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The incidence of pleuropulmonary disease in ankylosing spondylitis (AS) varies from 0 to 30% in the medical literature.1–4 The most frequently recognised manifestations are upper lobe fibrosis, mycetoma formation, and pleural thickening. The advent of high resolution computed tomography (HRCT) made it possible to examine the entire lung parenchyma and pleura in many conditions with diffuse lung disease by a non-invasive method.
Consecutive patients with a diagnosis of AS according to the modified New York criteria5 who attend our department during one year were included in the study. All patients had a prospective rheumatological assessment conducted by two rheumatologists (AEM and AB) using a structured questionnaire, a pulmonary function testing measurement, posteroanterior chest radiography; on the same day an HRCT of the thorax was performed using a Siemens Somatom S CT scanner with images windowed to highlight both lung and mediastinal structures. Nine HRCT slices were obtained on suspended respiration at 2 cm intervals from the lung apices to bases. The results of the chest radiographs and HRCT were assessed by a radiologist (SC) who was unaware of the clinical data of the patient. The CT scans were evaluated for the presence, distribution, and extent of airway and parenchymal abnormalities. Standard CT criteria were used to establish a diagnosis of interstitial lung disease (ILD), bronchiectasis, and emphysema.
Plain radiography was abnormal in only two patients. Twenty four patients (55%) showed abnormalities on HRCT. Table 1 lists the abnormalities detected on HRCT. Twenty (45%) patients had mild non-specific interstitial abnormalities of insufficient severity or extent to be labelled as ILD. Pulmonary function tests showed a restrictive process in eight patients, in whom three had normal chest HRCT and three had ILD. The two remaining patients had non-specific interstitial abnormalities (blebs, pleural thickening, parenchymal bands). Two patients had an obstructive process: one had normal chest HCRT and the other emphysema and apical fibrosis.
Our study disclosed a great percentage of defined as well as mild and non-specific interstitial abnormalities on HRCT undetectable on plain radiography in a series of patients with AS and without history of respiratory symptoms. Only one patient had evidence of ground glass shadowing, which is associated with active alveolitis (fig 1). This is usually considered a feature of early and potentially reversible disease. As previously described, the overall correlation of pulmonary function with radiographic appearance was poor. Casserly and Fenlon studied 26 patients with AS using HRCT and noted pulmonary abnormalities in 19 patients (73%).6,7 Findings consisted of interstitial lung disease (four patients), bronchiectasis (six patients), emphysema (four patients), apical fibrosis (two patients), mycetoma (one patient), and non-specific interstitial lung disease (12 patients). In that study plain radiographs revealed abnormalities in four patients. In contrast with our study, all patients with ILD had respiratory symptoms.
Another study conducted by Turetschek et al showed that 15/21 (71%) patients had abnormalities on thin section CT.8 The most common abnormalities were thickening of the interlobular septa (7/21 patients), mild bronchial wall thickening (6/21), pleural thickening and pleuropulmonary irregularities (6/21), and linear septal thickening (6/21). The HRCT findings in our study, as was the case in the study of Casserly et al,6 suggest an inflammatory process rather than a mechanical cause for the interstitial disease found in patients with AS. Twenty patients (45%) in our study had non-specific interstitial abnormalities as had 11 (42%) patients in the study of Casserly et al, which implied HRCT evidence of interstitial change that was of insufficient severity or extent to be labelled as ILD. The significance of such changes is unknown and must await a prospective longitudinal study to determine their natural history.
Supported in part by a grant from Pfizer.