Seronegative spondyloarthropathies and IgA glomerulonephritis: a report of four cases and a review of the literature

Pattern of ankylosing spondylitis in an Iranian population of 98 patients

The prevalence and pattern of ankylosing spondylitis (AS) can vary from country to country, according to genetic and environmental factors. This study aims to analyze the patterns of disease in a population of Iranian patients with AS. We performed a prospective study (2002-2007) analyzing 98 patients with diagnosis of AS according to the modified New York criteria. Selected patients underwent complete clinical (initial symptom, axial and peripheral involvement, heel enthesitis, extra-articular manifestations) and radiological (sacroiliac, lumbar, thoracic, and cervical spine) investigations, and these data were compared with sex, age at onset, and HLA-B27. There was predominance of men (71.4%), adult onset (>16 years, 90.8%), and positive HLA-B27 (73.4%). Family history of AS was noted in 14.3% of the patients. The predominant initial symptoms were inflammatory low back pain (44.2%). Radiological findings included syndesmophytes in 34.7% and "bamboo spine" in 16.3% of patients. Acute anterior uveitis was noted in 44.9% of patients. Male sex was associated with involvement of shoulder (P = 0.001). Female sex and juvenile-onset AS were associated with extra-articular involvement. Positive HLA-B27 was associated with hip involvement (P = 0.042) and adult-onset AS (P = 0.035). Analysis of the patterns of disease in this population of 98 southern Iranian patients with AS revealed that female sex and juvenile-onset AS were associated with extensive extra-axial involvement; and HLA-B27 was associated with hip involvement.

Reiter's syndrome: the classic triad and more

Reiter's syndrome, also known as reactive arthritis, is the classic triad of conjunctivitis, urethritis, and arthritis occurring after an infection, particularly those in the urogenital or gastrointestinal tract. Dermatologic manifestations are common, including keratoderma blennorrhagicum, circinate balanitis, ulcerative vulvitis, nail changes, and oral lesions. Epidemiologically, the disease is more common in men, although cases have also been reported in children and women. The pathophysiology has yet to be elucidated, although infectious and immune factors are likely involved. Clinical presentation, severity, and prognosis vary widely. Treatment is difficult, especially in HIV-positive patients. Prognosis is variable; 15% to 20% of patients may develop severe chronic sequelae.

Les manifestations rénales de la spondylarthrite ankylosante : à propos de 210 cas

PURPOSE

To define the epidemiology, clinical, biological and histological features of renal diseases in ankylosing spondylitis, ginving special attention to unusual forms.

METHODS

We retrospectively reviewed the medical record of 28 cases with renal involvement among 210 cases of ankylosing spondylitis seen over a 27 year period who met the Amor criteria.

RESULTS

Twenty-eight of 210 patients (13,3%) presented one or more signs of renal involvement: macroscopic hematuria (4 patients), microscopic hematuria (8 patients), proteinuria (15 patients), nephrotic syndrome (6 patients), decreased renal function (13 patients). Secondary renal amyloidosis and nephrolithiasis (8 patients) were the most common cause of renal involvement in ankylosing spondylitis followed by IgA nephropathy (3 patients).

CONCLUSION

The funding of renal abnormalities in 13,3% of our patients suggests that in this illness evidence of renal involvement should be actively investigated in ankylosing spondylitis.

Renal abnormalities in a population of patients with psoriatic arthritis

OBJECTIVE

To investigate the prevalence of and to identify predictive factors for renal abnormalities in patients with psoriatic arthritis (PsA).

METHODS

73 patients with PsA were consecutively examined by laboratory analyses and clinically for joint manifestations. Renal function was estimated by creatinine clearance and urinary albumin.

RESULTS

17 (23.3%) of the patients had renal abnormalities as defined by creatinine clearance below the lower cut off of normal distribution (mean - 2 SD) and/or urinary excretion of albumin more than 25 mg/24 h. These patients were significantly older at the time of the study, older at joint disease onset, had longer skin disease duration, increased serum levels of beta2-microglobulin, and higher incidence of increased ESR and/or CRP levels. Increased ESR/CRP levels had significantly predictive value in multivariate analysis.

CONCLUSIONS

In this study subclinical renal abnormalities was a prevalent finding. Predictive factor was inflammatory activity measured by laboratory variables. There were no predisposing effects of NSAID or DMARD therapy.

Elevation of serum IgA in spondyloarthropathies and IgA nephropathy and its pathogenic role

Ankylosing spondylitis and IgA nephropathy share some immunologic features, eg, elevated serum IgA and IgA-immune complex levels. These entities are frequently found as being associated. IgA and IgA immune complex catabolism involves asialoglycoprotein receptors and specific IgA Fc receptors (FcalphaR or CD89) on tissue and blood cells. Recent studies revealed impaired CD89 expression in both diseases. These abnormalities, which are associated with receptor saturation, might generate the increase in serum IgA and IgA immune complex levels by either altered recycling or failure of degradation. This article reviews the literature on IgA abnormalities and discusses the potential role of FcalphaR in IgA nephropathy and AS and the consequences of its similar defect in the two diseases.

Renal diseases in ankylosing spondylitis: review of the literature illustrated by case reports

Ankylosing spondylitis (AS) can be accompanied by extraarticular manifestations in the cardiovascular, pulmonary, neurologic and renal organs. Secondary renal amyloidosis is the most common cause of renal involvement in AS (62%) followed by IgA nephropathy (30%), mesangioproliferative glomerulonephritis (5%) as well as rarely membranous nephropathy (1%), focal segmental glomerulosclerosis (1%) and focal proliferative glomeruleonephritis (1%). Treatment associated nephrotoxicity may result from non-steroidal anti-inflammatory drugs or disease modifying agents. The purpose of this paper was to alert for the possibility of renal damage in AS and to analyse the frequencies of different etiologies of renal involvement. Two typical case reports of renal involvement in AS are presented to illustrate the clinical course of such patients. Renal side effects and possible pre-existing renal diseases should be taken into account while choosing the appropriate medication for patients with AS.

Renal abnormalities in ankylosing spondylitis

Renal abnormalities have been reported in Ankylosing Spondylitis (AS) patients. Possible mechanisms include the effects of nonsteroidal anti-inflammatory drugs (NSAIDs), an increased incidence of glomerulonephritis, particularly the ones associated with deposition of IgA-containing immune complexes and the renal deposition of amyloid. These observations prompted us to evaluate in detail the frequency and severity of renal dysfunction in 40 AS patients, consecutively selected attending the rheumatology disease unit outpatient clinic at Escola Paulista de Medicina, using sensitive tests of glomerular and tubular function. Fourteen of the 40 patients presented one or more signs of renal involvement: microscopic hematuria (9 patients), microalbuminuria (4 patients), decreased renal function assessed by serum creatinine (2 patients), and creatinine clearance (4 patients). None of the patients presented increased urinary excretion of retinol binding protein (RBP). The finding of renal abnormalities in 35% of our patients suggests that in this illness evidence of renal involvement should be actively investigated.

Inflammatory bowel disease and ankylosing spondylitis associated with cutaneous vasculitis, glomerulonephritis, and circulating IgA immune complexes

Two patients both with inflammatory bowel disease (IBD) and ankylosing spondylitis (AS) developed leucocytoclastic vasculitis of the skin and nephropathy. Immunofluorescence studies showed that there was perivascular deposition of immunoglobulin A in the skin biopsy specimens of both patients and in the renal mesangium of one patient. Serum samples of the two patients contained IgA immune complexes. The absence of previous reports on such a combination of symptoms in IBD or AS suggests that these patients may have a disease entity which is distinct from uncomplicated IBD or AS, and which may combine the immunopathological features of both underlying disorders.

Immunoglobulin A in the skin of patients with ankylosing spondylitis

Cutaneous immunofluorescence studies were carried out in 21 patients with ankylosing spondylitis (AS) and the results compared with those for 18 healthy subjects. The most prominent finding was the presence of IgA in dermal vessels of patients with AS (71% compared with 17% of the control group). IgG and IgM cutaneous deposits were also observed in patients with AS, but these results did not differ from those of the control group. A renal biopsy was performed in three of the patients presenting with unexplained microscopic haematuria. One of them had an IgA nephropathy, but no correlation was found between kidney and skin deposits of IgA. These findings suggest that IgA cutaneous deposits in AS are not a marker of IgA nephropathy but stress the role of immunoglobulin A in the pathogenesis of this disease.

Relation of microscopic haematuria in ankylosing spondylitis to circulating IgA containing immune complexes

Ankylosing spondylitis (AS) is associated with IgA nephropathy. To study the pathogenetic mechanism of this association the presence of haematuria and circulating IgA containing immune complexes (IgA ICs) in 70 patients with AS was determined. In this retrospective study haematuria was present in 15 patients and 25 patients had IgA ICs. Circulating IgA ICs were shown in 9/15 (60%) of the patients with haematuria and in 16/55 (29%) of those without haematuria. These results suggest that IgA ICs in patients with ankylosing spondylitis have a pathogenetic role in causing IgA nephropathy.