A 38-year-old man comes to the office due to exertional shortness of breath over the past 6 months. The patient says that his exercise capacity has significantly decreased compared to that of last year. He has chronic back pain, which responds well to ibuprofen and naproxen, and intermittent bilateral heel pain. The patient is a lifetime nonsmoker and does not drink alcohol. He has no family history of early cardiovascular disease or lung disease. Height is 179 cm (5 ft 10 in) and weight is 76 kg (167.6 lb). BMI is 23.7 kg/m². Physical examination shows impaired spinal mobility and limited chest expansion. The maximal apical impulse is displaced to the left. Which of the following is the most likely diagnosis?

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11ec25c8_d89d_cd9d_bc81_8dfe212a2b07_MD0003_00 This young patient with chronic back pain and intermittent bilateral heel pain (ie, enthesitis), as well as impaired spinal mobility and limited chest wall expansion, most likely has ankylosing spondylitis, a rheumatologic disease primarily involving inflammatory arthritis of the spine. Limited chest wall expansion does not fully explain his exertional shortness of breath and significantly reducing exercise capacity and does not account for a laterally displaced point of maximal apical impulse (PMI); therefore, this patient is likely developing heart failure due to chronic aortic regurgitation, a potential complication of ankylosing spondylitis. Aortic regurgitation occurs in up to 10% of patients with ankylosing spondylitis. It likely results from chronic inflammation of the aortic root and valve cusps, resulting in retraction of the valve cusps and consequent impaired valve closure. Over time, aortic regurgitation causes left ventricular volume overload with compensatory eccentric hypertrophy and lateral displacement of the PMI. Rarely, the chronic inflammation can extend into the interventricular septum and cause conduction abnormalities (eg, advanced atrioventricular block) as well. compensatory eccentric hypertrophy (Choice B) An atrial septal defect (ASD) typically occurs as a congenital defect and is not associated with ankylosing spondylitis. When symptomatic, ASD typically presents with signs and symptoms of right-sided heart failure (eg, lower extremity edema, hepatomegaly); left ventricular enlargement does not occur. (Choices C, D, and E) Inflammatory mitral stenosis and tricuspid leaflet sclerosis (leading to tricuspid stenosis) are potential complications of rheumatic heart disease. Mitral valve prolapse can occur due to myxomatous degeneration of the mitral valve. The mitral and tricuspid valves are not affected in ankylosing spondylitis. Educational objective: Ankylosing spondylitis is a rheumatologic inflammatory arthropathy that commonly involves chronic lower back pain, impaired spinal mobility, and enthesitis. Aortic regurgitation is a potential complication of ankylosing spondylitis, resulting from chronic inflammation of the aortic root and valve cusps. Other cardiac valves are not affected. References: Aortic involvement in ankylosing spondylitis. (http://www.ncbi.nlm.nih.gov/pubmed/18799070)

A 38-Year-Old Man Comes to the Office Due to Exertional