Classification of the spondyloarthropathies

Updates in non-neoplastic orthopaedic pathology: what you don't know can hurt you!

Even though the average surgical pathologist reviews far more non-neoplastic orthopaedic pathology on a daily basis, most current research focuses on rare tumours and their even less frequent molecular events. Our experiences among consults and focused conferences strongly suggest that there remains a practice gap regarding knowledge and diagnosing specific non-neoplastic orthopaedic conditions. One of the most frequent intraoperative consultations performed in the USA, among both academic and private institutions, relates to revision arthroplasty and the determination of infection in periprosthetic joints. Pathologists play a critical role in this algorithm, helping determine intraoperatively whether patients require antibiotic spacers prior to reimplantation. Many pathology departments have abandoned the examination of arthroplasty specimens because they (and their surgeons) mistakenly believe there is little clinically relevant information to be gained by thorough pathological examination. However, recent literature has challenged this concept, emphasising the importance of distinguishing avascular necrosis (from osteoarthritis/degenerative joint disease with secondary osteonecrosis), subchondral insufficiency fracture, septic arthritis (from so-called 'sterile' osteomyelitis/pseudoabscesses), underlying crystalline diseases and incidental/occult neoplasia. Histological evaluation of historically insignificant orthopaedic specimens, such as tenosynovium from carpal tunnel syndrome/trigger finger, is now seen as valuable in early diagnosis of cardiac amyloidosis. Not infrequently, orthopaedic conditions like haemosiderotic synovitis, osteocartilaginous loose bodies or rheumatoid nodules, may histologically mimic bona fide neoplasms, notably diffuse tenosynovial giant cell tumour, synovial chondromatosis and epithelioid sarcoma, respectively. Here is a review of the more common non-neoplastic orthopaedic conditions, those likely to be examined by the practising surgical pathologist, with updates and guidelines for establishing clinically relevant diagnoses.

Pharmacologic Treatment Strategies in Psoriatic Arthritis

PURPOSE

The goal of this narrative review was to provide current data on psoriatic arthritis (PsA) therapeutic strategies, supporting treatment decisions with a domain-based approach.

METHODS

This narrative review of treatment strategies for PsA focused on several disease domains (ie, peripheral arthritis, enthesitis, axial disease, dactylitis, skin and nail disease), as well as the so-called "related conditions" of uveitis, Crohn's disease, and ulcerative colitis. We searched PubMed, EMBASE, international guidelines, and recent congress abstracts.

FINDINGS

Currently, multiple approved treatment options offer a wide range of options, such as tumor necrosis factor (TNF) inhibitors; inhibitors of interleukin-17 (IL-17), IL-12/23 (IL-12/23), IL-23 (IL-23), and Janus kinase; the phosphodiesterase 4 inhibitor apremilast; and the T-cell modulator abatacept. However, no treatment option shows clear superiority concerning efficacy on peripheral arthritis and dactylitis over the others, whereas limited evidence suggests that the IL-17 inhibitor ixekizumab and the IL-12/23 inhibitor ustekinumab may be superior to TNF inhibitors in treating enthesitis. Recent data on enthesitis have also shown promising results for methotrexate. Treatment of axial PsA is mostly derived from axial spondyloarthritis, and more data are needed focusing on this specific subgroup of PsA patients. Thus far, the most important finding from the only randomized controlled trial in this specific population is that the IL-17 inhibitor secukinumab was superior to placebo in terms of clinical and radiologic end-points in axial PsA. Regarding psoriatic skin involvement, head-to-head trials in PsA as well as skin psoriasis showed the superiority of IL-17, IL-23, and IL-12/23 inhibitors over TNF inhibitors. When treating PsA with concurrent uveitis, according to the existing data, monoclonal TNF inhibitor antibodies should be preferred. In PsA and concomitant inflammatory bowel disease, treatment decisions must include the consideration of which specific type of inflammatory bowel disease (Crohn's disease or ulcerative colitis) is present, as some of the agents either lack data or are ineffective in treating these 2 conditions. In both types, IL-17 inhibitors should be avoided. When determining treatment strategy, comorbidities should be carefully assessed, and the corresponding risk profile of the respective treatment modalities should be taken into consideration.

IMPLICATIONS

There are many approved therapeutic options for treating patients with PsA, and additional emerging treatment options are in the pipeline. Individualized treatment decisions for each patient, depending on the leading disease phenotype, underlying comorbidities, and patient preferences, should be made based on shared decision-making.

Pivotal Role of Intestinal Microbiota and Intraluminal Metabolites for the Maintenance of Gut-Bone Physiology

Intestinal microbiota, and their mutual interactions with host tissues, are pivotal for the maintenance of organ physiology. Indeed, intraluminal signals influence adjacent and even distal tissues. Consequently, disruptions in the composition or functions of microbiota and subsequent altered host-microbiota interactions disturb the homeostasis of multiple organ systems, including the bone. Thus, gut microbiota can influence bone mass and physiology, as well as postnatal skeletal evolution. Alterations in nutrient or electrolyte absorption, metabolism, or immune functions, due to the translocation of microbial antigens or metabolites across intestinal barriers, affect bone tissues, as well. Intestinal microbiota can directly and indirectly alter bone density and bone remodeling. Intestinal dysbiosis and a subsequently disturbed gut-bone axis are characteristic for patients with inflammatory bowel disease (IBD) who suffer from various intestinal symptoms and multiple bone-related complications, such as arthritis or osteoporosis. Immune cells affecting the joints are presumably even primed in the gut. Furthermore, intestinal dysbiosis impairs hormone metabolism and electrolyte balance. On the other hand, less is known about the impact of bone metabolism on gut physiology. In this review, we summarized current knowledge of gut microbiota, metabolites and microbiota-primed immune cells in IBD and bone-related complications.

Seronegative spondyloarthropathy-associated inflammatory bowel disease

Seronegative spondyloarthropathy (SpA) usually starts in the third decade of life with negative rheumatoid factor, human leukocyte antigen-B27 genetic marker and clinical features of spinal and peripheral arthritis, dactylitis, enthesitis and extra-articular manifestations (EAMs). Cases can be classified as ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis, or juvenile-onset spondyloarthritis. Joint and gut inflammation is intricately linked in SpA and inflammatory bowel disease (IBD), with shared genetic and immunopathogenic mechanisms. IBD is a common EAM in SpA patients, while extraintestinal manifestations in IBD patients mostly affect the joints. Although individual protocols are available for the management of each disease, the standard therapeutic guidelines of SpA-associated IBD patients remain to be established. Nonsteroidal anti-inflammatory drugs are recommended as initial therapy of peripheral and axial SpA, whereas their use is controversial in IBD due to associated disease flares. Conventional disease-modifying anti-rheumatic drugs are beneficial for peripheral arthritis but ineffective for axial SpA or IBD therapy. Anti-tumor necrosis factor monoclonal antibodies are effective medications with indicated use in SpA and IBD, and a drug of choice for treating SpA-associated IBD. Janus kinase inhibitors, approved for treating SpA and ulcerative colitis, are promising therapeutics in SpA coexistent with ulcerative colitis. A tight collaboration between gastroenterologists and rheumatologists with mutual referral from early accurate diagnosis to appropriately prompt therapy is required in this complex clinical scenario.

Uveitis-related Factors in Patients With Spondyloarthritis: TReasure Real-Life Results

PURPOSE

Spondyloarthritis (SpA) is a group of diseases with overlapping skeletal and extra-articular features. Acute anterior uveitis (AAU) is the most common extra-articular manifestation of SpA. The relation between AAU and SpA is well defined in the current literature. Our study aims to analyze the frequency and factors associated with AAU in different forms of SpA in a large nationwide cohort of Turkish SpA patients.

DESIGN

Retrospective cohort study.

METHODS

The data were obtained from the TReasure database, which compiles data from records of the web-based Rheumatoid Arthritis (RA) and SpA patients treated with biological disease-modifying anti-rheumatismal drugs from different regions of Turkey. The clinical characteristics of SpA and uveitis are recorded.

RESULTS

Data of the 4,297 SpA patients were included in the study. Overall, 475 of 4,297 patients (11.0%) had experienced 1 or more episodes of uveitis. SpA patients with older age (P < .001), a smoking history (P = .004), delayed diagnosis (P = .001), longer disease duration (P < .001), arthritis (P < .001), positive HLA-B27 (P < .001), a family history of SpA (P < .001), and radiographic damage (presence of sacroiliitis, syndesmophytes, bamboo spine, hip involvement) (P < .001 for all) more commonly had uveitis. On the other hand, uveitis was less prevalent in patients with psoriasis and psoriatic arthritis (P < .001 for both).

CONCLUSION

Uveitis may be the key feature leading to SpA diagnosis. Patients with radiographic damage and long disease duration have an increased risk for uveitis in both male and female SpA patients. Patients with uveitis should be referred to a rheumatologist for a thorough evaluation of SpA.

Female with Ankylosing Spondylitis from the 7th–6th century BCE Lori Berd burial (Armenia)

A female skeleton from the Lori Berd archaeological cemetery, located near the city of Stepanavan (Lori Province of Armenia) is described. Palaeopathological analysis revealed a variety pathology (ankylosis of the sacroiliac joints, ankylosis of the vertebrae, syndesmophytes, ankylosed of the costovertebral and costotransverse joint fusions, kyphosis, lordosis, fracture of the anterior inferior iliac spine and traumatic lesions). This paper reports a new case of ankylosing spondylitis in a skeleton and a differential diagnosis performed to determine the etiology of the condition. The vertebral bodies remodel and together with the associated syndesmophytes form a continuous, smooth bone surface that is sometimes referred to as “bamboo spine”. In this skeleton changes in the spine, ribs, the sacrum, acetabulum, head of the femur and greater trochanter, as well as the anterior inferior iliac spine are typical of ankylosing spondylitis in advanced stage. Addtionally, there were signs of a traumatic death with injuries sustained to the scapula and vertebra. Using osteological markers in combination with the reconstruction of the archaeological context, the burial pattern suggests that the pathology the female suffered was likely due to her physical deficiencies.

Chronic seronegative spondyloarthropathy following acute Mycoplasma pneumoniae infection in a human leukocyte antigen B27-positive patient: a case report

Background

We report a case of a 30-year-old patient who presented with acute Mycoplasma pneumoniae infection that was complicated by reactive arthritis and asymmetric proximal myopathy and progressed to chronic spondyloarthropathy. Reactive arthritis and sacroiliitis are unusual extrapulmonary manifestations of M. pneumoniae infection, which is a common condition.

Case presentation

A 30-year-old Greek previously healthy man presented to our emergency department with fever, progressively worsening bilateral lower limb weakness, and asymmetric oligoarthritis. Our diagnosis was based on a positive polymerase chain reaction test for M. pneumoniae using blood and cerebrospinal fluid and magnetic resonance imaging findings that suggested sacroiliitis. Our patient was also found to be human leukocyte antigen B27 positive. His infection was successfully treated with a 14-day course of doxycycline; the arthritis was treated with naproxen and corticosteroids. His arthritis, which restricted his mobility, improved progressively, and he was discharged without any neurological symptoms.

Conclusions

In our case, an acute M. pneumoniae infection eventually progressed to chronic spondyloarthropathy. In our patient, M. pneumoniae infection may represent a random event, or it might be a necessary factor for the development of reactive arthritis, asymmetric proximal myopathy, and sacroiliitis, always in combination with the appropriate genetic background. Extrapulmonary manifestations of M. pneumoniae may occur even in the complete absence of respiratory symptoms, and the diagnosis of unusual complications, such as reactive arthritis, requires high clinical suspicion and extensive investigation.

Henoch-Schonlein purpura associated with HLA-B27 positive axial spondyloarthritis in a young man

Axial spondyloarthropathies are characterised by bilateral sacroiliitis, asymmetric oligoarthritis, association with the human leucocyte antigen (HLA)-B27, enthesitis and dactylitis. Although IgA nephropathy has a well-documented association with seronegative spondyloarthropathies, the association with Henoch-Schonlein purpura (HSP) has been documented only in few case reports. The present case is that of a 26-year-old man who presented with fever, lower limb arthritis, abdominal pain, palpable purpura over the buttocks and lower limbs, and clinical features of sacroiliitis. His blood tests showed elevated inflammatory markers and rheumatoid factor was negative. CT scan of the sacroiliac joints confirmed sacroiliitis. Skin biopsy revealed neutrophilic small vessel vasculitis. HLA-B27 was positive in blood. A diagnosis of HSP with HLA-B27 positive axial spondyloarthritis was made. HSP can be associated with HLA-B27 positive axial spondyloarthritis and has to be considered while evaluating for causes of cutaneous small vessel vasculitis in such patients.

Is the use of AGILE patency capsule prior to videocapsule endoscopy useful in all patients with spondyloarthritis?

BACKGROUND AND AIMS

As already known, spondyloarthritis patients present a striking resemblance in intestinal inflammation with early Crohn's disease. Moreover, the frequent use of nonsteroidal anti-inflammatory drugs is an important part of their treatment. Both conditions could lead to intestinal stenoses. Therefore we proposed to investigate the usefulness of the patency capsule test in patients with spondyloarthritis.

MATERIAL AND METHODS

64 consecutive patients (33 males; mean age 38 ± 11 years) that fulfilled the AMOR criteria for seronegative spondyloarthropathy (59.4% ankylosing spondylitis) lacking symptoms or signs of intestinal stenosis were enrolled and submitted to an AGILE™ capsule patency test followed by a video capsule endoscopy (PillCam SB2™), as part of a protocol investigating the presence of intestinal inflammatory lesions. After reviewing the VCE recordings, the Lewis score (of small bowel inflammatory involvement) was computed.

RESULTS

In only 5 patients (7.8%) of the study group, the luminal patency test was negative. However, there was no retention of the videocapsule in any of the patients. From the 59 patients with a positive patency test, 3 patients presented single small bowel stenoses (two with ulcerated overlying inflamed mucosa, one cicatricial), all being traversed by the videocapsule along the length of the recording. None of the patients with a negative test had bowel stenoses. There was no correlation between the patency test and the Lewis score, the C reactive protein value, diagnosis of inflammatory bowel disease, or the family history of spondyloarthritis, psoriasis or inflammatory bowel disease.

CONCLUSION

The AGILE patency capsule does not seem to be a useful tool for all patients with spondyloarthritis prior to small bowel videocapsule endoscopy (ClinicalTrial.gov ID NCT 00768950).

Ligaments of the Costovertebral Joints including Biomechanics, Innervations, and Clinical Applications: A Comprehensive Review with Application to Approaches to the Thoracic Spine

Few studies have examined the costovertebral joint and its ligaments in detail. Therefore, the following review was performed to better elucidate their anatomy, function and involvement in pathology. Standard search engines were used to find studies concerning the costovertebral joints and ligaments. These often-overlooked ligaments of the body serve important functions in maintaining appropriate alignment between the ribs and spine. With an increasing interest in minimally invasive approaches to the thoracic spine and an improved understanding of the function and innervation of these ligaments, surgeons and clinicians should have a good working knowledge of these structures.

Golimumab in refractory uveitis related to spondyloarthritis. Multicenter study of 15 patients

OBJECTIVE

To assess the efficacy of golimumab (GLM) in refractory uveitis associated to spondyloarthritis (SpA).

METHODS

Multicenter study of SpA-related uveitis refractory to at least 1 immunosuppressive drug. The main outcome variables were degree of anterior and posterior chamber inflammation, visual acuity, and macular thickness.

RESULTS

A total of 15 patients (13 men/2 women; 18 affected eyes; mean age 39 ± 6 years) were evaluated. The underlying SpA subtypes were ankylosing spondylitis (n = 8), psoriatic arthritis (n = 6) and non-radiographic axial SpA (n = 1). The ocular involvement patterns were recurrent anterior uveitis in 8 patients and chronic anterior uveitis in 7. Before GLM they have received methotrexate (n = 13), sulfasalazine (n = 6), pulses of methylprednisolone (n = 4), azathioprine (n = 3), leflunomide (n = 2), and cyclosporine (n = 1). Overall, 10 of them had also been treated with TNF-α blockers; etanercept (n = 7), adalimumab (n = 7), infliximab (n = 6), and certolizumab (n = 1). GLM was given at the standard dose (50mg/sc/monthly) as monotherapy (n = 7) or in combination with conventional immunosuppressive drugs (n = 8), mainly methotrexate. Most patients had rapid and progressive improvement of intraocular inflammation parameters. The median number of cells in the anterior chamber at 2 years [0 (0-0)] was significantly reduced compared to baseline findings [1 (0-3); p = 0.04]. The mean best corrected visual acuity value also improved (0.84 ± 0.3 at 2 years versus 0.62 ± 0.3 at baseline; p = 0.03). Only minor side effects were observed after a mean follow-up of 23 ± 7 months.

CONCLUSIONS

Our results indicate that GLM may be a useful therapeutic option in refractory SpA-related uveitis.

Diagnostic clinical prediction rules for specific subtypes of low back pain: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To identify diagnostic clinical prediction rules (CPRs) for low back pain (LBP) and to assess their readiness for clinical application.

BACKGROUND

Significant research has been invested into the development of CPRs that may assist in the meaningful subgrouping of patients with LBP. To date, very little is known about diagnostic forms of CPRs for LBP, which relate to the present status or classification of an individual, and whether they have been developed sufficiently to enable their application in clinical practice.

METHODS

A sensitive electronic search strategy using 7 databases was combined with hand searching and citation tracking to identify eligible studies. Two independent reviewers identified relevant studies for inclusion using a 2-stage selection process. The quality appraisal of included studies was conducted by 2 independent raters using the Quality Assessment of Diagnostic Accuracy Studies-2 and checklists composed of accepted methodological standards for the development of CPRs.

RESULTS

Of 10 014 studies screened for eligibility, the search identified that 13 diagnostic CPRs for LBP have been derived. Among those, 1 tool for identifying lumbar spinal stenosis and 2 tools for identifying inflammatory back pain have undergone validation. No impact analysis studies were identified.

CONCLUSION

Most diagnostic CPRs for LBP are in their initial development phase and cannot be recommended for use in clinical practice at this time. Validation and impact analysis of the diagnostic CPRs identified in this review are warranted, particularly for those tools that meet an identified unmet need of clinicians who manage patients with LBP.

LEVEL OF EVIDENCE

Diagnosis, level 2a-.

Role of IL-17 in psoriasis and psoriatic arthritis

The role of T cell subpopulations in human disease is in a transition phase due to continuous discovery of new subsets of T cell, one of which is Th17, characterized by the production of signature cytokine IL-17. In the last couple of years, many articles are coming out on the role of Th17 and its signature cytokine IL-17 in different autoimmune diseases like rheumatoid arthritis, psoriasis, psoriatic arthritis (PsA), SLE and multiple sclerosis. Psoriasis and PsA are immune-mediated diseases, affecting the skin and joints, respectively. Initially, it was thought that psoriasis and PsA were Th1-mediated diseases; however, studies in knockout animal models (IL-17 knockout mice) as well as human experimental data indicate that Th17 and its signature cytokine IL-17 have a critical role in the pathogenesis of psoriatic disease. Th17 cells have been identified from the dermal extracts of psoriatic lesions. Subsequently, our research group has substantiated this observation that Th17 cells are enriched in the papillary dermis of psoriatic plaques and in freshly isolated effector T lymphocytes from the synovial fluid of PsA patients, and we have reported that the majority of these CD4 + IL-17+ T cells are of memory phenotype (CD4RO(+)CD45RA(-)CD11a(+)). Recent reports also suggest that the synovial tissue in psoriatic arthritis is enriched with IL-17R, and its most well recognized receptor IL-17RA is functionally active in psoriatic arthritis. In this review article, we have discussed the role of IL-17 in psoriatic disease and have narrated about the novel IL17/IL-17R antibodies currently in preparation for its therapeutic uses in autoimmune diseases.

The use of ultrasound for the assessment of enthesitis in patients with spondyloarthritis

Seronegative spondyloarthritis (SpA) represents a group of diseases that share certain genetic, clinical, and radiographic features. Enthesitis, inflammation at the site of tendon insertion into the bone, involving both the axial and the peripheral joints, is an important sign of SpA. Clinical diagnosis of enthesitis, however, is neither sensitive nor specific; thus, the diagnosis of enthesitis often relies on typical abnormalities in imaging studies. Due to its low costs and availability, ultrasound is emerging as the preferred technique for detection of enthesitis for both clinical and research purposes. Ultrasonographic features of enthesitis include tendon hypoechogenicity and thickening, calcifications, bone erosions, and Doppler signal. Several semi-quantitative scoring systems have been developed to quantify ultrasonographic abnormalities of the entheses. These methods have been used for early diagnosis and classification of SpA as well as for monitoring response to treatment.

Similarities and differences in fluorodeoxyglucose positron emission tomography/computed tomography findings in spondyloarthropathy, polymyalgia rheumatica and rheumatoid arthritis

OBJECTIVES

We assessed fluorine-18 ((18)F)-labelled fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) findings in patients with seronegative spondyloarthritis (SpA), polymyalgia rheumatica (PMR), and rheumatoid arthritis (RA).

METHODS

We studied 53 patients with SpA (n=21), PMR (n=16), or RA (n=16) admitted to our hospital between 2006 and 2011. Disease activity in the ischial tuberosities, greater trochanters, spinous processes, vertebral bodies, and sacroiliac joints (SIJ) were evaluated by determining FDG accumulation using maximum standardized uptake values (SUV(max)) and FDG scores.

RESULTS

SUV(max) for ischial tuberosities was significantly higher in PMR than SpA or RA. SUV(max) for greater trochanters and spinous processes was significantly higher in PMR than RA (P<0.001) and significantly higher in SpA than in PMR or RA for SIJ (P=0.01). No significant difference in vertebral scores was observed among groups (P=0.488). FDG scores yielded similar results. X-ray findings were consistent with PET/CT findings in 3/15 (20%) patients with sacroiliitis, whereas magnetic resonance imaging findings were consistent with PET/CT findings in 4/7 (57.1%) patients.

CONCLUSIONS

PET/CT detection of inflammation in the ischial tuberosities, greater trochanters, and spinous processes discriminated between PMR and RA, but not between SpA and PMR. PET/CT findings can distinguish SpA from RA and PMR and are useful for the early diagnosis of sacroiliitis.

A life-threatening abscess in a patient treated with a tumour necrosis factor-alpha antagonist: a case report

A 25-year-old man with a 3-year history of ankylosing spondylitis presented with a sudden onset of pain in his left thigh. His ankylosing spondylitis had been treated for 2 years with the tumour necrosis factor-alpha (TNF-alpha) antagonist infliximab. The initial diagnosis was a muscular tear, and non-steroidal anti-inflammatory drugs were prescribed. 40 days later, the patient had tender swelling with warmth and light redness on his left thigh. His knee function had decreased markedly. His C-reactive protein level was 320 mg/l and white cell count was 30.4 x10(9)/l, indicating severe infection. Magnetic resonance imaging revealed a loculated fluid collection in the quadriceps musculature measuring 30 cm. Hyperintensity seen on T1-weighted images was suggestive of infection. The infliximab therapy was stopped and repeated debridement and drainage performed, with about 2.5 litres of pus evacuated. Flucloxacillin was administered for 2 weeks. The wound was closed 9 days later. The patient was discharged 20 days after surgery. An alternative immunosuppressive therapy--abatacept--was introduced. At the 18-month follow-up, the patient reported only light discomfort in the thigh during exercise, with a mildly impaired range of knee movement. No infectious complications recurred.

Gastrointestinal lesions associated with spondyloarthropathies

Subclinical gut inflammation has been described in up to two-thirds of patients with spondyloarthropathies (SpA). Arthritis represents an extra-intestinal manifestation of several gastrointestinal diseases, including inflammatory bowel disease (IBD), Whipple’s disease, Behcet’s disease, celiac disease, intestinal bypass surgery, parasitic infections of the gut and pseudomembranous colitis. Moreover about two-thirds of nonsteroidal anti-inflammatory drug users demonstrate intestinal inflammation. Arthritis may manifest as a peripheral or axial arthritis. The spondyloarthropathy family consists of the following entities: ankylosing spondylitis, undifferentiated spondyloarthritis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with IBD, juvenile onset spondyloarthritis. This topic reviews the major gastrointestinal manifestations that can occur in patients with SpA and in nonsteroidal anti-inflammatory drugs users.

Spondyloarthritis: clinical suspicion, diagnosis, and sports

Spondyloarthritis (SpA), a family of inflammatory back diseases including ankylosing spondylitis, is an important and under-recognized cause of chronic back pain in younger patients who are likely to participate in sports and athletic activities. These diseases are characterized by the presence of inflammatory back pain--lumbar or buttock/hip pain lasting longer than 3 months associated with improvement with activity, worsening with rest, relief with non-steroidal anti-inflammatory drugs (NSAIDs), and morning stiffness lasting longer than 30 min. There are also characteristic radiographic findings involving the sacroiliac joints, vertebrae, and in certain diseases, the peripheral joints. Exercise has long been recognized as a key component of the therapy of SpA, yielding benefits in mobility, pain, stiffness, functionality, and depression. Sports also pose a risk to patients with SpA as these patients are at high risk of spinal fracture and spinal cord injury.

Increased numbers of circulating polyfunctional Th17 memory cells in patients with seronegative spondylarthritides

OBJECTIVE

A distinct subset of proinflammatory CD4+ T cells that produce interleukin-17 was recently identified. These cells are implicated in different autoimmune disease models, such as experimental autoimmune encephalomyelitis and collagen-induced arthritis, but their involvement in human autoimmune disease has not yet been clearly established. The purpose of this study was to assess the frequency and functional properties of Th17 cells in healthy donors and in patients with different autoimmune diseases.

METHODS

Peripheral blood was obtained from 10 psoriatic arthritis (PsA), 10 ankylosing spondylitis (AS), 10 rheumatoid arthritis (RA), and 5 vitiligo patients, as well as from 25 healthy donors. Synovial tissue samples from a separate group of patients were also evaluated (obtained as paraffin-embedded sections). Peripheral blood cells were analyzed by multiparameter flow cytometry and immunohistochemistry. Cytokine production was examined by enzyme-linked immunosorbent assay and intracellular cytokine staining using specific monoclonal antibodies. Synovial tissue was examined for infiltrating T cells by immunohistochemical analysis.

RESULTS

We found increased numbers of circulating Th17 cells in the peripheral blood of patients with seronegative spondylarthritides (PsA and AS), but not in patients with RA or vitiligo. In addition, Th17 cells from the spondylarthritis patients showed advanced differentiation and were polyfunctional in terms of T cell receptor-driven cytokine production.

CONCLUSION

These observations suggest a role of Th17 cells in the pathogenesis of certain human autoimmune disorders, in particular the seronegative spondylarthritides.

[Diagnosis of early spondyloarthritis]

PURPOSE

Spondyloarthritis (SpA) encompass different diseases with common characteristics, ankylosing spondylitis (AS) being the most typical. Undifferentiated SpA may evolve into AS. In France, SpA and rheumatoid arthritis could have the same prevalence. AS has a profound impact on the quality of live and function of patients as well as social and economic consequences for the society.

KEY POINTS

There is a mean delay of five to eight years between onset of symptoms and diagnosis of AS. This is due to the fact that radiographic sacroiliitis is delayed. The purpose of an earlier diagnosis is emphasized by the need for a better management, the new diagnostic method including magnetic resonance imaging and ultrasonography, and by the efficacy of anti-TNF therapy. The current criteria (New-York, Amor, ESSG) are classification but not diagnostic criteria. Their sensitivity is insufficient for an early diagnosis of SpA. Several groups are studying methods to ensure an early diagnosis. The group of Berlin has proposed, for patients suffering inflammatory chronic back pain, an algorithm using clinical, radiological and biological signs with, if necessary, search of HLA-B27 and MRI of sacroiliac joints. But this system is theoretical and the group of Maastricht found it of little effectiveness. Furthermore, it does not take account patients with symptoms beginning out of the spine.

CONCLUSION

We believe that only the follow-up of cohorts constituted of patients with early SpA will enable us to improve our knowledge regarding diagnostic criteria and new tools for early diagnosis, as well as outcome, prognosis and early management of SpA and AS.

Spinal arthropathy associated with Ochrobactrum anthropi in free-ranging cane toads (Chaunus [Bufo] marinus) in Australia

Inflammatory or degenerative pathology involving the vertebral bodies and/or ventral intervertebral joints has been described in numerous species, both captive and free ranging, including mammals, birds, and snakes, although never in amphibians. We described 15 cases of a newly recognized spinal arthropathy in adult cane toads (Chaunus [Bufo] marinus), an invasive species in Australia. Grossly appreciable lesions consisted primarily of ventral proliferation of bone and cartilage that resulted in ankylosis. Histologic examination of the entire vertebral columns of the 15 affected toads revealed 13 toads to have lesions at multiple intervertebral sites, totalling 41 intervertebral joints with lesions. Most lesions involved bone and cartilage proliferation that resulted in fusion of the joint, with (n = 15) or without (n = 9) associated pyogranulomatous inflammation. In the remaining 17 affected joints, histologic lesions were characterized by degeneration of articular cartilage without joint fusion. In addition, in one of these joints, there was also hemorrhage and pyogranulomatous inflammation. Bacterial culture of affected joints in 9 toads and grossly normal joints in 4 control toads resulted in isolation of Ochrobactrum anthropi in 7 affected toads but in none of the controls (P < .01). We proposed an interaction between degenerative and bacterial etiologies in the pathogenesis of this condition. Invasive toads may be predisposed to this condition because of their large size; increased rates of movement; and, possibly, immunosuppression resulting from inhabiting a novel environment.

[Inflammatory spine disease as a cause of back pain]

PURPOSE

The aim of this review is to evaluate the role of inflammatory spine disease in patients with chronic back pain. The contribution of imaging modalities for the diagnostic evaluation of back pain is discussed.

MATERIAL AND METHODS

A systematic literature search based on the classification of seronegative spondyloarthropathies and rheumatoid arthritis was performed. The results of this search and the experiences in a large collective of rheumatological patients are analyzed.

RESULTS

The prevalence of rheumatoid arthritis (1-2%) is comparable to that of spondyloarthropathies (1.9%). The etiology of these entities is not fully elucidated. Magnetic resonance imaging is increasingly used for early detection and surveillance of therapy with TNF-alpha antagonists.

DISCUSSION

Bone marrow edema, which is only detectable with MRI, represents an early sign of inflammation. Therapy with TNF-alpha antagonists is based on clinical and laboratory criteria, and signs of inflammation in MRI. MRI is useful for assessment of the effectiveness of anti-inflammatory therapy.

Update on anti-tumor necrosis factor therapy in the spondyloarthropathies including psoriatic arthritis

PURPOSE OF REVIEW

The introduction of the macromolecule tumor necrosis factor inhibitors etanercept, infliximab, and adalimumab has proven very successful for patients with spondyloarthropathies. The greatest experience has accrued in ankylosing spondylitis and psoriatic arthritis. This paper reviews data from clinical trials with tumor necrosis factor inhibitors in ankylosing spondylitis and psoriatic arthritis.

RECENT FINDINGS

Treatment with tumor necrosis factor inhibitors has not only resulted in substantial improvement in the signs and symptoms of arthritis but has also improved functional status and quality of life in ankylosing spondylitis and psoriatic arthritis. Improvements in associated inflammatory features, such as enthesitis in psoriatic arthritis and uveitis in ankylosing spondylitis, have also been observed. Moreover, treatment has been shown to inhibit the progression of radiographic joint damage in psoriatic arthritis and to attenuate spinal inflammation in ankylosing spondylitis. The notable success of tumor necrosis factor inhibitors has not only changed the treatment paradigms for these conditions but has also stimulated studies aimed at improving diagnosis, prognostic stratification, and other aspects of clinical care.

SUMMARY

The introduction of tumor necrosis factor inhibitors for patients with ankylosing spondylitis and psoriatic arthritis has had a tremendous impact on daily clinical care.

Synovial biomarkers in the spondylarthropathies

PURPOSE OF THE REVIEW

To explore the concept of a biomarker, or surrogate endpoint, to enhance early diagnosis or predict the response to therapeutic intervention in patients with spondylarthropathy.

RECENT FINDINGS

Immunopathologic studies have suggested that the features of spondylarthropathy are distinctive, supporting a prominent role for innate immune cells, and can be consistently differentiated from rheumatoid arthritis. Successful treatment of spondylarthropathy synovitis resulted in rapid and sustained decrease in infiltration by macrophage populations and neutrophils, and decreased expression of many proinflammatory mediators. Consistent with studies in rheumatoid arthritis, significant correlations between the effects of both methotrexate and infliximab on disease activity and sublining macrophage populations were reported. These observations highlight the possibility that macrophage populations may be a synovial tissue biomarker of therapeutic intervention in spondylarthropathy. Preliminary studies have evaluated advanced genomic and proteomic methodologies in spondylarthropathy.

SUMMARY

Defining the immunopathology of spondylarthropathy has been associated with identifying potential biomarkers of the clinical response to therapeutic intervention. A surrogate marker of arthritis activity in spondylarthropathy could profoundly enhance screening for efficacy and optimization of dose ranges in early-phase randomized clinical trials.