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P-347
Multipl Sklerozlu Hastada Geliflen Ankilozan Spondilit Hastal›¤›: Olgu Sunumu
Ebru Aytekin, Nil Çaglar, Levent Özgönenel, fiule Tütün, Fatma Atefl
Sa¤l›k Bakanl›¤› ‹stanbul E¤itim ve Araflt›rma Hastanesi Fiziksel T›p ve
Rehabilitasyon Klini¤i, ‹stanbul
Ankilozan Spondilitli (AS) hastalarda nörolojik semptom ve bulgulara nadiren
rastlanmaktad›r. Altta yatan nedenler genellikle ilerleyici araknoidit, kauda ekina sendromu,
atlantoaksiyel subluksasyon ve spinal k›r›klar fleklindedir. Multipl Skleroz (MS) ile birlikteli¤i
izole vakalar olarak bildirilmifltir. Bu olgu sunumunda hem MS hem de AS tan›s› olan 40
yafl›ndaki erkek hasta sunulmufltur. 40 yafl›ndaki herhangi bir ifli olmayan erkek hasta poliklini¤imize
6 y›ld›r mevcut olan inflamatuar karakterde bel a¤r›s› flikayeti ile baflvurdu. Sabah
tutuklu¤u 20dk idi. Özgeçmiflinde 16 y›l önce tan› konmufl olan MS hastal›¤› mevcuttu.
Hastan›n kas- iskelet sistem muayenesinde bel ve sa¤ kalça hareketleri tüm yönlere k›s›tl› idi.
Tragus duvar mesafesi 25 cm, modifiye schober 2,5 cm, el-parmak zemin mesafesi 20cm,
gö¤üs ekspansiyonu 3 cm idi. Nörolojik muayenesinde tüm ekstremitelerde de¤iflen derecelerde
kas gücü kayb› vard›. Derin tendon refleksleri normoaktif, patolojik refleksi yoktu.
Yürümesi ataksik ve kanedyen yard›m›yla yürüyordu. Oftalmolojik muayanesinde patoloji
yoktu. Sakroiliak eklem manyetik rezonans görüntülemesinde bilateral sakroiliak eklemlerde
daralma, düzensizlik, sklerotik de¤ifliklikler ve kemik ili¤i ödemi izlendi. Hastaya bu bulgularla
Ankilozan Spondilit tan›s› kondu. Literatürde AS ve MS birlikteli¤i desteklenmifltir. Bu birliktelik
daha çok benzer T hücre arac›l› immunogenetik defektlere sahip olmalar›na
ba¤lanm›flt›r. Hangi hastal›¤›n bir di¤erinin komplikasyonu oldu¤u bilinmemektedir. Erken tan›
her iki hastal›¤›n prognozu aç›s›ndan çok önemli oldu¤undan hastalar›m›za kas iskelet sistemi
muayenesi yan›nda ayr›nt›l› bir nörolojik muayene yapmam›z gerekti¤i kan›s›nday›z.
Anahtar Kelimeler: Ankilozan Spondilit, inflamatuar bel a¤r›s›, multipl Skleroz
P-348
Ankilozan Spondilite Ba¤l› Temporomandibuler Eklem ve
Difl Tutulumu: Olgu Sunumu
‹lknur Aktafl 1, Feyza Ünlü Özkan 1, Ezgi Tunador 2, Serpil Kaplan Yalç›nkaya 3,
Meryem Y›lmaz 1, Duygu fiilte 1, Nilgün fienol Güler 1, Turan Uslu 1
1 Fatih Sultan Mehmet E¤itim ve Araflt›rma Hastanesi, Fiziksel T›p ve Rehabilitasyon Klini¤i, ‹stanbul
2 Kad›köy A¤›z ve Difl Sa¤l›¤› Merkezi, ‹stanbul
3 Ba¤c›lar E¤itim ve Araflt›rma Hastanesi Difl Klini¤i, ‹stanbul
Otuz iki yafl›ndaki erkek hasta onbefl y›ld›r ankilozan spondilit (AS) nedeniyle romatoloji
taraf›ndan takip edilmektedir. Tedavi sürecinde metotreksat, non-steroid antienflamatuar
ilaçlar, kalsiyum ve D vitamini preparatlar› ve osteoporoz için bifosfonatlar kullanan hasta son
6 ayd›r infliximab almaktad›r. Klini¤imize temporomandibuler eklem (TME) a¤r›s› ile baflvuran
hasta, daha önce difl a¤r›s› nedeniyle difl hekimine müracat etti¤ini ve yirmi yafl difl çekimi
s›ras›nda diflinin k›r›ld›¤›n› ifade etmekteydi. Difl hekiminden al›nan hikayede; cerrahi olarak
diflin ç›kar›lmaya çal›fl›ld›¤› ancak baflar›l› olunamad›¤›, bunun üzerine çekilen panoromik çene
ve difl grafisinde giriflim yap›lan diflin yan› s›ra di¤er difllerin de çene kemi¤i ile tam ankiloze
oldu¤unun görüldü¤ü, ileri cerrahi müdahalenin mandibula k›r›¤›na neden olabilece¤i
düflünülerek diflin kalan k›sm› a¤›zda b›rak›larak tedavinin sonland›r›ld›¤› ö¤renildi. Olgu
klini¤imizde de¤erlendirildi¤inde; Lomber Modifiye Schober: 0 cm, gö¤üs ekspansiyonu: 0
cm, BASDAI:1. 6, BASFI: 8,5, lateral lomber fleksiyon: 44 cm, oksiput duvar mesafesi 26 cm
olarak ölçüldü. Postur öne e¤ikti ve bastonla zorlukla yürüyordu. Dizler 90 derece fleksiyonda
ankiloze, el parmaklar›nda deformite olusturmufl periferik eklem tutulumlar› da vard›.
Hastan›n a¤›z aç›kl›¤› 2 cm idi. TME’ler palpasyonla ileri derecede hassast›. Bu durum AS’nin
TM eklem tutulumuna ba¤land›. AS’li olgularda difl ve TME’lerin de tutulabilece¤i ve ankiloze
olabilece¤i düflünülerek mutlaka panaromik çene grafileri ile olgular de¤erlendirilmeli ve
tedavi plan› ona göre düzenlenmelidir. Ayr›ca bu tutulum bölgeleri için olgular mutlaka bilgilendirilmeli,
difl hekimlerine hastal›klar› ile ilgili uyar›da bulunmalar› hat›rlat›lmal›d›r.
Anahtar Kelimeler: Ankilozan spondilit, difl, temporomandibuler eklem
325
23. Ulusal Fiziksel T›p ve Rehabilitasyon Kongresi / 23 rd National Physical Medicine & Rehabilitation Congress
Türk Fiz Rehab Derg 2011:57Özel Say›; 1-334 /Turk J Phys Med Rehab 2011:57Suppl; 1-334
P-347
Occurrence of Ankylosing Spondylitis in a Patient with Multiple
Sclerosis: Case Report
Ebru Aytekin, Nil Çaglar, Levent Özgönenel, fiule Tütün, Fatma Atefl
Research and Training Hospital Ministry of Health Istanbul Physical Medicine and
Rehabilitation Clinic, Istanbul
In patients with Ankylosing Spondylitis (AS) neurological signs and symptoms are rarely
encountered. Underlying reasons usually include progressive arachnoidit, cauda equina
syndrom, atlanto-axiel subluxation and spinal fractures. Occurrence with multiple Sclerosis
(MS) had been reported in isolated cases. In this case report, a male patient, who was
diagnosed as AS and MS was presented. A 40 year old unemployed male patient applied to
our outpatient clinic with a history of back pain with inflammatory character, presented for
6 years. Morning stiffness was 20 minutes. In his history, he was diagnosed as MS 16 years
ago. ‹n his musculoskeletal examination back and right hip movements were limited in all
directions. Tragus-wall distance was 25cm, modified Schober was 2,5 cm, finger floor
distance was 20 cm and chest expansion was 3 cm. ‹n his neurological examination, varying
degrees of muscle power loss was detected in all extremities Deep tendon reflexes were
normoactive pathological reflexes were absent. He had an ataxic gait pattern and he was
using a cane. There was no prominent feature in his opthalmologic examination. Bilateral
sacroiliac narrowing, ›rregularity, increased sclerosis and bone marrow edema were
radiologic findings in his sacroiliac magnetic resonance imaging. The patient was diagnosed
as AS with these findings. MS and AS association has been supported in the literature. This
association is possibly due to similar T cell mediated immunological defect. ‹t is unknown that
which disease causes the other one or both occurs together. Because of the importance
of early diagnosis for the prognosis of both diseases; we have to performe detailed
neurological and musculoskeletal examinations of our patients.
Keywords: Ankylosing spondylitis, inflammatory back pain, multipl sclerosis
P-348
Temporomandibuler Joint and Tooth Involvement Due to
Ankylosing Spondylitis: Case Report
‹lknur Aktafl 1, Feyza Ünlü Özkan 1, Ezgi Tunador 2, Serpil Kaplan Yalç›nkaya 3,
Meryem Y›lmaz 1, Duygu fiilte 1, Nilgün fienol Güler 1, Turan Uslu 1
1Fatih Sultan Mehmet Research and Education Hospital Physical Therapy and
Rehabilitation Clinic, Istanbul
2Kad›köy Oral and Dental Care Center, Istanbul
3Ba¤c›lar Research and Education Hospital Dental Clinic, Istanbul
A 32 years old male had been followed by the rheumatology clinic with the diagnosis of
ankylosing spondylitis (AS) for about 15 years. His medical treatment included metotrexate,
non-steroidal anti-inflammatory drugs, calcium, vitamin D and biphosphonates for
osteoporosis. He was on infliximab therapy for six months. The patient was referred to our
clinic with severe temporomandibular joint (TMJ) pain. He stated that he had consulted a
dentist before with toothache and his wisdom tooth had been fractured during the tooth
extraction. Medical histoy taken from the dentist informed that upon unsuccessful attempt
of surgical extraction of the tooth, panaromic jaw and teeth x-ray was ordered which revealed
total ankylosis of all teeth with mandibula along with the fractured tooth. Further surgical
intervention was avoided because of the risk of mandibular fracture, and treatment was
ended with the remaining portions of the fractured tooth left in the mouth. Assessment of
the patient in our clinic, showed that lumbar modified Schober was 0 cm, thoracic expansion
was 0 cm, BASDAI score was 1.6, BASFI score was 8.5 cm, lumbar lateral flexion was 44 cm,
occiput-to-wall distance was 26 cm. His posture was flexed and he was walking with
difficulty with the aid of a crutch. He had severe peripheral joint involvement leading to knee
ankylosis in 90 degree flexion and deformities of fingers. The mouth opening of the patient
was 2 cm and TMJ was severely painful with palpation. This was related with the TMJ
involvement of AS. TMJ and teeth can be involved in AS leading to total ankylosis. For this
reason panaromic jaw x-ray should be included in the evaluation in case of a dental problem
and treatment should be planned according to the outcome. All patients should be informed
about this involvement of AS and advised for warning and informing their dentist about the
situation.
Keywords: Ankylosing spondylitis, tooth, temporomandibular joint