Reverzibilna oligospermija u bolesnika s neradiografskim aksijalnim spondiloartritisom uslijed liječenja sulfasalazinom – prikaz bolesnika

Marija Rogoznica, Mila Stazić, Tatjana Kehler

Axial spondyloarthritis (axSpA) is an inflammatory rheumatic disease, which belongs to the group of spondyloarthritis, and predominantly affects the axial skeleton. Research shows that sulfasalazine (SSZ) can cause changes in the semen analysis (spermiogram). The patient, born in 1984, was referred to a rheumatologist due to back pain that had lasted for three years. During the clinical examination, there was pain in the left sacroiliac joint (SIJ ) as well as sternocostal entheses and restricted movements in the right hip. Further diagnostic processing determined the presence of the Human Leukocyte Antigen (HLA ) B27. Magnetic resonance imaging confirmed the existence of chronic changes in the left SIJ , degenerative changes in the right hip with areas of bone marrow edema, a smaller amount of effusion and synovial thickening. A diagnosis of non-radiographic axSpA was made. SSZ was introduced along with non-steroidal anti-rheumatic drug (NSAID) therapy. Five months after sulfasalazine (SSZ) was introduced into therapy, drug-induced infertility was suspected. A spermiogram was performed, and, following that, oligoasthenozoospermia was confirmed: reduced absolute sperm count (9.95 — reference interval (ref.int.) > 39 million/ milliliter [ml]), reduced sperm concentration (2.94 —
ref. int. > 15 million/ml), reduced sperm motility percentage (17 — ref. int. > 40%), reduced percentage of progressively motile sperm (17 — ref. int. > 32%) and immotile sperm result: 83/ml. SSZ was discontinued, which resulted in an improvement in all of the semen parameter findings. The causes of infertility in men are multifactorial, they are related to the underlying disease, drug therapy and
other urological, endocrinological and genetic causes. Most studies on the effects of sulfasalazine (SSZ) on fertility were conducted on patients suffering from inflammatory bowel diseases. The mechanism of toxicity of sulfasalazine (SSZ) on infertility is unknown. The assumption is that the active metabolite, sulfapyridine, leads to oxidative stress with consequent effects on semen quality. Routine monitoring of sexual function and family planning is necessary.

Aksijalni spondiloartritis (axSpA) je upalna reumatska bolest, pripada skupini spondiloartritisa, a zahvaća dominantno aksijalni skelet. Poznato je iz istraživanja da sulfasalazin (SSZ) može uzrokovati promjene u spermiogramu. Bolesnik (rođen 1984.) javlja se reumatologu radi križobolje s trajanjem od tri godine. U kliničkom pregledu nalazimo bolan lijevi sakroilijakalni zglob (SIZ ) kao i sternokostalne enteze te blokirane kretnje u desnom kuku. Daljnjom dijagnostičkom obradom utvrđen je HLA B27 (engl. Human Leukocyte Antigen). Magnetskom rezonancijom verificirane su kronične promjene lijevoga SIZ -a te osteodegenerativne promjene desnog kuka uz zone koštanog edema te manju količinu izljeva i zadebljanje sinovijalne membrane. Postavljena je dijagnoza neradiografskog axSpA. Uz terapiju nesteroidnim antireumaticima (NSAR) uveden je SSZ. Pet mjeseci od početka liječenja SSZ-om javila se sumnja na neplodnost uzrokovana lijekom. Učinjen je spermiogram, verificirana je oligoastenozoospermija: smanjen apsolutni broj spermija (9,95 – referetni interval [ref. int.] > 39 milijuna/mililitru [ml]), smanjena koncentracija (2,94 – ref. int. >15 milijuna/ml), smanjen postotak pokretljivosti (17 – ref. int. >40%), smanjen postotak progresivno pokretljivih spermija (17 – ref. int. >32%) te nalaz nepokretnih spermija 83/ml. Ukinut je SSZ, na što dolazi do poboljšanja nalaza svih parametara spermiograma. Multifaktorijalni su uzroci neplodnosti u muškaraca, povezani su s osnovnom bolešću, terapijom te drugim uzrocima, urološkim, endokrinološkim i genetskim. Većina istraživanja o učincima SSZ-a na plodnost provedena je u bolesnika s upalnim bolestima crijeva. Toksičan mehanizam na neplodnost je nepoznat; aktivan metabolit, sulfapiridin dovodi do oksidativnog stresa s posljedičnim djelovanjem na spermije. Nužno je rutinsko praćenje spolne funkcije i planiranje obitelji.