“…Owing to this effect, a positive diagnosis of AKU can be made on the first days of life by observing dark-stained diapers (Wagner, Knott, Machaffie, & Walsh, 1960) and later on by measuring 24-hour urine HGA levels. The second stage of the disease begins in adulthood, when pigmentation occurs in sclera, ear cartilage, and when a degenerative form of arthropathy becomes the most common clinical presentation of AKU (Khammassi, Mohsen, Abdelhedi, Tougourti, & Hamza, 2010). Ochronotic arthritis has features resembling other rheumatologic diseases, such as rheumatoid arthritis, ankylosing spondylitis and degenerative osteoarthritis, affecting primarily the larger joints such as hips and knees.…”