{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T21:38:38Z","timestamp":1790890718367,"version":"4.1.0"},"reference-count":36,"publisher":"Springer Science and Business Media LLC","issue":"3","license":[{"start":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T00:00:00Z","timestamp":1771545600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T00:00:00Z","timestamp":1771545600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100021855","name":"University of Ioannina","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100021855","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Rheumatol Int"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Spondyloarthritis (SpA) is a chronic inflammatory disease involving axial (ax-SpA), and peripheral joints (p-SpA). It mainly affects young individuals and symptoms begin before the age of 45 years. Late onset (LO) ax-SpA, presenting after the age of 50, is rare. It is usually underdiagnosed in favor of other disorders, which are very common in this population. A 70-year-old woman presented with fever of unknown origin (FUO), back pain, malaise, weakness and high acute phase reactants, without any other clinical or laboratory findings. After an intensive and extensive investigation, to exclude several diseases and disorders, our patient, despite being old and almost asymptomatic for SpA features was diagnosed as having LO-axSpA. The patient was treated successfully with adalimumab. We discuss the differential diagnosis of FUO in an elderly woman with constitutional symptoms and elevated inflammatory markers. This is the first case of LO-axSpA presenting with FUO, therefore, physicians must be aware of rare manifestations of ax-SpA in the elderly population. Rigorous and extensive investigation is required to reach the correct diagnosis.<\/jats:p>","DOI":"10.1007\/s00296-026-06079-3","type":"journal-article","created":{"date-parts":[[2026,2,20]],"date-time":"2026-02-20T04:10:00Z","timestamp":1771560600000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Late onset axial spondyloarthritis presenting with fever of unknown origin. A case-based review"],"prefix":"10.1007","volume":"46","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5193-2284","authenticated-orcid":false,"given":"Paraskevi V.","family":"Voulgari","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-8134-9128","authenticated-orcid":false,"given":"Anastasia K.","family":"Zikou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2232-0326","authenticated-orcid":false,"given":"Alexandros A.","family":"Drosos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,20]]},"reference":[{"key":"6079_CR1","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1016\/j.ejim.2023.06.026","volume":"117","author":"AA Drosos","year":"2023","unstructured":"Drosos AA, Venetsanopoulou AI, Voulgari PV (2023) Axial spondyloarthritis: evolving concepts regarding the disease\u2019s diagnosis and treatment. Eur J Int Med 117:21\u201327. https:\/\/doi.org\/10.1016\/j.ejim.2023.06.026","journal-title":"Eur J Int Med"},{"issue":"6","key":"6079_CR2","doi-asserted-by":"publisher","first-page":"451","DOI":"10.2165\/00002512-200522060-00001","volume":"22","author":"E Toussirot","year":"2005","unstructured":"Toussirot E, Wendling D (2005) Late-onset ankylosing spondylitis and related spondylarthropathies: clinical and radiological characteristics and Pharmacological treatment options. Drugs Aging 22(6):451\u2013469. https:\/\/doi.org\/10.2165\/00002512-200522060-00001","journal-title":"Drugs Aging"},{"issue":"4 Suppl 55","key":"6079_CR3","first-page":"S139","volume":"27","author":"I Olivieri","year":"2009","unstructured":"Olivieri I, Pipitone N, D\u2019 Angelo S et al (2009) Late-onset rheumatoid arthritis and late-onset spondyloarthritis. Clin Exp Rheumatol 27(4 Suppl 55):S139\u2013S145","journal-title":"Clin Exp Rheumatol"},{"issue":"1","key":"6079_CR4","doi-asserted-by":"publisher","first-page":"69","DOI":"10.1093\/rheumatology\/30.1.69","volume":"30","author":"A Calin","year":"1991","unstructured":"Calin A, Elswood J, Edmunds L (1991) Late onset ankylosing spondylitis\u2013a distinct disorder? Br J Rheumatol 30(1):69\u201370. https:\/\/doi.org\/10.1093\/rheumatology\/30.1.69","journal-title":"Br J Rheumatol"},{"issue":"10","key":"6079_CR5","first-page":"2283","volume":"28","author":"S Brophy","year":"2001","unstructured":"Brophy S, Calin A (2001) Ankylosing spondylitis: interaction between genes, joints, age at onset, and disease expression. J Rheumatol 28(10):2283\u20132288","journal-title":"J Rheumatol"},{"issue":"6","key":"6079_CR6","doi-asserted-by":"publisher","first-page":"1110","DOI":"10.3899\/jrheum.120184","volume":"39","author":"I Olivieri","year":"2012","unstructured":"Olivieri I, D\u2019Angelo S, Palazzi C et al (2012) Late-onset spondyloarthritis: subset that should not be forgotten. J Rheumatol 39(6):1110\u20131112. https:\/\/doi.org\/10.3899\/jrheum.120184","journal-title":"J Rheumatol"},{"issue":"11","key":"6079_CR7","doi-asserted-by":"publisher","first-page":"1409","DOI":"10.1007\/s00296-011-1999-3","volume":"31","author":"AY Gasparyan","year":"2011","unstructured":"Gasparyan AY, Ayvazyan L, Blackmore H, Kitas GD (2011) Writing a narrative biomedical review: considerations for authors, peer reviewers, and editors. Rheumatol Int 31(11):1409\u20131417. https:\/\/doi.org\/10.1007\/s00296-011-1999-3","journal-title":"Rheumatol Int"},{"issue":"30","key":"6079_CR8","doi-asserted-by":"publisher","first-page":"e225","DOI":"10.3346\/jkms.2024.39.e225","volume":"39","author":"IC Benlidayi","year":"2024","unstructured":"Benlidayi IC, Gupta L (2024) CAse-BAsed review sTandards (CABARET): considerations for Authors, Reviewers, and editors. J Korean Med Sci 39(30):e225. https:\/\/doi.org\/10.3346\/jkms.2024.39.e225","journal-title":"J Korean Med Sci"},{"issue":"2","key":"6079_CR9","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1007\/s00296-002-0237-4","volume":"23","author":"E Feldtkeller","year":"2003","unstructured":"Feldtkeller E, Khan MA, van der Heijde D et al (2003) Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatol Int 23(2):61\u201366. https:\/\/doi.org\/10.1007\/s00296-002-0237-4","journal-title":"Rheumatol Int"},{"issue":"3","key":"6079_CR10","doi-asserted-by":"publisher","first-page":"241","DOI":"10.1002\/art.1780270301","volume":"27","author":"SM van der Linden","year":"1984","unstructured":"van der Linden SM, Valkenburg HA, de Jongh BM et al (1984) The risk of developing ankylosing spondylitis in HLA-B27 positive individuals. A comparison of relatives of spondylitis patients with the general population. Arthritis Rheum 27(3):241\u2013249. https:\/\/doi.org\/10.1002\/art.1780270301","journal-title":"Arthritis Rheum"},{"key":"6079_CR11","doi-asserted-by":"publisher","unstructured":"Said-Nahal R, Miceli-Richard C, Berthelot JM et al (2000) The Familial form of spondylarthropathy: a clinical study of 115 multiplex families. Groupe Fran\u00e7ais d\u2019etude G\u00e9n\u00e9tique des spondylarthropathies. Arthritis Rheum 43(6):1356\u20131365. https:\/\/doi.org\/10.1002\/1529-0131(200006)43:6%3C1356::AID-ANR20%3E3.0.CO;2-Y","DOI":"10.1002\/1529-0131(200006)43:6%3C1356::AID-ANR20%3E3.0.CO;2-Y"},{"issue":"2","key":"6079_CR12","doi-asserted-by":"publisher","first-page":"569","DOI":"10.1002\/art.21619","volume":"54","author":"M Rudwaleit","year":"2006","unstructured":"Rudwaleit M, Metter A, Listing J et al (2006) Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Arthritis Rheum 54(2):569\u2013578. https:\/\/doi.org\/10.1002\/art.21619","journal-title":"Arthritis Rheum"},{"issue":"6","key":"6079_CR13","doi-asserted-by":"publisher","first-page":"777","DOI":"10.1136\/ard.2009.108233","volume":"68","author":"M Rudwaleit","year":"2009","unstructured":"Rudwaleit M, van der Heijde D, Landew\u00e9 R et al (2009) The development of assessment of spondyloarthritis international society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 68(6):777\u2013783. https:\/\/doi.org\/10.1136\/ard.2009.108233","journal-title":"Ann Rheum Dis"},{"issue":"12","key":"6079_CR14","doi-asserted-by":"publisher","first-page":"1476","DOI":"10.1002\/art.1780351211","volume":"35","author":"LD Carbone","year":"1992","unstructured":"Carbone LD, Cooper C, Michet CJ et al (1992) Ankylosing spondylitis in Rochester, Minnesota, 1935\u20131989. Is the epidemiology changing? Arthritis Rheum 35(12):1476\u20131482. https:\/\/doi.org\/10.1002\/art.1780351211","journal-title":"Arthritis Rheum"},{"issue":"4","key":"6079_CR15","doi-asserted-by":"publisher","first-page":"239","DOI":"10.1097\/00002281-200007000-00002","volume":"12","author":"E Feldtkeller","year":"2000","unstructured":"Feldtkeller E, Bruckel J, Khan MA (2000) Scientific contributions of ankylosing spondylitis patient advocacy groups. Curr Opin Rheumatol 12(4):239\u2013247. https:\/\/doi.org\/10.1097\/00002281-200007000-00002","journal-title":"Curr Opin Rheumatol"},{"issue":"9","key":"6079_CR16","first-page":"1214","volume":"16","author":"JJ Dubost","year":"1989","unstructured":"Dubost JJ, Sauvezie B (1989) Late onset peripheral spondyloarthropathy. J Rheumatol 16(9):1214\u20131217","journal-title":"J Rheumatol"},{"issue":"9","key":"6079_CR17","first-page":"577","volume":"58","author":"JJ Dubost","year":"1991","unstructured":"Dubost JJ, Ristori JM, Zmantar C et al (1991) [Seronegative rheumatism of late onset. Incidence and atypical forms of spondylarthropathy]. Rev Rhum Mal Osteoartic 58(9):577\u2013584","journal-title":"Rev Rhum Mal Osteoartic"},{"issue":"5","key":"6079_CR18","first-page":"899","volume":"22","author":"I Olivieri","year":"1995","unstructured":"Olivieri I, Padula A, Pierro A et al (1995) Late onset undifferentiated seronegative spondyloarthropathy. J Rheumatol 22(5):899\u2013903","journal-title":"J Rheumatol"},{"issue":"10","key":"6079_CR19","doi-asserted-by":"publisher","first-page":"927","DOI":"10.1007\/s00296-007-0331-8","volume":"27","author":"I Olivieri","year":"2007","unstructured":"Olivieri I, Garcia-Porrua C, Padula A et al (2007) Late onset undifferentiated spondyloarthritis presenting with polymyalgia rheumatica features: description of seven cases. Rheumatol Int 27(10):927\u2013933. https:\/\/doi.org\/10.1007\/s00296-007-0331-8","journal-title":"Rheumatol Int"},{"issue":"5","key":"6079_CR20","doi-asserted-by":"publisher","first-page":"1008","DOI":"10.3899\/jrheum.111082","volume":"39","author":"C Montilla","year":"2012","unstructured":"Montilla C, Del Pino-Montes J, Collantes-Estevez E et al (2012) Clinical features of late-onset ankylosing spondylitis: comparison with early-onset disease. J Rheumatol 39(5):1008\u20131012. https:\/\/doi.org\/10.3899\/jrheum.111082","journal-title":"J Rheumatol"},{"issue":"4","key":"6079_CR21","doi-asserted-by":"publisher","first-page":"1468","DOI":"10.1093\/rheumatology\/keab544","volume":"61","author":"A Boel","year":"2022","unstructured":"Boel A, L\u00f3pez-Medina C, van der Heijde DMFM et al (2022) Age at onset in axial spondyloarthritis around the world: data from the assessment in spondyloarthritis international society peripheral involvement in spondyloarthritis study. Rheumatology (Oxford) 61(4):1468\u20131475. https:\/\/doi.org\/10.1093\/rheumatology\/keab544","journal-title":"Rheumatology (Oxford)"},{"issue":"1","key":"6079_CR22","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1016\/s0891-5520(05)70286-5","volume":"10","author":"SE Carsons","year":"1996","unstructured":"Carsons SE (1996) Fever in rheumatic and autoimmune disease. Infect Dis Clin North Am 10(1):67\u201384. https:\/\/doi.org\/10.1016\/s0891-5520(05)70286-5","journal-title":"Infect Dis Clin North Am"},{"issue":"5","key":"6079_CR23","doi-asserted-by":"publisher","first-page":"789","DOI":"10.1016\/j.berh.2016.10.005","volume":"30","author":"CM Mulders-Manders","year":"2016","unstructured":"Mulders-Manders CM, Simon A, Bleeker-Rovers CP (2016) Rheumatologic diseases as the cause of fever of unknown origin. Best Pract Res Clin Rheumatol 30(5):789\u2013801. https:\/\/doi.org\/10.1016\/j.berh.2016.10.005","journal-title":"Best Pract Res Clin Rheumatol"},{"issue":"235","key":"6079_CR24","first-page":"1055","volume":"61","author":"JM Wouters","year":"1986","unstructured":"Wouters JM, van de Putte LB (1986) Adult-onset still\u2019s disease; clinical and laboratory features, treatment and progress of 45 cases. Q J Med 61(235):1055\u20131065","journal-title":"Q J Med"},{"issue":"9","key":"6079_CR25","doi-asserted-by":"publisher","first-page":"e0184323","DOI":"10.1371\/journal.pone.0184323","volume":"12","author":"SJ Byun","year":"2017","unstructured":"Byun SJ, Bae WH, Jung SM et al (2017) Fever as an initial manifestation of spondyloarthritis: A retrospective study. PLoS ONE 12(9):e0184323. https:\/\/doi.org\/10.1371\/journal.pone.0184323","journal-title":"PLoS ONE"},{"issue":"6","key":"6079_CR26","doi-asserted-by":"publisher","first-page":"e0128979","DOI":"10.1371\/journal.pone.0128979","volume":"10","author":"R Guo","year":"2015","unstructured":"Guo R, Cao L, Kong X et al (2015) Fever as an initial manifestation of enthesitis-related arthritis subtype of juvenile idiopathic arthritis: retrospective study. PLoS ONE 10(6):e0128979. https:\/\/doi.org\/10.1371\/journal.pone.0128979","journal-title":"PLoS ONE"},{"key":"6079_CR27","doi-asserted-by":"publisher","first-page":"1195995","DOI":"10.3389\/fmed.2023.1195995","volume":"10","author":"A Vitale","year":"2023","unstructured":"Vitale A, Caggiano V, Silva I et al (2023) Axial spondyloarthritis in patients with recurrent fever attacks: data from the AIDA network registry for undifferentiated autoinflammatory diseases (USAIDs). Front Med (Lausanne) 10:1195995. https:\/\/doi.org\/10.3389\/fmed.2023.1195995","journal-title":"Front Med (Lausanne)"},{"issue":"11","key":"6079_CR28","doi-asserted-by":"publisher","first-page":"e8207","DOI":"10.1002\/ccr3.8207","volume":"11","author":"M Mehdipour Dalivand","year":"2023","unstructured":"Mehdipour Dalivand M, Abdolazimi R, Manafi-Farid R et al (2023) A case of ankylosing spondylitis presenting with fever of unknown origin diagnosed as aortitis: A case report. Clin Case Rep 11(11):e8207. https:\/\/doi.org\/10.1002\/ccr3.8207","journal-title":"Clin Case Rep"},{"issue":"8","key":"6079_CR29","doi-asserted-by":"publisher","first-page":"e230113","DOI":"10.1136\/bcr-2019-230113","volume":"12","author":"N Kanda","year":"2019","unstructured":"Kanda N, Takeda K, Hatakeyama S et al (2019) Ankylosing spondylitis presenting with enthesitis at an uncommon site and fever of unknown origin. BMJ Case Rep 12(8):e230113. https:\/\/doi.org\/10.1136\/bcr-2019-230113","journal-title":"BMJ Case Rep"},{"issue":"9","key":"6079_CR30","doi-asserted-by":"publisher","first-page":"1506","DOI":"10.1002\/art.42145","volume":"74","author":"T Renson","year":"2022","unstructured":"Renson T, de Hooge M, De Craemer AS et al (2022) Progressive increase in sacroiliac joint and spinal lesions detected on magnetic resonance imaging in healthy individuals in relation to age. Arthritis Rheumatol 74(9):1506\u20131514. https:\/\/doi.org\/10.1002\/art.42145","journal-title":"Arthritis Rheumatol"},{"issue":"1","key":"6079_CR31","first-page":"58","volume":"45","author":"E Pelechas","year":"2020","unstructured":"Pelechas E, Kosta P, Voulgari PV, Drosos AA (2020) Bertolotti syndrome: a not-to-miss cause of chronic low back pain in young adults. Acta Rheumatol Port 45(1):58\u201360","journal-title":"Acta Rheumatol Port"},{"issue":"11","key":"6079_CR32","doi-asserted-by":"publisher","first-page":"1550","DOI":"10.1136\/annrheumdis-2019-215589","volume":"78","author":"WP Maksymowych","year":"2019","unstructured":"Maksymowych WP, Lambert RG, \u00d8stergaard M et al (2019) MRI lesions in the sacroiliac joints of patients with spondyloarthritis: an update of definitions and validation by the ASAS MRI working group. Ann Rheum Dis 78(11):1550\u20131558. https:\/\/doi.org\/10.1136\/annrheumdis-2019-215589","journal-title":"Ann Rheum Dis"},{"issue":"11","key":"6079_CR33","doi-asserted-by":"publisher","first-page":"2499","DOI":"10.1016\/j.mayocp.2020.02.007","volume":"95","author":"MN Magrey","year":"2020","unstructured":"Magrey MN, Danve AS, Ermann J, Walsh JA (2020) Recognizing axial spondyloarthritis: A guide for primary care. Myo Clin Proc 95(11):2499\u20132508. https:\/\/doi.org\/10.1016\/j.mayocp.2020.02.007","journal-title":"Myo Clin Proc"},{"issue":"7","key":"6079_CR34","doi-asserted-by":"publisher","first-page":"1939","DOI":"10.1007\/s10067-022-06100-7","volume":"41","author":"CA Hay","year":"2022","unstructured":"Hay CA, Packham J, Ryan S, Mallen CD, Chatzixenitidis A, Prior JA (2022) Diagnostic delay in axial spondyloarthritis: a systematic review. Clin Rheumatol 41(7):1939\u20131950. https:\/\/doi.org\/10.1007\/s10067-022-06100-7","journal-title":"Clin Rheumatol"},{"issue":"4","key":"6079_CR35","doi-asserted-by":"publisher","first-page":"1873","DOI":"10.1093\/rheumatology\/keae521","volume":"64","author":"D Poddubnyy","year":"2025","unstructured":"Poddubnyy D, Garrido-Cumbrera M, Sommerfleck F et al (2025) Diagnostic delay in patients from the international map of axial spondyloarthritis: geographic, sociodemographic and disease-related factors. Rheumatology (Oxford) 64(4):1873\u20131879. https:\/\/doi.org\/10.1093\/rheumatology\/keae521","journal-title":"Rheumatology (Oxford)"},{"key":"6079_CR36","doi-asserted-by":"publisher","first-page":"840475","DOI":"10.5402\/2011\/840475","volume":"2011","author":"I Hmamouchi","year":"2011","unstructured":"Hmamouchi I, Bahiri R, Hajjaj-Hassouni N (2011) Clinical and radiological presentations of late-onset spondyloarthritis. ISRN Rheumatol 2011:840475. https:\/\/doi.org\/10.5402\/2011\/840475","journal-title":"ISRN Rheumatol"}],"container-title":["Rheumatology International"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00296-026-06079-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00296-026-06079-3","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00296-026-06079-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T18:32:26Z","timestamp":1781634746000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00296-026-06079-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,20]]},"references-count":36,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["6079"],"URL":"https:\/\/doi.org\/10.1007\/s00296-026-06079-3","relation":{},"ISSN":["1437-160X"],"issn-type":[{"value":"1437-160X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,20]]},"assertion":[{"value":"19 November 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 January 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 February 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"All authors (PV. Voulgari, AK. Zikou & AA. Drosos) declare no conflicts of interest.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"<!--Emphasis Type='Bold' removed-->Conflict of interest"}},{"value":"as per our institution\u2019s ethic\u2019s approval, when there is no sensitive data of the patient presented (face characteristics, name\/surname\/date of birth on photos\/x-rays\/ct\/mri etc.) there is no need for a specific approval. This study was performed in accordance with the Helsinki Declaration of 1964 and its later amendments. All presented material is published after written consent of the patient, although sensitive data and personal details are not included in the publication.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Research involving human participants and\/or animals"}}],"article-number":"53"}}