Rheumatoid arthritis with atypical neck pain and dysphagia
A 57-year-old female presented for the second opinion on worsening joint pain, progressive neck pain, and dysphagia. She was diagnosed with seropositive (RF, CCP) rheumatoid arthritis 3 years ago. Diffuse neck pain and stiffness that increased with movement began around the same time. She reported progressive dysphagia for solids and liquids that were unexplained despite extensive workup including an upper GI endoscopy. She had received multiple DMARDs and biologics, including several infusions of rituximab, with no change in her neck pain. Physical examination showed a protracted head position with markedly diminished cervical spine range-of-motion. X-rays showed a large mass of heterotopic ossification anterior to the C2- C7 vertebral bodies, consistent with DISH.

DISH is a rare idiopathic non-inflammatory condition characterized by exuberant bony ossification at multiple entheseal sites as well as calcification of the anterior longitudinal ligament of the spine. CT scan demonstrated anterior osteophytes significantly displacing the oropharynx (Fig. 1). DISH or Forestier’s disease is an uncommon etiology for progressive dysphagia attributed to anterior osteophytes or restriction of neck flexion due to cervical spine ankylosis. Surgical excision of cervical osteophytes typically leads to excellent symptomatic results.