USMLE® Step 1 style questions USMLE
A 35-year-old man comes to the emergency department for evaluation of right eye pain and redness. The pain started suddenly, and it is difficult for him to open the right eye in a well lit room. The patient has a history of chronic atraumatic low back pain for which he intermittently takes ibuprofen. Chart review reveals three similar episodes of eye pain requiring emergency department visits; however, the patient failed to follow up with an opthamologist. The patient’s right eye appears injected with associated photophobia. X-ray of the patient's spine is shown below.
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Laboratory analysis demonstrates a C-reactive protein level 26 mg/L (normal <10 mg/L). If left untreated, this patient is at risk of developing which of the following complications?
Ankylosing spondylitis exam links
Content Reviewers:Rishi Desai, MD, MPH
Contributors:Tanner Marshall, MS, Evan Debevec-McKenney, Harry Delaney, MBChB
Ankylosing spondylitis can be broken down - Ankylosing means stiffening, spondylo- refers to the vertebra, and -itis refers to inflammation.
So ankylosing spondylitis is a chronic inflammatory disease that affects the vertebral joints and makes the spine really stiff, but can also cause inflammation in other parts of the body like the eyes and blood vessels.
Ankylosing spondylitis, also called Bechterew disease, is part of a group of diseases called seronegative spondyloarthropathies.
Spondyloarthropathies are all autoimmune diseases that affect the joints, and they’re seronegative, which refers to the fact that rheumatoid factor, which is an autoantibody, is not found in the blood.
Alright, so in the healthy adult, the vertebral column is made up of 33 bones.
From top to bottom, the first seven bones are the cervical vertebrae, the next twelve are the thoracic vertebra and the next five, are the lumbar vertebrae.
Below that is a bone called the sacrum, which is attached to the pelvic bone on either side, called the ilium, and where they meet is the sacroiliac joint.
Below the sacrum is a tiny bone called the coccyx or tailbone.
There are two types of joints between the vertebra.
Between each of the vertebral bodies is an intervertebral disc which is made of type I and type II collagen and has two parts, the annulus fibrosis, an outer fibrous ring, and the nucleus pulposus, an inner jelly-like substance.
This disc forms a joint between each vertebra, and it allows slight movement and acts as a shock absorber.
In addition to the intervertebral discs, each vertebra has joints called facet joints with the vertebra above and the vertebra below, one on each side.
These joints are synovial, meaning they have a joint capsule and a small amount of synovial fluid in between.
When you stretch your back the capsule in these joints stretches too and decreases the pressure in the joint space, which makes any gas suddenly come out of solution, making a cracking sound!
They help guide and limit the range of motion in your spine.
In ankylosing spondylitis there’s chronic inflammation of the intervertebral joints and the facet joints of the spine.
The exact cause of the inflammation is unclear, but it’s thought to be due to an autoimmune process - which is when the immune system attacks its own tissue - in this case the type I and type II collagen in the joints.
But unlike many other autoimmune conditions, no autoantibody has been specifically linked to the disease.
Normally, the cells of the immune system are ready to spot and destroy anything foreign that could cause the body harm.
To help with this, most cells in the body have a set of proteins that combine together to form something called a major histocompatibility complex, or MHC, class I molecule that sits on the surface of their cell membrane.
Most individuals with ankylosing spondylitis have the gene HLA-B27, which is a gene that encodes for a specific type of MHC class I molecule.
These surface proteins act kind of like a serving platter, presenting molecules from within the cell for the immune system to continually sample.
A type of T-lymphocyte, called a CD8+ T-cell, also known as a cytotoxic T-cell, uses its T-cell receptors to bind to the antigen presented by the MHC class I molecule.
Normally though the molecule’s just a sample from the cell, and the immune system recognizes it as harmless, and this is known as a self-antigen, and there’s no response.
Ankylosing spondylitis (AS) is a form of arthritis that primarily affects the spine. This chronic condition can lead to fusion of the vertebrae, resulting in a rigid spine. AS can also affect the sacroiliac joints, peripheral joints, and digits, and in severe cases, it can lead to disability. Some of the symptoms seen in AS include back pain, postural abnormalities, buttock pain, and pain in the peripheral joints such as the hips, knees, and ankles.
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