The central nervous system examination and slit lamp examination of the eye were unremarkable. A grade IV pansystolic murmur was present, best heard in the 4 th and 5 th intercostal spaces on the left side, which increased in intensity on inspiration. On auscultation, S1 and S2 were heard with a loud P2. The cardiovascular system examination showed raised jugular venous pulse, positive hepatojugular reflex. Respiratory examination showed pectus excavatum, decreased chest expansion, antero-posterior: transverse diameter ratio of 1:1, bilateral reduced air entry and vesicular breath sounds. There was limited range of motion at bilateral hip and knee joint and difficulty in spine flexion with loss of cervical and lumbar lordosis. On general physical examination, bilateral pitting pedal oedema was noted. There was no history of chest pain, cough, haemoptysis, paroxysmal nocturnal dyspnoea, jaundice, rash, involuntary movements, painful nodes on palms and soles, photosensitivity, recent gastro-intestinal or genito-urinary infection, diarrhoea, abdominal pain, neck pain, photophobia, eye pain and discharge, blood or mucus discharge per rectum, smoking, or family history of similar disease. He developed progressive abdominal distension and pedal oedema since the last 1 month and fever for last five days. Since last year, the patient started experiencing breathlessness, which had progressed from grade 1 to grade 4 (Modified medical research council dyspnoea scale) over time, with symptoms worsening on lying down. The patient occasionally took pain killers from local pharmacies (Non-Steroidal Anti-Inflammatory Drugs- NSAIDs), but he reported progressive restriction of spine, hip and knee movements despite treatment. Hence, in a patient of AS, a strong index of suspicion should be there for both usual and unusual extra-articular manifestations and a complete work-up would help in early diagnosis and treatment.Ī 32-year-old male presented with a 5-year history of low back ache, knee and hip pain, insidious in onset, accompanied by morning stiffness with improvement on activity. His condition was acutely stabilised with diuretics, anti-hypertensive drugs, anti-pyretics, antibiotics and oxygen inhalation followed by maintenance on Non-steroidal anti-inflammatory agents. Here, we present a case of unusual AS in a 32-year-old non-smoker male with a major involvement of peripheral joints along with spine and chronic obstructive lung disease with apical fibro-bullous cavity and right sided heart failure over a short duration of disease course. Cardiorespiratory involvement in AS is rare and is usually present in long standing disease as restrictive lung disease, conduction abnormalities or aortic insufficiency. Genetic predisposition in AS leads to its common association with certain extra-articular diseases-anterior uveitis (25-30%), psoriasis (10%) and inflammatory bowel diseases (50%). Ankylosing Spondylitis (AS) is a chronic progressive inflammatory spondyloarthropathy typically involving the axial skeleton, especially the sacroiliac joints and spine.
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