Disabling bony ankylosis of hip, knee and axial spine in a neglected patient of ankylosing spondylitis.

To cite: Varshney AN, Kumar N, Anand R, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-009890 DESCRIPTION A 38-year-old man presented with inflammatory low-back pain starting at the age of 18 years. It was associated with morning stiffness that eases with works and worsens in the night, along with difficulty in changing posture in bed. After 12 years of onset of disease, the entire spine started becoming increasingly stiff with gradual loss of lumbar lordosis and development of thoracic kyphosis. At the same time he also reported pain and swelling in bilateral knee joint, limiting his day-to-day activity and later developed stiffness of joint and disability. For the 4 years he has been completely bedridden and unable to perform his routine activities without help. On examination, we found fixed flexion deformity of knee joint and severe kyphosis of spine with the patient unable to stand on his own. On primary investigations, erythrocyte sedimentation rate=73 (>10), C reactive protein=174.4 (>5), human leucocyte antigen B27 positive, X-ray reveals fusion of bilateral sacroiliac joint along with ankylosis of spine (figure 1) and knee (figure 2). Ankylosing spondylitis (AS) usually starts in second to third decade of life and progresses over decades to produce varying kyphosis, restricted neck movements with radiological evidences of sacroilitis in early stage and complete fusion of joint in later stages with or without spinal fusion. Nearly 30% of patients with AS develop peripheral arthritis. This is usually rare and is asymmetric with oligoarthitis affecting larger joints particularly hip and knee. With modern antirheumatic tumour necrosis factor-blockers and non-steroidal anti-inflammatory