Diffuse Idiopathic Skeletal Hyperostosis (DISH) of Young Adults. Lessons to be Learnt

Case Report

Austin J Orthopade & Rheumatol. 2016; 3(4): 1043.

Diffuse Idiopathic Skeletal Hyperostosis (DISH) of Young Adults. Lessons to be Learnt

Mader R1,2*, Fawaz A¹, Bieber A¹ and Novofastovsky I¹

¹Rheumatic Diseases Unit, Ha’Emek Medical Center, Israel

²The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Israel

*Corresponding author: Mader R, Rheumatic Diseases Unit, Ha’Emek Medical Center, Rabin Rd, Israel

Received: August 29, 2016; Accepted: October 27, 2016; Published: November 01, 2016


DISH is a condition characterized by ossification and calcification of soft tissues, mainly ligaments and entheses. The disease is poorly recognized but is often associated with metabolic and constitutional derangements, increased cardiovascular risk and at times, dreadful complications following medical procedures or minor trauma. The prevalence is variable but increases remarkably with age, and in certain elder populations may reach 35%. It has been suggested that 10 years are needed from the initiation of the process to its full radiographic manifestation. There is very little data about young individuals (ie =40 years of age) affected by the disease. We describe 4 patients affected by DISH in their 4th decade of life and in whom the process of ossification and calcifications, presumably, started to evolve in their 3rd decade of life. The clinical characteristics of the patients are discussed. Investigations of these rare cases might shed light on the pathogenetic mechanisms, and initiating factors that promote the formation of DISH.

Keywords: Diffuse idiopathic skeletal hyperostosis; Metabolic syndrome; Enthesopathy


DISH is a condition characterized by calcifications and ossifications of soft tissues, mainly ligaments and entheses. Although the first description of DISH dates back to 1950 [1], a large body of evidence shows DISH to be of more ancient origin [2].

The etiology of DISH is unknown. However, several metabolic, genetic, and constitutional factors were reported to be associated with this condition. These include: obesity, a high waist circumference ratio, hypertension, Diabetes Mellitus (DM), hyperinsulinemia, dyslipidemia, elevated growth hormone levels, elevated insulin like growth factor-1, hyperuricemia, use of retinoids and genetic factors [3-7]. A recent study showed that patients with DISH are more often affected by metabolic syndrome and have an increased risk for cardiovascular morbidity [8].

Due to the spinal stiffness the patients affected by DISH are exposed to complications that may derive from minor trauma or medical procedures [9,10]

The condition is unequally distributed between males and females (in a ratio of ~2:1), and its prevalence rapidly increases with age [11]. The prevalence of DISH varies according to geographical location, population studied and obviously age. In an epidemiological outpatient study, the prevalence of DISH in patients over 50 years of age has been reported to be 25% for males and 15% for females [12]. A study aiming to find the prevalence of DISH in the Netherlands by screening 501 chest radiographs obtained for unrelated medical conditions corroborated these results (17% of the individuals over the age of 50 years in this study had DISH) and demonstrated that male gender and advancing age increase the probability of the development of DISH.NRR17). An autopsy study reported that in a series of 75 spines studied at autopsy 28% had DISH [11].

The reported prevalence in the fifth decade of life was extremely low ranging from 0.3 and 0.2% in males and females respectively in the Finish population to none in the female Italian population [13,14]. There is no data on patients in their 4th decade of life, probably because of its rarity. However, there have been a few description of familial cases of DISH in very young patients suggestive for a genetic basis [15,16]. Early diagnosis is important to better understand the evolution of this condition, and eventually intervene, in the future, in its course. A case series of 4 patient’s =40 years of age, diagnosed with DISH are described and their contribution to our understanding is discussed.

Case Presentation

Four patients with DISH, diagnosed at =40 years of age were identified from our data base and herein described. The cases were extracted from our data base of 200 patients fulfilling the Resnick classification criteria for DISH. The age at diagnosis has been established usually at the first or second visit in the rheumatic diseases unit. The final diagnosis has been established by a single observer (RM).

Citation: Mader R, Fawaz A, Bieber A and Novofastovsky I. Diffuse Idiopathic Skeletal Hyperostosis (DISH) of Young Adults. Lessons to be Learnt. Austin J Orthopade & Rheumatol. 2016; 3(4): 1043. ISSN: 2472-369X