A 39-year-old man was admitted to the hematologic department of our facility for peripheral blood stem cell transplantation in April 2009, following an initial diagnosis of acute myeloid leukemia in October 2008. An initial complete remission was achieved with induction chemotherapy and two cycles of consolidation chemotherapy with an IDV/BHAC (idarubicin-N4-behenoyl-L
arabinofuranosyl-cytosine) regimen. Prior to the stem cell transplantation, our patient was referred to a rheumatologist for consultation regarding progressive neck pain and stiffness. He had been diagnosed as having ankylosing spondylitis 20
years previously, but never received regular clinical treatment or follow-up. Additionally, he was also not receiving regular medication for ankylosing spondylitis, but was instead using painkillers such as nonsteroidal anti-inflammatory drugs (NSAIDs) or intermittent physical rehabilitation to alleviate the progressively worsening neck pain. A physical examination of our patient revealed limited motion of the cervical spine, although his chest expansion and the range of motion of the lumbar spine were within normal limits. The peripheral blood counts reported were as follows: hemoglobin, 10.6g/dL; white blood cell count, 4720
cells/L with normal differential cell count; and platelets, 128
cells/L. His erythrocyte sedimentation rate was 66mm/hour and his C-reactive protein level was 0.29mg/dL. The results of immunological studies were negative for anti-nuclear antibody and both complement and immunoglobulin levels were within normal ranges, although HLA-B27 was positive. Urine analysis results were unremarkable. Radiologic findings were consistent with ankylosing spondylitis: bilateral sacroiliac joint fusion and bamboo spine. Examination of the cervical spine revealed C5 to C6 disc space narrowing with the formation of syndesmophytes.
Our patient was initially treated with NSAIDs and was scheduled to receive anti-TNF therapy following stem cell transplantation. In April 2009, he received allogeneic peripheral blood stem cell transplantation following a pre-transplantation conditioning regimen of 1320cGy total body irradiation and 60mg/kg cyclophosphamide for two days. The donor was an HLA-matched 29-year-old man. The HLA phenotype of our patient was A 1102, 3303; B 2704, 5801; C 0302, 1202 and that of the donor was the same. Our patient received an intravenous injection of 0.03mg/kg tacrolimus following oral administration of 0.120mg/kg tacrolimus, and intravenous injection of 5mg/body surface area methotrexate for graft-versus-host disease (GVHD) prophylaxis. No evidence of acute GVHD was reported following stem cell transplantation. Our patient was discharged one month following the stem cell transplantation without any complications.
Five months after the peripheral blood stem cell transplantation, our patient reported reduced posterior neck pain, and an X-ray of the cervical spine revealed partial regression of the syndesmophytes (Figure ). A magnetic resonance imaging (MRI) scan of our patient’s spine 25
months after the peripheral blood stem cell transplantation indicated no osteitis in the cervical spine (Figure ). Furthermore, neither anti-TNF therapy or NSAID medication were prescribed due to our patient’s improved condition. Our patient has remained asymptomatic and has received no medication for ankylosing spondylitis for nearly three years. He received immunosuppressive therapy with tacrolimus for seven months following the peripheral blood stem cell transplantation, but all medication was stopped after that period. His condition has been stable without any recurrence of the hematologic disease.
Cervical spine X-rays. Serial X-rays of the cervical spine revealed syndesmophyte formation between C5 and C6 and subsequent regression following peripheral blood stem cell transplantation in April 2008.
Magnetic resonance imaging scan of the spine from May 2011. The magnetic resonance imaging scan acquired in May 2011 indicated no evidence of osteitis in the cervical spine.