked functional deterioration Referred to Rheumatology Consultant BASDAI 9.0 Sue Gurden; AS Case Study 2012
  • Slide 22
  • Medical Interventions (2001-2003) Chronic Pain Amitriptyline Gabapentin Botox Injections Baclofen IM Depomedrone Clonazepam Thoracic Epidural (steroid) Sue Gurden; AS Case Study for AStretch 2012
  • Slide 23
  • Ant-TNF Prescribed Remicade & MTX (Feb 2004) Marked Improvement scores BASDAI 3.8 May 2004 BASDAI 2.6 Sept. 2004 Wonderful! Felt the difference immediately Sue Gurden; AS Case Study for AStretch 2012
  • Slide 24
  • Objective Markers / Goals BASMI BASDAI BASFI BASGI 24.9.2004 3.8 2.6 2.2 1.9 30.9.2005 3.6 2.8 5.5 0.7 29.9.2006 4.8 6.4 4.8 6.2 28.9.2007 3.9 3.8 3.2 2.2 25.1.2008 4.2 6.1 6.0 6.4 30.1.2009 5.0 7.0 5.7 9.4 19.4.2010 5.8 6.78 7.4 7.0 4.7.2011 4.8 8.03 8.0 7.45 Sue Gurden; AS Case Study for AStretch 2012
  • Slide 25
  • Reasoning Developed Abdominal pain and changes in bowel habits Remicade MTX combination discontinued Despite IM steroids functional deterioration + Subsequent scores are reflective of her medication changes 2006 Adalimumab 2007 ANA +ve Symptoms of Lupus Discontinued Adalimumab 2008 Chose to restart Sue Gurden; AS Case Study for AStretch 2012
  • Slide 26
  • Side effects of Infliximab Mild stomach pain or upset 4a Bloody, black, or tarry stools 4a Nausea, vomiting, or diarrhea 4a Sue Gurden; AS Case Study for AStretch 2012 4. Inflximab side effects; http://www.drugs.com/sfx/infliximab-side-effects.html (Last Accesses July 2012)http://www.drugs.com/sfx/infliximab-side-effects.html
  • Slide 27
  • 2008 ?Allergic Reaction to Adalimumab Swelling Hands face Ankle Oedema persistent despite discontinuation Gall stones Liver enzymes+ Complex Cholecystectomy Sue Gurden; AS Case Study for AStretch 2012
  • Slide 28
  • Side Effects of Infliximab Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue) 4b biliary pain, cholecystitis, cholelithiasis, and hepatitis have been reported. 4c Sue Gurden; AS Case Study for AStretch 2012
  • Slide 29
  • 2009-2010 Adulinimab re-introduced May 2009 General Health and Function improved Nov 2009 developed Pustular Psoriasis (palmer and plantar) ** Has gradually decreased her involvement with NASS as feet are painful and unable to exercise in hydrotherapy pool Sue Gurden; AS Case Study for AStretch 2012
  • Slide 30
  • Side effects Psoriasiform eruption (erythematous, slightly scaling, well-shaped pruriginous plaques) has been reported. 4d Development of antibodies to Ant-TNF(up to 51%), development of antinuclear antibodies (about 50%), newly detected anti-dsDNA antibodies (about 20%), lupus and lupus-like syndromes (uncommon) 5 Sue Gurden; AS Case Study for AStretch 2012 Humira side effects; http://www.drugs.com/sfx/humira-side-effects.html; (Last accessed July2012)
  • Slide 31
  • What to do? Considering this ladies complicated history and her present deterioration how best can this be managed? Sue Gurden; AS Case Study for AStretch 2012
  • Slide 32
  • Problem List Reactions to meds Effect of discontinuation on AS Reduced function and ability to continue physical activities Pain management Sue Gurden; AS Case Study for AStretch 2012
  • Slide 33
  • Treatment Plan Referral to Dermatology effective management of Psoriasis Referral to specialist MDT clinic to monitor and manage medication, pain and functional issues of AS Sue Gurden; AS Case Study for AStretch 2012
  • Slide 34
  • Combined clinics March 2011; Off, Adulinimab due to orthopaedic Surgery Generally unwell; night sweats, back pain, fatigue and fainting; no local signs of infection Symptoms probably due to AS BASDAI 7.2 PLAN: Resume Adulinimab; Review 2/12 Sue Gurden; AS Case Study for AStretch 2012
  • Slide 35
  • Outcome June 2011 ANA +ve ds DNA anti-body Adulinimab discontinued MRI Imaging sequences requested Enterocoxib trial with BP monitoring July 2011 BASDAI 7.5 Referred to Gastro-enerology Switch to Etanercept Sue Gurden; AS Case Study for AStretch 2012
  • Slide 36
  • Mode of action Ant-TNF TNF-alpha; mediator of inflammation and tissue damage in inflammatory arthritis Selectively bind TNF-alpha in the cellular micro environment, thereby preventing interaction with membrane-bound TNF receptors on target cells. Etanercept is a recombinant fusion protein of the soluble type II TNF receptor on a human IgG1 backbone Adalimumab is a recombinant human monoclonal antibody specific to TNF Golimumab is a fully human anti-TNF IgG1 monoclonal antibody that targets and neutralises both the soluble and membrane-bound forms of TNF Sue Gurden; AS Case Study for Astretch 2012
  • Slide 37
  • Adverse Effects Tuberculosis; Bacterial infections, including sepsis and pneumonia, invasive fungal infections, and other opportunistic infections Demyelinating disease, seizures, aplastic anaemia, pancytopaenia, and drug-induced lupus Formation of antibodies efficacy Etanercept does not appear to generate neutralising antibodies Sue Gurden; AS Case Study 2012
  • Slide 38
  • TREATMENT November 2011 3/12 trail Golimumab March 2012 Continuing on Golimumab Reports 100% improvement No side effects Sue Gurden; AS Case Study for Astretch 2012
  • Slide 39
  • Questions? Sue Gurden; AS Case Study for AStretch 2012

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