To the Editor:
I thank Dr. Verdone for his valuable comments. I agree that diffuse idiopathic skeletal hyperostosis (DISH) is under diagnosed, and the clinical manifestations were not investigated properly. It is true that the number of published articles on this topic did not grow significantly, but there is certainly more awareness of the sometimes dreadful complications it might inflict1,2. Although DISH and osteoarthritis (OA) can coexist, it is not surprising that, despite several distinguishing features, patients with DISH are often discussed in conjunction with OA patients3. At present, the definition of DISH is based mainly on the characteristic radiological findings involving, in particular, the thoracic spine. The notion that the condition is not limited to the spine led researchers to use the widely accepted term DISH, introduced by Resnick, et al4. The extraspinal manifestations of DISH are numerous and have been recently reviewed5. At present, entheseal new bone formation, either spinal or peripheral, can be detected by imaging techniques and therefore, too late in their evolution. In contrast to ankylosing spondylitis (AS), DISH is considered at present to be a noninflammatory condition. Nevertheless, AS and DISH may, infrequently, co-exist, and occasionally DISH may present with a clinical picture that closely resembles AS. A recent paper addressed the distinguishing features of these 2 entities6. The association of DISH with metabolic syndrome, diabetes mellitus, and an increased cardiovascular risk has been recently reiterated7,8. With the increasing prevalence of these disorders in Western societies, an increase in the prevalence of DISH might be expected. It is therefore not surprising that in a hospital setting, up to one-third of elderly patients were affected by DISH9. It is therefore imperative to redefine the clinical characteristics, to investigate tools for early detection, and better understand the pathogenetic mechanisms of this condition in order to allow better preventive and therapeutic measures. Your letter and this response further emphasize why it is “time for a change10.”
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