Prevalence and clinical manifestations of ankylosing spondylitis in young Greek males

Inflammatory Arthritis Among Military Servicemen From a Rheumatology Center in Singapore

INTRODUCTION

Musculoskeletal disorders are one of the most common reasons military servicemen seek medical care during their line of duty. This study aims to review the clinical profile and outcomes of military personnel with inflammatory arthritis (IA) referred to a specialist rheumatology center in Singapore.

MATERIALS AND METHODS

Consecutive new case referrals from the Singapore Armed Forces medical centers during the study period January 1, 2010, to December 31, 2019, were retrospectively studied.

RESULTS

There were 123 referrals, comprising 112 (91.1%) males, with the majority being Chinese (110, 89.4%). The mean age was 25.5 ± 11.1 years. The most common diagnoses were gout (including chronic tophaceous gout; 34, 27.6%), spondyloarthritis (18, 14.6%), palindromic rheumatism (8, 6.5%), rheumatoid arthritis (4, 3.3%), and juvenile idiopathic arthritis (4, 3.3%). Among servicemen with gout, all were male, the majority (31, 91.3%) were Chinese, and mean age was 34.1 ± 8.8 years. Mean body mass index (BMI) was 27.5 ± 3.9 kg/m2, of which 41.2% had moderate-risk and 47.1% high-risk BMI for cardiovascular disease and diabetes mellitus (DM). Comorbidities included hyperlipidemia (14), hypertension (6), and type 2 DM (3). Urate lowering therapy was initiated in 27 (79.4%) patients, comprising allopurinol (85.2%), probenecid (11.1%), and their combination (3.7%). One patient developed allopurinol-induced hepatitis; none had severe cutaneous adverse reactions. Among the remaining patients with IA, conventional synthetic disease-modifying antirheumatic drugs (DMARDs) used were sulfasalazine (8), methotrexate (4), hydroxychloroquine (4), and leflunomide (2). Biologic DMARDs used in five patients comprised adalimumab (3) and golimumab (2).

CONCLUSION

Servicemen with IA and good functional status can still be physically fit and deployable into certain combat and service support vocations. This will optimize manpower resources in military organizations with a shrinking young workforce.

An infected Andersson lesion presented with incomplete paraplegia in a patient with ankylosing spondylitis. A unique case report with literature review

INTRODUCTION

A relatively rare and unknown entity in patients with ankylosing spondylitis is the Andersson lesion (AL). It was first described by Andersson in 1937 as destructive vertebral or disco-vertebral lesion of the spine without history of trauma. AL may result from inflammation or stress fracture of the rigid spine, while there is no evidence for an infectious origin. To our knowledge, only one case with an infected AL has been published many years ago; we hereby present the second case, but the first one with severe neurologic deterioration.

CASE PRESENTATION

A 79-year-old male patient was presented to our emergency department and his neurological examination on admission revealed incomplete paraplegia below the Th10 level. Plain radiograms at the level of 10th thoracic vertebra revealed a lesion mimicking a severe vertebral fracture. The computed tomography confirmed the diagnosis of the AL and due to the significant local instability and the neurologic deficit, the patient underwent posterior decompression and stabilization. During decompression, we noticed purulence and extensive debridement was performed. The cultures of the Th10 pus revealed Enterococus sp, while the same pathogen was developed to urine cultures. The patient received intravenous antibiotics for 4 weeks, followed by per os antibiotic therapy. At the 18-month follow-up our patient had significant improvement of this functional status.

DISCUSSION

Most studies support that inflammatory or traumatic/mechanical (pseudarthrosis) etiology are the most possible causes of Anderson lesions. Possible neurological deterioration should be investigated and demonstrates significant spinal instability. The integrity of the posterior column should be investigated, and exclusion of other concomitant lesions should be done. In cases with instability due to the fractured posterior elements, surgical intervention is mandatory. Spine surgeons should be competent to differentiate fracture from the Andersson lesion. In this rare case we highlight also that spine surgeons should obtain intraoperative cultures in cases with Andersson lesions, to exclude the minor possibility of the infectious origin of the entity and/or the possible secondary contamination of the affected area.

Worldwide Differences in Clinical Phenotype of Axial Spondyloarthritis

PURPOSE OF REVIEW

This review aims to describe the variations in the clinical presentation of axial spondyloarthritis (axSpA) across the globe.

RECENT FINDINGS

We searched the PubMed database and screened more than 1360 articles; 60 of them were selected based on relevance to the topic being discussed and the goals of the review. Most of the clinical manifestations, including IBP, peripheral arthritis, and extra-articular involvement are seen in different regions of the world, but with appreciable clinical heterogeneity, possibly related to a smaller number of patients from some countries, and global variation in the prevalence of HLA-B27. For example, HLA-B27-positive patients have an earlier age of onset, higher prevalence of acute anterior uveitis, and greater familial occurrence. Peripheral arthritis and enthesitis are most commonly seen among axSpA patients from Latin America and Asia, whereas IBD appears to be slightly more common among Middle Eastern and North African patients. The main weakness encountered while reviewing these data is that some studies were small, and others were cross-sectional and retrospective; hence the inferences may have a selection bias. AxSpA is a very heterogenous disease with varied presentation across the globe, in part related to HLA-B27 positivity. It is imperative to further investigate the key regional differences as they impact timely disease recognition and initiation of early treatment. Therefore, there is a need for a large worldwide systematic study to capture the clinical picture of AxSpA in a more uniform manner.

The Early Phases of Ankylosing Spondylitis: Emerging Insights From Clinical and Basic Science

In our paper, we discuss how the early phases of ankylosing spondylitis (AS) are linked to peri-firbocartilagenous osteitis in the sacroiliac joint and entheseal bone related anchoring sites. This skeletal proclivity is linked to an abnormal immunological response to skeletal biomechanical stress and associated microdamage. A key event in the early stages of AS appears to be the association with subclinical Crohn's-like colitis with this gut inflammation being pivotal to the osteitis reaction. Whether this osteitis is consequent to non-specific intestinal innate immune activation or adaptive immune responses against specific microbiotal or self-antigens is unknown. Recurrent iritis is an HLA-B27 associated feature that may predate AS and pursues a course independent of joint involvement, and points toward the pivotal role of organ specific immunology over generalized systemic immune responses in disease expression. Human genetics and animal model studies strongly incriminate the IL23/17 axis and TNF-α in disease pathogenesis. Preliminary work shows a strong convergence of innate immune cells including type 3 innate lymphoid-cells (ILC3) and γδ T-cells in skin, gut, entheseal, and eye inflammation. Despite the HLA-B27 association, the role of adaptive immunity, especially CD8+ T-cells mediated responses remains unproven and alternative theories have been proposed. The emerging non-dependence of axial inflammation on IL-23 but dependence on IL-17A is an unexpected new twist that awaits full explanation. In this mini-review, we discuss the key events in the early stages of human AS from clinical and basic science aspects, which could be crucial for attempted disease prevention studies in at risk subjects.

Serum DKK-1 level in the development of ankylosing spondylitis and rheumatic arthritis: a meta-analysis

To explore the association of serum Dickkopf-1 (DKK-1) levels with the development of ankylosing spondylitis (AS) and rheumatic arthritis (RA) in humans, databases including PubMed, EBSCO, Springerlink, Ovid, WANFANG and China National Knowledge Infrastructure (CNKI) were searched to identify relevant studies. On the basis of rigorous inclusion and exclusion criteria, case–control studies of the relationships between serum DKK-1 levels and AS and RA published before December 2014 were enrolled. Statistical analyses were performed using Comprehensive Meta-analysis 2.0 (CMA 2.0). Seven case–control trials with a total of 300 AS patients, 136 RA patients and 232 healthy controls were included in this study. Meta-analysis results revealed that DKK-1 serum levels were significantly higher in AS patients than in normal controls (standard mean differences (s.m.d.)=0.301, 95% confidence interval (CI)=0.094–0.507, P=0.004), whereas no significant difference in DKK-1 serum levels was observed between RA patients and healthy controls (s.m.d.=0.798, 95% CI=−2.166–3.763, P=0.598). Serum DKK-1 level may be closely related to the development of AS but not of RA.

Polymorphisms of HLA-A, -B, -Cw and DRB1 antigens in Moroccan patients with ankylosing spondylitis and a comparison of clinical features with frequencies of HLA-B*27

Ankylosing spondylitis (AS) is very often associated with human leukocyte antigen (HLA), particularly HLA-B*27. However, the strength of this association and clinical features may vary in different ethnic groups. Our study aims to assess the distribution of HLA-A, -B, -Cw and DRB1 alleles in Moroccan patients with AS and to compare the clinical features of AS and the frequencies of HLA-B27 in patients from Morocco with other series. Seventy-five patients diagnosed with AS and assessed for clinical manifestations were selected and compared to 100 healthy controls. HLA class I and II antigens were typed by polymerase chain reaction sequence-specific oligonucleotide. HLA-B27 subtypes were studied by polymerase chain reaction amplification with sequence-specific primers. HLA-B27 was found in 64% of patients. It was positively associated with younger age at disease onset, family history, and uveitis while it had a negative association with late onset. Six B*27 subtypes were identified in the AS group. HLA-B*2705 and B*2702 were the most common observed subtypes. Among other HLA genes, a significant increase in the prevalence of HLA-Cw*02 and HLA-DRB*15 was found in AS patients. HLA-B27 is involved in the predisposition of AS in the Moroccan population. HLA-B*2705 and B*2702 were the predominant subtypes supporting previous reports in Caucasian spondyloarthropathies. Other HLA genes, HLA-Cw*02 and HLA-DRB1*15, seem to confer predisposing effect to the disease. However, the lower frequency of HLA-B27 compared to the literature in our study suggests the existence of different genetic and/or environmental factors in Morocco.

The role of sex in uveitis and ocular inflammation

Uveitides can be due to non-infectious and infectious etiologies. It has been observed that there is a gender difference with a greater preponderance of non-infectious uveitis in women than in men. This review will describe both non-infectious and infectious uveitides and describes some of the current autoimmune mechanisms thought to be underlying the gender difference. It will specifically look at non-infectious uveitides with systemic involvement including juvenile idiopathic arthritis, spondyloarthopathies, sarcoidosis, Behçet’s disease, and Vogt-Koyanagi-Harada disease and at uveitides without systemic involvement including sympathetic ophthalmia, birdshot chorioretinitis, and the white dot syndromes. Infectious uveitides like acute retinal necrosis, progressive outer retinal necrosis, and cytomegalovirus mediated uveitis will be mentioned. Different uveitides with female- or male- predominance are presented and discussed.

Increasing proportion of female patients with ankylosing spondylitis: a population-based study of trends in the incidence and prevalence of AS

OBJECTIVE

With the introduction of MRI in diagnosis and tumour necrosis factor inhibitors for treatment, the field of ankylosing spondylitis (AS) has undergone significant changes. We carried out a population-based study of the trends in incidence and prevalence of AS over the past 15 years.

METHODS

This is a retrospective analysis of provincial health administrative databases. Residents of Ontario, Canada aged 15 years or older diagnosed with AS between 1995 and 2010 were included in the study. Crude as well as age-standardised and sex-standardised incidence and prevalence of AS between 1995 and 2010 were calculated. Trends in prevalence and incidence of male and female patients with AS were separately analysed.

RESULTS

We identified 24,976 Ontarians with AS. Age/sex-standardised AS prevalence increased from 79/100,000 in 1995 to 213/100,000 in 2010. Men had higher prevalence than women, but the male/female prevalence ratio decreased from 1.70 in 1995 to 1.21 by 2010. A higher proportion of male compared with female patients with AS were diagnosed in the 15-45 age group. Annual incidence rates revealed increasing diagnosis of AS among women after 2003.

CONCLUSIONS

The prevalence of AS in Ontario has nearly tripled over the past two decades. The proportion of women with new diagnosis of AS is increasing, a trend that began around the year 2003. A higher proportion of male compared with female patients with AS are diagnosed at an earlier age.