MRI-negative Inflammatory Back Pain as an Unusual Manifestation of Takayasu Arteritis: A Case Report

Takayasu arteritis and spondyloarthritis are two rheumatological diseases whose co-existence is well-documented in the literature. Data on the presence of inflammatory back pain in Takayasu arteritis without a diagnosis of spondyloarthritis, however, is scarce. Here, we present a 33-year-old man who was admitted to the emergency department with acute-onset chest pain associated with left carotidynia, carotid bruit and left arm claudication, normal ECG, and CT angiographic features of Takayasu arteritis including stenosis and occlusion of the aorta and its branches. Two years prior, he had undergone a clinical work-up for an inflammatory back pain accompanied by alternating buttocks pain, morning stiffness lasting more than half an hour, and heel pain. His ESR was elevated (128 mm/1st hr) but he had negative serological tests (anti-dsDNA, anti-CCP, HLA-B27) and negative MRI of the sacroiliac joints. He was prescribed NSAIDs and placed on adalimumab 40 mg IM every two weeks since then but had to switch to etanercept, 2 months prior to his emergency admission due to supply issues. Oral prednisolone was initiated at a dose of 60mg/day with symptomatic improvement in both his inflammatory back pain and his chest pain but had to be switched to methotrexate and infliximab due to steroid side effects. Inflammatory aortitis should be considered as a possibility during the assessment of inflammatory back pain to mitigate the risks of delayed diagnosis.

高安动脉炎（Takayasu arteritis）与脊柱关节炎（spondyloarthritis）均为风湿性疾病，二者共存的临床病例在文献中已有充分记载。然而，针对未确诊脊柱关节炎的高安动脉炎患者伴发炎性腰背痛的相关研究数据仍较为匮乏。本文报告1例33岁男性患者，因急性起病胸痛就诊于急诊科，伴随左侧颈动脉痛、颈动脉杂音及左上肢间歇性跛行，心电图检查未见异常；CT血管成像显示符合高安动脉炎的特征性改变，包括主动脉及其分支的狭窄与闭塞。该患者2年前曾因炎性腰背痛接受临床排查，当时伴随交替性臀部疼痛、持续半小时以上的晨僵及足跟疼痛。患者红细胞沉降率（ESR）升高（128 mm/第1小时），但血清学检测（抗双链DNA抗体、抗环瓜氨酸肽抗体、HLA-B27）均为阴性，骶髂关节MRI检查亦无异常。此后患者被处方非甾体抗炎药（NSAIDs），并接受每两周一次的40mg肌内注射阿达木单抗治疗，但因药物供应短缺，需在本次急诊入院前2个月更换为依那西普治疗。患者起始口服泼尼松龙60mg/日，其炎性腰背痛与胸痛症状均得到显著改善，但因糖皮质激素的不良反应，需更换为甲氨蝶呤联合英夫利昔单抗治疗。在炎性腰背痛的临床评估中，应将炎性主动脉炎纳入鉴别诊断范畴，以降低延误诊断的风险。