Uveitis and rheumatic diseases

HLA-B27 typing in the categorisation of uveitis in a HLA-B27 rich population

AIMS

To determine whether HLA-B27 typing helps the clinician in the diagnostic examination of uveitis in a HLA-B27 rich population and also whether the clinical picture of HLA-B27 positive unilateral acute or recurrent anterior uveitis (AAU) is distinguishable from the idiopathic negative form.

METHODS

During a 3 year period 220 consecutive patients with undetermined uveitis at onset were examined in the Helsinki University Eye Clinic. HLA-B27 antigen was tested for 85% of the patients. Other laboratory or x ray examinations were performed on the basis of the anatomical classification of uveitis and the biomicroscopic features characteristic of uveitis associated systemic diseases.

RESULTS

HLA-B27 antigen was found significantly more often in patients with anterior (71%) and acute/recurrent unilateral (79%) uveitis than in patients with intermediate, posterior panuveitis (7%), and chronic (7%) or bilateral (12%) forms. Of the 16 cases of HLA-B27 negative unilateral AAU, five showed biomicroscopic features representing uveitis entities. The remaining 11 cases did not differ in any respect from the cases of HLA-B27 positive unilateral AAU.

CONCLUSION

HLA-B27 antigen helps the clinician in the diagnostic examination of unilateral AAU. Positive test results serve as a clue to search for spondyloarthropathies, and negative results indicate the need to look for specific uveitis entities and other systemic diseases. The occurrence of HLA-B27 positivity in conjunction with uveitis entities other than unilateral AAU is of the same level or less than in the population of Finland in general.

Studies of arthritis and other lesions induced in rats by injection of mycobacterial adjuvant. V. Changes affecting the skin and mucous membranes. Comparison of the experimental process with human disease

A generalized disease is induced experimentally in the rat by administration of Freund's adjuvant. The primary clinical and pathologic lesions are arthritis, periarthritis, peritendinitis, and periostitis in the joints of the extremities and tail. Accompanying the arthritis in some cases, and never observed in its absence, are other specific tissue lesions including iridocyclitis, nodular lesions in the glabrous skin (ear, genitalia, feet, tail), transient rashes, a chronic skin disease, genitourinary lesions, and diarrhea. These make up a striking and characteristic picture. The arthritis usually precedes the other lesions and, together with the skin disease may show a prolonged and fluctuating course. Visceral lesions do not occur. Histologically, the basic lesion is a lymphocytic and histiocytic infiltration, initially perivascular and subsequently more disseminated. In addition, in the region of the joints and in the corpora cavernosa of the penis, there is extensive proliferation of mesenchymal cells, especially fibroblasts. Foci of fibrinoid necrosis are seen in the articular and nodular lesions, and destructive lesions of the joints are common. Such a combination of tissue lesions has not previously been described in experimental pathology. The experimental disease is shown to have both similarities to and differences from Reiter's syndrome, rheumatoid arthritis, and certain other disorders which occur in man.

Acute anterior uveitis: clinical and experimental aspects

Acute anterior uveitis (AAU) or iritis is an inflammatory disorder of the anterior structures of the eye that may be associated with a number of disease entities. A significant proportion of patients will have no evidence of an underlying disorder and are labeled as idiopathic. Within this group approximately 50% will possess the human leukocyte antigen, HLA-B27, and some will have an associated spondyloarthropathy such as ankylosing spondylitis or Reiter's syndrome. Nevertheless, a number of HLA-B27-positive patients have no apparent underlying rheumatic disorder. The potential interplay of HLA-B27 and certain infective agents in the pathogenesis of AAU is discussed with particular reference to Yersinia species. Presentation of a uveitogenic peptide, similar to the arthritogenic peptide model in spondyloarthropathies, may be a mechanism involved in the development of AAU. Experimental models in animals have increased our understanding of the roles of retinal proteins and bacterial peptides, as well as T cells and cytokines, in the pathogenesis of uveitis. As in animal models of arthritis, certain retinal peptides (in conjunction with adjuvant therapy) can induce uveitis in animals. The treatment of isolated AAU usually involves topical medication and the prognosis is good. Occasional cases, especially those associated with systemic disorders, may require the addition of systemic corticosteroids or other immunosuppressive medications.

Serum immunoglobulins in acute anterior uveitis

Serum levels of immunoglobulin A, G, and M were examined in 99 patients with acute anterior uveitis (AAU). The mean level of serum IgA was raised (p less than 0.001) in AAU patients when compared with healthy control subjects. The levels of serum IgG and IgM were not significantly different from those in the control group. The raised levels of serum IgA were found to occur predominantly in the HLA-B27 positive group of patients (p less than 0.001) and were highest in HLA-B27 positive patients with sacroiliitis or associated spondylarthritic diseases (p less than 0.001). The HLA-B27 negative group of AAU patients did not have a significantly raised mean serum IgA. The raised level of serum IgA in HLA-B27 positive AAU patients suggests that there has been a response to an environmental or infectious agent(s) acting across a mucosal tissue in these patients. This agent could be responsible for the initiation of the acute ocular inflammation.

Acute anterior uveitis, ankylosing spondylitis, back pain, and HLA-B27

One hundred and sixty-nine patients with acute anterior uveitis were studied for the presence of HLA-B27 tissue type, radiological evidence of ankylosing spondylitis, and a history of back pain. 60% were male; 45% were HLA-B27+. The male:female ratio in the HLA-B27+ group was the same as in the whole group. 24% had radiological evidence of ankylosing spondylitis, and, of these, 83% were HLA-B27+ while 17% were HLA-B27-. There was a definite correlation between the severity of the ankylosing spondylitis and preponderance of males in the HLA-B27+ group of patients. Significant back pain occurred in 60% of HLA-B27+ patients but in only 14% of HLA-B27- patients. The importance of the selection of patients and of consistency in the use of diagnostic criteria in studies relating to ankylosing spondylitis and acute anterior uveitis is stressed.

HL-A 27 and acute anterior uveitis

51 (30 men and 21 women) of 90 consecutive patients with acute non-granulomatous anterior uveitis were HL-A 27 positive. This frequency of 55-7 per cent compares with 8-2 per cent in controls. Twenty-three patients (18 men and 5 women) had in addition evidence of systemic disease, including ankylosing spondylitis, sacroiliitis and Reiter's syndrome, sometimes associated with psoriasis. Twenty-eight of 63 patients without evidence of systemic disease were HL-A 27 positive, suggesting that the uveitis in many of these cases has a similar aetiology to those with rheumatic disease. The uveitis associated with HL-A 27 is typically unilateral, associated with mechanical ptosis, and a painful diffusely red, photophobic, and lacrimating eye, generally lasting 3 weeks or more. Protein extravasation into the aqueous is considerable, cells are usually present in the aqueous and anterior vitreous, and keratic precipitates are never mutton fat in appearance. Recurrent episodes are characteristic. The association with HL-A 27 suggests that many if not most cases of non-granulomatous anterior uveitis have a close aetiological relationship to ankylosing spondylitis and Reiter's syndrome and it is likely that infective agents, leading to an unusual immunologically mediated inflammatory response in predisposed individuals, are involved. Ten patients with granulomatous anterior uveitis were HL-A 27 negative.

Arthritis and genital infection in paraplegic patients

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Bone and joint changes in paraplegic men

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Ocular presentations of Still's disease and their treatment: iridocyclitis in Still's disease: its complications and treatment

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