Search Results (135)

Background/Objectives: Real-world evidence on bimekizumab treatment persistence and longitudinal disease activity in spondyloarthritis remains limited. This study assessed 12-month treatment persistence, changes in disease activity, and factors associated with discontinuation in patients with psoriatic arthritis and axial spondyloarthritis treated in routine clinical practice. Methods: We conducted a single-arm observational ambispective multicenter cohort study including 207 patients who initiated bimekizumab between December 2023 and November 2024. Treatment persistence was evaluated using Kaplan–Meier analysis and exploratory Cox proportional hazards models. Changes in disease activity were assessed using paired complete-case analyses, supplemented by available-case generalized estimating equation sensitivity analyses. Results: At 12 months, treatment persistence was 81.2%. Discontinuation occurred in 39 patients and was mainly attributed to lack of effectiveness. Persistence differed by sex in univariate analysis, with higher retention in males. Axial psoriatic arthritis classification was associated with an increased risk of discontinuation compared with peripheral psoriatic arthritis in the exploratory adjusted Cox model (HR: 3.02; 95% CI: 1.28–7.14). Obesity was not significantly associated with treatment discontinuation. Significant within-patient reductions were observed in BASDAI, ASDAS-CRP, and DAPSA among patients with available assessments. Conclusions: At 12 months, 81.2% of patients remained on treatment, and disease activity scores decreased among evaluable patients. Because this study had no comparator arm, these changes cannot be causally attributed to bimekizumab. The association between axial psoriatic arthritis classification and lower persistence should be considered hypothesis-generating because of the limited number of events, low event-to-parameter ratios, and absence of standardized axial PsA classification criteria. Safety data were restricted to adverse events leading to treatment discontinuation. Full article

Background: To compare retinal microvascular parameters assessed by optical coherence tomography angiography (OCTA) among patients with axial spondyloarthritis (axSpA) receiving different biologic and targeted synthetic therapies and to evaluate the association between smoking status and OCTA-derived retinal microvascular parameters. Methods: This cross-sectional study included 159 eyes of 82 patients with radiographic or non-radiographic axSpA receiving tumor necrosis factor inhibitors (TNFi), interleukin-17 inhibitors (IL-17i), or Janus kinase inhibitors (JAKi) for at least one year. At the time of examination, all patients had BASDAI scores below the established threshold for active disease (BASDAI < 4). Comprehensive ophthalmic evaluation and swept-source OCTA imaging were performed. Superficial capillary plexus vessel density and foveal avascular zone (FAZ) areas in both the superficial (SCP) and deep capillary plexus (DCP) were assessed. Statistical analyses were adjusted for age, sex, smoking status, history of uveitis, treatment duration, and ocular variables. Results: Significant differences were observed among treatment groups in the deep foveal avascular zone (DCP-FAZ) area (p = 0.0060). Post hoc analyses demonstrated larger DCP-FAZ values in patients receiving TNFi than in those receiving IL-17i (p = 0.0010), and larger values in the IL-17i group than in the JAKi group (p = 0.0151). No significant differences were observed in superficial FAZ area or superficial capillary plexus vessel density between treatment groups. Patients receiving JAKi were older and had a shorter treatment duration than those in the other groups. Smoking status was associated with a significantly smaller deep FAZ area (p = 0.0019), whereas no significant association was observed for superficial FAZ measurements. A weak positive correlation was found between intraocular pressure and deep FAZ area (r = 0.18, p = 0.0237), and treatment duration was weakly positively correlated with deep FAZ area (rho = 0.16, p = 0.0454). Conclusions: Retinal microvascular parameters differed among patients with axSpA receiving different classes of biologic and targeted synthetic therapies. Differences were observed primarily in the deep FAZ area, while smoking status was also associated with deep retinal microvascular parameters. Because of the cross-sectional design, these findings should be interpreted as associations rather than evidence of treatment effects. OCTA may provide a useful non-invasive method for assessing retinal microvascular characteristics in patients with axSpA. Further longitudinal studies are warranted to clarify the relationship between systemic therapies, smoking status, and retinal microvascular changes. Full article

Patients with autoimmune rheumatic diseases, particularly rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), experience excess cardiovascular risk that is not fully captured by conventional lipid measurements. In active RA, lower cholesterol may coexist with higher vascular risk, a pattern known as the lipid paradox. We propose that systemic inflammation can uncouple lipid concentration from lipoprotein function and organize the evidence along five mechanistic axes. Inflammatory cytokines, mainly interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), IL-1β, IL-17/IL-23 and type I interferons, remodel lipoprotein metabolism. High-density lipoproteins (HDL) lose protective functions and may become pro-inflammatory. Apolipoprotein-B particles are oxidized or otherwise modified, linking lipid metabolism to autoimmunity. Macrophage cholesterol imbalance and cholesterol crystals activate inflammasome pathways in experimental atherosclerosis, while immune-cell metabolic rewiring may amplify cytokine output; these mechanisms are treated as extrapolated when direct rheumatic-disease evidence is limited. The pathways converge on endothelial dysfunction and thrombo-inflammation. RA and SLE are the mechanistic anchors, whereas psoriatic disease, axial spondyloarthritis, systemic sclerosis, vasculitides and antiphospholipid syndrome are weighted by evidence category. Standard lipid panels may therefore underestimate risk in selected contexts, especially during active inflammatory disease. Full article

The clinical and pathogenetic intersection of Familial Mediterranean Fever (FMF) and axial spondyloarthritis (axSpA) represents a compelling frontier in modern rheumatology, challenging the traditional binary classification of inflammatory diseases. FMF is a monogenic autoinflammatory disorder caused by mutations in the MEFV gene, characterized by dysregulation of the pyrin inflammasome and surges in interleukin-1β (IL-1β), while axSpA is an immune-mediated condition linked to the HLA-B27 antigen and the IL-23/IL-17 axis. Following a structured search of PubMed/MEDLINE and Scopus, this review integrates PRISMA-informed screening of epidemiological data with a comprehensive narrative synthesis of the molecular pathogenesis and clinical management of this association. The analysis demonstrates a substantially elevated prevalence of spondyloarthritis among FMF patients compared to the general population. It explores the molecular “bridge” where innate immune activation provides the requisite cytokine milieu for the expansion of Th17 cells that drive spinal inflammation. Clinical evidence defines a distinct FMF-associated spondyloarthritis phenotype, characterized by a balanced sex distribution, early onset, and high risk of destructive hip involvement and AA amyloidosis, particularly in M694V carriers. Management strategies focus on dual biologic blockade in refractory cases, targeting both the upstream IL-1 pathway and downstream TNF or IL-17 effectors. This report identifies critical knowledge gaps, emphasizing the need for large-scale clinical trials to optimize outcomes for this complex patient population. Full article

Background/Objectives: Axial spondyloarthritis (axSpA) was long considered a male disease, yet women often report higher disease activity; whether this reflects sex differences or comorbidity is unclear. In an under-studied Saudi cohort, we examined sex differences in disease activity and function and associations with fibromyalgia and body mass index (BMI). Methods: A retrospective cross-sectional analysis of de-identified baseline data included 160 adults who met the Assessment of SpondyloArthritis International Society (ASAS) criteria at a single center. Between-sex comparisons used Benjamini–Hochberg correction; sequential multivariable regression evaluated attenuation of the sex–disease activity association after covariate adjustment. Results: Of 160 patients, 56 (35%) were women. Women more often had non-radiographic disease, higher BMI, fibromyalgia, and elevated erythrocyte sedimentation rate (ESR) (all q < 0.05), and scored higher on the symptom-based Bath Ankylosing Spondylitis Disease Activity Index (BASDAI; median 5.65 [IQR 4.67–6.60] vs. 5.15 [4.30–5.72]; p = 0.007, q = 0.044). The Bath Ankylosing Spondylitis Functional Index (BASFI) was borderline (q = 0.052), and C-reactive protein (CRP)-anchored Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP) did not differ significantly (median 3.70 [IQR 3.00–3.90] vs. 3.50 [3.00–3.80]; p = 0.099, q = 0.148). The female BASDAI difference was attenuated after adjustment for concomitant fibromyalgia. Higher ESR was partly attenuated after adjustment for BMI, whereas CRP did not differ by sex. In the analysis restricted to participants without fibromyalgia, between-sex estimates for BASDAI, BASFI, and ASDAS-CRP were smaller and imprecise. Conclusions: The attenuation of the female-sex association with BASDAI after adjustment for concomitant fibromyalgia should be interpreted as statistical attenuation only. Because fibromyalgia and BASDAI share symptom domains, particularly pain and fatigue, this attenuation may partly reflect overlapping symptom content and possible classification circularity rather than an explanatory or causal relationship. Full article

Objectives: To evaluate the real-world diagnostic and therapeutic impact of repeat sacroiliac joint magnetic resonance imaging (SIJ MRI) in patients undergoing assessment for axial spondyloarthritis (axSpA). Methods: This retrospective study included patients who underwent at least two SIJ MRI examinations from January 2010 to January 2026 at a single tertiary center. Demographic, clinical, laboratory, and imaging data were extracted from electronic medical records. MRI findings were classified according to Assessment of SpondyloArthritis International Society (ASAS) definitions. Changes between MRI1 and MRI2, diagnostic reassessment, treatment modification, and factors associated with diagnostic change were analyzed. Results: A total of 229 patients were included. The median interval between MRI examinations was 34 months. Among patients with initially negative or suspicious MRI findings, 13.0% converted to MRI-positive status on MRI2, whereas 44.8% of those with positive MRI1 findings regressed to negative or suspicious categories. Bone marrow edema (BME) was less frequent on MRI2 than MRI1 (38.0% vs. 50.2%, p = 0.003), while fat metaplasia (9.6% vs. 3.1%, p < 0.001) and sclerosis (34.9% vs. 26.6%, p = 0.006) were more common. Repeat MRI was associated with diagnostic reassessment in 41 patients (17.9%) and treatment modification in 27 patients (11.8%). In multivariate analysis, MRI1 BME positivity (OR 3.13, 95% CI 1.47–6.63, p = 0.003) and higher CRP levels (OR 1.06, 95% CI 1.01–1.11, p = 0.017) were independently associated with diagnostic reassessment. Conclusions: In routine clinical practice, repeat SIJ MRI was associated with diagnostic reassessment and treatment modification in a subset of patients undergoing evaluation for axSpA. Diagnostic reassessment was more frequently observed in patients with baseline inflammatory MRI findings and elevated inflammatory markers. Full article

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease affecting the sacroiliac joints and spine and is associated with an increased risk of fractures due to persistent inflammation, reduced mobility and treatment-related factors. In radiographic axSpA (r-axSpA), assessment of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA) may be limited by structural spinal changes. This cross-sectional study, conducted between March 2024 and June 2025, evaluated skeletal fragility in patients with r-axSpA using Radiofrequency Echographic Multi-Spectrometry (REMS)-derived Fragility Score (FS). Ninety patients with r-axSpA and sex-matched healthy controls underwent clinical assessment and REMS evaluation of lumbar spine and hip BMD, T-scores and spinal FS. Patients with r-axSpA had lower body mass index and higher rates of smoking, prior fractures and inflammatory markers compared with controls, while disease activity reflected a moderate burden. No significant differences in BMD or T-scores were observed between groups. However, FS was significantly higher in patients with r-axSpA (46.6 ± 15.4 vs. 31.2 ± 13.3, p = 0.004), corresponding to a higher fracture risk category, whereas correlations between FS and clinical parameters were not statistically significant. These findings suggest that REMS-derived FS may identify increased skeletal fragility in r-axSpA beyond conventional BMD measurements. Full article

Background/Objectives: Ankylosing Spinal Disorders (ASDs) encompass a heterogeneous group of rheumatic diseases characterized by progressive ankylosis of the axial skeleton, including Ankylosing Spondylitis (AS), Diffuse Idiopathic Skeletal Hyperostosis (DISH), and Non-Radiographic Axial Spondyloarthritis (nr-AxSpA). Spinal ankylosis profoundly alters the biomechanical properties of the vertebral column, transforming it into a rigid long-bone equivalent and dramatically increasing fracture risk even after low-energy trauma. Once a fracture occurs, the long lever arm created by the ankylosed segments generates enormous mechanical stress at the fracture site, making surgical stabilization mandatory in the vast majority of cases. Long posterior instrumentation is the treatment of choice; however, no consensus exists regarding the optimal number of instrumented levels. The aim of this study is to clinically and radiologically evaluate long posterior instrumentation in the 3 + 3 (3 proximal and 3 caudal screws), 3 + 2 (3 proximal and 2 caudal screws), or 2 + 2 (2 proximal and 2 caudal screws) configuration for the treatment of traumatic ASD thoracolumbar vertebral fractures, in terms of implant failure, infection rate, and mortality. Methods: Between 2018 and 2023, 65 consecutive patients with ASD-related thoracolumbar vertebral fractures were treated at our institution. After applying pre-defined inclusion and exclusion criteria, 37 patients were enrolled. Patients were retrospectively divided into three groups according to the posterior arthrodesis configuration (notation indicates number of instrumented vertebral levels proximal + distal to the fracture: 3 + 3, 3 + 2, or 2 + 2). Radiological outcomes were assessed for loosening, screw cut-out, and implant breakage. Infection and mortality rates within 3 months from surgery were evaluated as secondary endpoints. Statistical analysis was performed using the Fisher exact test (significance set at p < 0.05). Results: Thirty-seven patients (28 males and 9 females; mean age 77 ± 7.3 years) were included, with a mean follow-up of 30 ± 5.3 months. Instrumentation configurations were as follows: 23 (3 + 3), 5 (3 + 2), and 9 (2 + 2). Three implant failures (8.1%) and four infections (10.8%) were recorded. Eleven patients died within 3 months of surgery. A statistically significant difference was found between instrumentation length and mechanical complications (p = 0.0468), while no significant difference was observed for infection (p = 1) or mortality rate (p = 0.137). Conclusions: In this exploratory retrospective cohort, the 3 + 3 configuration was associated with the lowest observed rate of implant failure in ASD thoracolumbar fractures, suggesting a potential mechanical advantage over shorter constructs that warrants confirmation in larger prospective studies. No significant correlation was found between instrumentation length and infection rate or early mortality. Prospective, multicentre studies with larger cohorts are warranted to establish definitive guidelines for instrumentation length in this challenging patient population. Full article

Spondyloarthritis associated with inflammatory bowel diseases (IBD-SpA), also known as enteropathic arthritis, is an independent entity belonging to the spondyloarthritis (SpA) group. In recent years, a great amount of new data has been published regarding the pathogenesis and treatment of the disease. In this narrative review we present the main pathogenetic pathways along the gut–joint axis, the genetics of IBD and SpA, the role of environmental factors and that of the microbiome, as well as the main immunopathological processes including immune cells and inflammatory mediators. We cover the clinical picture, the specifics of axial and peripheral SpA-IBD, and briefly discuss the diagnostics. There are common options in the pharmacotherapy of SpA and IBD; however, some drugs that control arthritis (e.g., NSAIDs, IL-17 inhibitors) might not be suitable for the treatment of IBD. Based on the pathogenetic role of the microbiome, it is suggested that pharmacotherapy can be supplemented with non-pharmacological remedies, such as diet including the administration of short-chain fatty acids (SCFAs). Finally, we briefly look at the future that might include rational, even personalized treatment. Full article

Background: Fatigue is a common and disabling symptom in axial spondyloarthritis (axSpA), yet its magnitude relative to the general population and potential sex-specific differences remain insufficiently characterized, particularly in older adults. We therefore aimed to assess fatigue in adults aged ≥ 50 years with axSpA, using the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F) scale, to compare fatigue levels with age- and sex-matched controls, and to explore sex-specific differences and clinical factors associated with fatigue. Methods: We conducted an observational case–control study including consecutive patients with axSpA aged ≥ 50 years and control subjects frequency-matched by age and sex. Fatigue was assessed using the FACIT-F, and clinically relevant fatigue was defined as a FACIT-F score < 40. Case–control comparisons were stratified by sex, and sex-stratified multivariable linear regression models were applied. Results: The study included 173 patients with axSpA (120 men, 53 women; mean age: 64.2 years) and 383 controls. Clinically relevant fatigue was more frequent in women than in men (84.9% vs. 50.0%; p < 0.001). Women reported more severe fatigue than men (FACIT-F: 29.4 ± 10.4 vs. 37.4 ± 10.2; p < 0.001). In case–control comparisons, fatigue was greater in patients than in controls in both sexes, with descriptively larger differences among women. In sex-stratified multivariable analyses, the ASAS Health Index (ASAS-HI) was independently associated with fatigue in both men and women. In reduced models including age, BASDAI, and ASAS-HI, ASAS-HI remained independently associated with FACIT-F in both men (β: −1.74, 95% CI: −2.08 to −1.41) and women (β: −1.80, 95% CI: −2.35 to −1.26; p < 0.001 for both). BASDAI showed an additional independent association in women (β: −1.19, 95%: CI −2.09 to −0.30; p = 0.010), but not in men. Conclusions: Fatigue is highly prevalent and clinically relevant in adults aged ≥50 years with axSpA, with a clear sex-specific pattern. Women experience a greater fatigue burden, and comparisons with controls suggest a larger excess among women. Fatigue represents an important dimension of disease burden in axSpA, with stronger associations with overall health status than with conventional inflammatory measures. Full article

Spondyloarthritis represents a group of chronic immune-mediated rheumatic diseases that manifest as peripheral or axial musculoskeletal involvement. In axial spondyloarthritis (axSpA), the milestones of structural damage are represented by inflammation, followed by erosions in the sacroiliac joints (SIJ) and new bone formation. The purpose of this narrative review is to address the unmet needs regarding targeted risk stratification of disease progression in axSpA. While studies concerning predictive biomarkers have been conducted, their use in clinical practice has not yet been validated. Analysis of disease progression in patients recently diagnosed with non-radiographic axSpA, with fulfillment of the Assessment of Spondyloarthritis International Society criteria, determined a mean time of structural changes progression of 2.4 years. While factors such as human leukocyte antigen (HLA)-B27 and C-reactive protein are useful in classifying patients into risk categories regarding radiographic progression, novel biomarkers are needed in clinical practice to further facilitate treatment strategy selection. Choosing biomarkers to analyze the potential of both spinal and SIJ radiographic progression is useful in monitoring patients and reducing the burden of disease. Fetuin-A, sclerostin, and autoantibodies against Cluster of Differentiation 74 (anti-CD74) were associated with SIJ changes in various studies. Regarding spinal structural damage, adipokines, particularly leptin and visfatin, have been extensively studied and have shown promising results. Dickkopf-1, a regulator of the Wnt signaling pathway, vascular endothelial growth factor, and matrix metalloproteinase-3 have also presented associations with worsening modified Stoke Ankylosing Spondylitis Spine Score. The potential of each biomarker may be heightened by their use in prediction models with the purpose of implementation in clinical practice, particularly in improving patient outcomes and tailoring treatment strategies for individuals with spinal structural damage. Full article

Background: Crohn‘s disease (CD) is frequently complicated by extraintestinal manifestations, including axial spondyloarthritis (axSpA). Both diseases share genetic (HLA-B27, IL23R, ERAP1/2) and immunopathological mechanisms (Th17/IL-23 axis). Their co-occurrence increases the risk of systemic complications such as AA amyloidosis. Case presentation: We report a 42-year-old male with HLA-B27-positive axSpA who developed CD shortly after initiating secukinumab (IL-17A inhibitor). Following discontinuation of secukinumab and surgical management of CD, the patient experienced rapidly progressive AA amyloidosis affecting the kidneys and intestines, leading to acute kidney injury and requiring hemodialysis. Potential triggering factors included a preceding intestinal infection and self-administered infrared physiotherapy. Conclusions: Coexistent CD and axSpA significantly increases the risk of severe AA amyloidosis. IL-17 inhibitors should be used with extreme caution in patients with subclinical or active CD. Early screenings for proteinuria and low-threshold biopsy are essential to detect AA amyloidosis. In patients with both conditions, TNF-α or IL-12/23 inhibitors are preferred over IL-17 blockade. Full article

Background/Objectives: The therapeutic arsenal for axial spondyloarthritis (axSpA) now includes multiple biologic and targeted synthetic DMARDs (b/tsDMARDs). Following the failure of an advanced therapy, clinicians may either cycle (switch to another drug with the same mechanism of action) or swap (switch to a drug with a different mechanism). The optimal strategy remains unclear. This study aimed to compare the real-world effectiveness of cycling versus swapping in axSpA patients. Methods: This mono-centric, retrospective observational study included axSpA patients who failed ≥1 line of b/tsDMARD therapy. Subsequent treatment courses were classified as cycling (CG) or swapping (SG). Drug retention rates were compared using Kaplan–Meier analysis. A Cox proportional hazards model identified factors associated with treatment persistence. Results: We analyzed 156 patients (59 radiographic, 97 non-radiographic), corresponding to 343 treatment courses (CG: 213; SG: 130). Retention rates at 1, 2, and 3 years were 62.7%, 49.3%, and 39.2% (CG) versus 69.8%, 47.8%, and 31.8% (SG) (HR: 1.13, 95% CI: 0.83–1.53; p = 0.442). In the multivariable model, only a more recent prescription year was associated with higher discontinuation risk (HR: 1.08 per year, 95% CI: 1.03–1.12; p < 0.001). Conclusions: In this real-world cohort, cycling and swapping strategies demonstrated comparable treatment persistence over three years following advanced therapy failure in axSpA. The choice of subsequent therapy should be individualized, as no strategy proved superior. Full article

Background: Central sensitization (CS) has been held responsible for both persistent pain and high disease activity scores in Spondyloarthritis (SpA). The Central Sensitization Inventory (CSI) is a questionnaire used to determine CS frequency: a score of at least 40 is associated with a high likelihood of CS. Objectives: To investigate the prevalence of CS in our cohort and its association with clinical characteristics of patients and their quality of life. Methods: Adult patients with a diagnosis of Psoriatic Arthritis (PsA) or Axial Spondyloarthritis (AxSpA) who were also classifiable according to ClASsification criteria for Psoriatic Arthritis (CASPAR) and Assessment of SpondyloArthritis international Society (ASAS) criteria respectively, and regularly followed at the SpA outpatient clinic of our Unit were consecutively enrolled from April to November 2023. Their epidemiologic, clinical and clinimetric data were collected, as well as patient-reported outcome measures (PROMs) [CSI, Health Assessment Questionnaire (HAQ), FACIT-Fatigue (FACIT-F), SHORT-FORM 36 (SF-36), and Hospital Anxiety and Depression Scale (HADS)]. Considering the definition of “difficult-to-treat” rheumatoid arthritis, we defined as “multi-failure” those patients who were treated with more than two biologic disease-modifying anti-rheumatic drugs (bDMARDs) with different mechanisms of action. Intergroup comparisons were assessed by using Chi-square, t-test and ANOVA. p-values < 0.05 were considered significant. Results: A total of 100 patients were enrolled, 46 male (46.0%) and 54 female (54.0%), with a mean age of 59.4 ± 9.8 years and a mean disease duration of 14.8 ± 10.1 years; 79 patients (79%) had a diagnosis of PsA and 21 (21%) of AS. Forty-two patients (42.0%) had a CSI score ≥ 40. Significant correlations were found between a CSI score ≥ 40 and female sex (p = 0.004), the occurrence of enthesitis (p = 0.05), DAPSA-CRP (p = 0.02) and ASDAS scores (p = 0.03), a multi-failure condition (p = 0.01), fibromyalgia (FM) (p = 0.004), thyroid disease (p = 0.016) and obesity (p = 0.047). Regarding PROMs, significant correlations were found between CSI and values of HADS (both anxiety and depression), FACIT-F, HAQ and all the domains of SF-36 (p-value < 0.0001). Conclusions: Our data confirmed that more than 40% of SpA patients had CSI values ≥ 40 and underlined how CS could widely impair their disease burden. A routinary evaluation of CS and a multifactorial biopsychosocial perspective in the diagnosis and management of chronic pain in patients with SpA could help rheumatologists in improving their quality of care. Full article

Background and clinical significance: Autoimmune hepatitis (AIH) and ankylosing spondylitis (AS) are distinct immune-mediated disorders that only rarely coexist. Diagnostic interpretation becomes especially challenging when the liver biochemistry is not classically hepatocellular and the histology is unavailable. Case presentation: We report a 51-year-old man with inflammatory back pain, polyarthralgia, weight loss, fatigue, night sweats and fever. Laboratory tests showed marked systemic inflammation, anemia and a cholestatic-predominant liver profile with associated aminotransferase elevation. Imaging demonstrated bilateral sacroiliitis and syndesmophytosis. Liver workup excluded viral, obstructive, metabolic, hereditary and inflammatory bowel disease-associated cholangiopathic causes. Antinuclear antiboidies (ANA) and anti liver cyotsole 1 antiboidies (anti-LC-1) were positive, IgG was mildly elevated, magnetic resonance cholangio-pancreatography (MRCP) was negative for primary sclerosing cholangitis and the simplified AIH score was six. A liver biopsy was proposed but refused. The patient received a short course of prednisone for rheumatologic flare control, followed by nonsteroidal anti-inflammatory treatment and sulfasalazine, with normalization of liver tests during follow-up. Conclusions: This case is suggestive, but not diagnostic, of autoimmune hepatitis in a patient with ankylosing spondylitis. In the absence of histology and in the setting of a cholestatic-predominant biochemical profile, the findings may be more appropriately interpreted as an autoimmune hepatitis-like syndrome. The main teaching point is that abnormal liver tests in AS warrant structured evaluation beyond drug toxicity and viral hepatitis, particularly when autoimmune serology is positive, even in a cholestatic-predominant presentation. Full article