A Rare Cause of Weight Loss in an 80y Old Ankylosing Spondylitis Patient

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An 80 year old male patient presented with weight loss of 13 kg, swallowing problems, cachexia, sarcopenia and a rigid spine. Ankylosing spondylitis (AS) HLA B27 positive, diagnosed in his thirties, was intermittently treated with NSAIDs in earlier years but for the last decades almost asymptomatic. Extra-articular features were never documented. Follow-up by a rheumatologist stopped 30 years ago. Patient adapted to spine rigidity but a neurosurgeon performed a laminectomy C4–C5 in 1990 because of spinal stenosis.
A barium esophagogram revealed esophageal compression by a massive anterior ligamental calcification process (Fig. 1). An esophagogastroscopy confirmed extrinsic compression on the posterior pharynx (Fig. 2). Imaging confirmed AS with bilateral sacroiliac joint fusion, syndesmophytes and fusion of most zygapophyseal (ZA) joints (Fig. 3).
Patient demonstrated throat clearing, coughing, globus sensation, gurgling voice and breathing, gagging of food and liquids. Because of dysphagia and high risk of aspiration, enteral nutrition via percutaneous endoscopic gastrostomy tube was started.
Swallowing problems due to cervical spine abnormalities are uncommon and may comprise massive degenerative osteophytes and diffuse idiopathic spinal hyperostosis.1 Problems secondary to AS are less frequent and may be secondary to cervical deformities2 but also major syndesmophytes or large anterior ligament ossifications.3 The morphology of the syndesmophytes can be influenced by the presence or absence of ankylosis of the ZA joints at the corresponding level.4,5 The laminectomy performed in this patient might have induced instability explaining the gross morphology of the enthesophytes. A similar finding was noted at the L2–L3 level with a non-fused ZA joint and more osteophyte-like bony outgrowth.
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