The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general

IgG-seq identifies immune-reactive enteric bacteria in Crohn's disease with spondyloarthritis

Joint inflammation is the most common extraintestinal manifestation of Crohn's disease (CD). Although alterations in the enteric microbiota are described in CD with spondyloarthritis (CD-SpA), it is not known whether distinct taxa serve as markers for clinical subtypes of axial (AxSpA) or peripheral SpA (pSpA) in CD. Moreover, it is not yet known whether these taxa generate a specific systemic IgG response. Here, we sequenced the fecal microbiome from 106 individuals (44 CD, 39 CD-SpA, 14 CD-AxSpA, and 9 healthy controls [HC]). This unique cohort revealed distinct taxonomic compositions of CD and CD-SpA compared to HC and demonstrates that the composition of the CD-AxSpA microbiome is distinct from that of CD-pSpA. Using autologous serum, we identified enteric bacteria recognized by serum IgG and demonstrate differences in the IgG coating index of specific bacterial genera associated with CD-SpA. The IgG coating index of Mediterraneibacter gnavus differentiated patients with CD-pSpA and is positively associated with joint disease activity. This work illustrates divergent microbiome compositions in CD-SpA subtypes, as well as the recognition of distinct enteric bacteria by serum IgG with the potential to serve as a marker of joint inflammation in CD.

Rethinking spondyloarthritis: beyond lumping and splitting

PURPOSE OF REVIEW

The classification of spondyloarthritis (SpA) has long been debated, with ongoing discussions about whether to "lump" various subtypes together or "split" them into smaller distinct disease categories. This review explores the evolution of the SpA concept and discusses novel approaches that move beyond traditional models of SpA classification.

RECENT FINDINGS

Since its introduction in the 1970s, the SpA concept has undergone substantial modifications, incorporating advances in genetics, imaging, and clinical research. The recognition of axial and peripheral SpA as distinct yet overlapping entities has reshaped classification and drug approval processes. Data-driven methodologies have provided new insights into disease heterogeneity. Recent research highlights the limitations of traditional classification systems, emphasizing the need for unbiased approaches that integrate clinical and molecular features.

SUMMARY

Current historically derived classification paradigms for SpA are largely based on clinical phenotype and fail to capture the full spectrum of disease heterogeneity. Defining SpA subsets by incorporating genetic and immunological characteristics may improve diagnostic precision and improve outcomes. Future research should focus on refining classification frameworks across the entire clinical spectrum of SpA to improve patient stratification, guide treatment decisions, and address existing gaps in SpA care.

A combined analysis of spinal mobility and gait spatiotemporal parameters in axial spondyloarthritis using wearable sensors

BACKGROUND

Axial spondyloarthritis is a chronic rheumatic disease which impacts spinal mobility and physical functions, including gait. However, current clinical assessments mostly rely on composite indices and questionnaires which involve a degree of subjectivity. This study aimed to assess the discriminant validity of wearable sensors for objective monitoring of axial spondyloarthritis in clinical practice.

METHODS

Twenty participants with axial spondyloarthritis and 20 healthy controls were included. Spinal mobility alongside gait were assessed while data were collected using inertial measurement units. Data were compared between the two groups and classification performance was assessed by performing receiver-operating characteristic curve analysis. Finally, correlations between parameters measured through inertial measurement units and clinical measures were also evaluated.

FINDINGS

The axial spondyloarthritis group showed significantly reduced trunk maximum angles in all planes and direction of motion. Gait was characterized by a reduction in cadence (P = 0.004) and speed (P = 0.015). The combination of gait cadence and trunk kinematics enhanced the classification performance (sensitivity = 95 % vs. 55 % with trunk sagittal range of motion alone). Trunk kinematic variables were correlated to mobility items of clinical measures while spatiotemporal gait parameters showed correlations with the disease activity and its functional impact in daily life.

INTERPRETATION

The present study demonstrated the ability of inertial measurement units to effectively discriminate axial spondyloarthritis individuals, with an enhanced classification performance while combining trunk kinematics and gait spatiotemporal parameters. These findings highlight the potential of wearable sensors as valuable tools for assessment and follow-up in clinical practice.

Performance of spondyloarthritis-specific health utilities based on the ASAS Health Index: an ancillary analysis from the ASAS-HI validation study

OBJECTIVES

To compare the Spondyloarthritis (SpA)-specific universal utility estimation from ASAS Health Index (U-ASAS-HI) with generic utilities and to understand the contribution of health outcomes, personal- and country-level factors to the U-ASAS-HI.

METHODS

This was an ancillary analysis of the ASAS-HI international validation study. SpA patients who completed the ASAS-HI, 5-level EuroQol-5D (EQ-5D-5L) and Short Form-36 (SF-36) questionnaires were selected, and utilities calculated. Correlations between U-ASAS-HI and generic utility values were tested. Potential explanatory variables were evaluated in a linear multivariable mixed-effects model analysis with multilevel modelling fitted by country.

RESULTS

The number of patients included was 1425, with a mean (s.d.) age of 42 (13.5) years, with 65% male. The mean (s.d.) utility scores were for EQ-5D-5L 0.75 (0.11), for short-form 6-dimension (SF-6D) 0.72 (0.24), and for U-ASAS-HI 0.42 (0.29). Correlation between U-ASAS-HI and EQ-5D-5L and SF-6D was strong (r = 0.75 and r = 0.72, respectively; P < 0.001). The linear mixed-effects model showed that worse disease activity (ASDAS) and lower physical function (BASFI) were associated with lower U-ASAS-HI. Additionally, younger age, female gender, higher comorbidity score and symptoms of depression were associated with lower U-ASAS-HI. SpA subtype had no influence on health utility. The random effects model indicated an intercept s.d. of 0.045 with a 5.5% variance ratio between countries and the total U-ASAS-HI variation.

CONCLUSION

The U-ASAS-HI captures the physical and mental impact of SpA, as well as personal contextual factors such as age, gender and comorbidities. The influence of the country of residence seems negligible. The U-ASAS-HI algorithm has sufficient support to be used in health economic evaluations for SpA patients across different countries.

Development of START, a novel multimedia-based symptom appraisal tool for autoimmune rheumatic diseases

OBJECTIVES

To facilitate earlier diagnosis of autoimmune rheumatic diseases (ARDs), we aimed to (i) develop Symptom Testing for Autoimmune RheumaTic diseases (START), a novel multimedia-based symptom appraisal tool for ARDs and (ii) pilot test START among established ARD cases and non-ARD controls.

METHODS

We developed START using a social cognitive theory-based theoretical framework and consensus-based lists of ARDs and manifestations from our previous work. START was revised through reviews by an expert panel of rheumatologists and cognitive debriefing interviews (CDIs) with patients newly referred for assessment of ARDs. We pilot tested START to evaluate its sensitivity, specificity and test-retest reliability in detecting patients with known ARDs.

RESULTS

Of the 59 manifestations of ARDs identified from our previous work, 33 reached expert consensus for content validity, 26 were removed because they were non-specific or late features of ARDs. Similar manifestations were grouped, resulting in 19 items. The phrasing and formatting of items in START were revised based on findings from the CDIs with 36 patients and expert panel review. Visual illustrations such as photos and drawings were included to improve comprehension of items in START, using an online platform for implementation. Pilot testing in 145 patients with ARDs, 133 patients with non-ARDs and 155 healthy controls found that the sensitivity, specificity and test-retest reliability in detecting patients with any ARDs were 86.2%, 80.9% and 0.789, respectively.

CONCLUSION

A novel multimedia-based symptom appraisal tool for ARDs was developed, which addresses the limitations of existing tools and exhibited promising sensitivity and specificity in detecting patients with known ARDs.

Spondyloarthritis features in IBD patients: prevalence, referral trends and clinical implications. A questionnaire-based study

OBJECTIVES

This study examines the prevalence of spondyloarthritis (SpA) features in patients with inflammatory bowel disease (IBD) and their rates of referral to rheumatologists.

MATERIAL AND METHODS

A questionnaire was administered to 2087 IBD patients (≥18 years) in Sweden, assessing demographics, medications and SpA features based on the ASAS and ESSG classification criteria. Patient that met our self-reported adapted criteria are referred to as suspected SpA.

RESULTS

Among the 1032 respondents, 59.1% met our questionnaire-based adapted SpA criteria. However, depending on different criteria (based on adapted ASAS, ESSG, peripheral or axial symptoms) only 24.3-44.0% of these patients had been referred to a rheumatologist. Patients with suspected SpA had higher usage of immunomodulators (42.8-48.8% vs. 37.0%), biologics (27.1-32.4% vs. 14.9%) and steroids (58.1-64.8% vs. 46.2%) compared to those without suspected SpA. Additionally, suspected SpA patients reported a higher incidence of active colitis (30.4-40.4% vs. 11.8%). Logistic regression analysis identified significant associations between suspected axial SpA and factors such as age, smoking, psoriasis, anterior uveitis and a high P-SCCAI score (≥5). Female gender and BMI ≥30 kg/m2 were linked to suspected peripheral SpA.

CONCLUSION

The study highlights a significant prevalence of self-reported SpA in IBD patients, with many remaining undiagnosed and un-referred to rheumatologists. These findings emphasize the need for greater awareness and improved collaboration between gastroenterologists and rheumatologists for better SpA management in IBD patients.

Patients with Higher Pulse Wave Velocity Are More Likely to Develop a More Severe Form of Knee Osteoarthritis: Implications for Cardiovascular Risk

Background/Objectives: Knee osteoarthritis (KOA) is a progressive degenerative joint disease characterised by low-grade inflammation and is associated with increased cardiovascular (CV) risk and arterial stiffness. Pulse wave velocity (PWV) is a quantitative measure of arterial stiffness and an important tool for detecting subclinical arterial calcification and CV risk. This study aimed to determine whether PWV can distinguish radiographically mild KOA (Kellgren-Lawrence grades 1-2) from severe KAO (Kellgren-Lawrence grades 3-4) in terms of CV risk factors. Methods: A total of 223 postmenopausal women with KOA participated in this cross-sectional study. Assessments included anthropometry, laboratory analyses, blood pressure and PWV measurements, a 6 min walk test, pain evaluation using a visual analogue scale (VAS), and completion of the International Physical Activity Questionnaire (IPAQ). Results: PWV was significantly higher in the severe KOA group (10.53 m/s vs. 8.78 m/s, p < 0.001). A cut-off value of 8.4 m/s effectively distinguished between severe and mild forms of KOA (AUC = 0.798, p = 0.001). OA grade, pain, age, waist circumference, WHR, SCORE 2/SCORE 2OP, systolic blood pressure, serum glucose, HbA1c, uric acid, creatinine, and erythrocyte sedimentation rate were increased in the group with PWV > 8.4 m/s, compared to the group with PWV ≤ 8.4 m/s. Conversely, eGFR, the 6 min walk test and physical activity of patients were reduced in the group with PWV > 8.4 m/s. A patient with a PWV > 8.4 m/s has a 1.77 times higher chance of developing a more severe form of the disease than a patient with a lower PWV. Conclusions: Patients with a higher PWV are more likely to develop a more severe form of KOA, which is associated with increased cardiovascular risk.

Comparative Characteristics of Axial Spondyloarthritis and Psoriatic Arthritis with Axial Involvement

of the study was to compare clinical characteristics of patients with axial spondyloarthritis (axSpA)/ankylosing spondylitis (AS) and with axial psoriatic arthritis (axPsA). MATERIALS AND METHODS: . A total of 100 patients were examined: 45 with axSpA/AS (group 1) and 55 with axPsA (group 2). Patients of group 1 were included according to axSpA/AS criteria; patients of group 2, according to CASPAR (ClASsification criteria for Psoriatic ARthritis) criteria, and having axial involvement (axPsA). Axial involvement was detected in case of radiologically significant sacroiliitis (SI, bilateral grade ≥2 or unilateral grade ≥3), or active MRI significant sacroiliitis, or ≥1 syndesmophyte(s) of the cervical and/or lumbar spine. Patients were evaluated for the presence of inflammatory back pain (IBP) by ASAS (Assessment of Spondyloarthritis International Society) criteria. RESULTS AND DISCUSSION. : Patients of group 1 were younger (p < 0.001), more often were HLA-B27 positive (p < 0.001), and more often had IBP (p = 0.001). Patients of group 2 had older age (> 40 years) at back pain onset (p < 0.001) and more often had peripheral arthritis (p < 0.001), dactylitis (p = 0.004), and skin psoriasis (p < 0.001). Nail psoriasis was found only in group 2 patients (p < 0.001). Group 1 patients more often had heel enthesitis (p = 0.005). Group 2 patients had worse axial disease activity scores: BASDAI (Bath Ankylosing Spondylitis Disease Activity Index; p = 0.006) and ASDAS-СRP (Ankylosing Spondylitis Disease Activity Score with C-reactive protein level determination; р < 0.001); and worse patient-reported outcomes: BASFI (Bath Ankylosing Spondylitis Functional Index; p = 0.004), patients' pain (p = 0.005) and patients' global assessments (p = 0.036). Patients of group 2 had more syndesmophytes of the lumbar (р = 0.009) and cervical (р = 0.007) spine. Only in group 2 patients, chunky "non-marginal" syndesmophytes (in 32.1%), as well as spinal lesions without sacroiliitis (in 20.0%) were found. Patients of group 2 had more joint erosions (р = 0.001), osteolysis (р = 0.015), juxta-articular bone formation (р < 0.001) and joint ankyloses (р = 0.02). All patients of group 1 and only 80% of group 2 (р = 0.003) met ASAS criteria for axSpA. AxSpA/AS and axPsA seem to be two different diseases. In our cohort of patients, axPsA patients had worse disease status compared to axSp and AS.

Imaging in clinical trials of axial spondyloarthritis: what type of imaging should be used

Axial spondyloarthritis (axSpA) is a chronic inflammatory condition predominantly affecting the sacroiliac joints and spine. Early and accurate diagnosis is crucial to prevent structural damage and improve patient outcomes. Imaging plays a pivotal role in axSpA diagnosis, monitoring, and clinical trials, offering insights into both inflammatory activity and structural progression. Conventional radiography has been foundational for detecting structural changes, such as syndesmophytes and erosions, but it is limited by poor sensitivity for early disease detection and significant interobserver variability. Advanced imaging modalities, such as magnetic resonance imaging (MRI) and low-dose computed tomography (ld-CT), have emerged as more sensitive tools. MRI excels in identifying active inflammation, particularly bone marrow edema, and is integral to early diagnosis and disease monitoring. ld-CT provides superior spatial resolution for detecting structural lesions while minimizing radiation exposure. However, challenges remain in achieving standardized imaging protocols and consistent scoring systems across clinical trials. Scoring systems like the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), Spondyloarthritis Research Consortium of Canada (SPARCC) scores, and Berlin methods require rigorous calibration to ensure reliability. The purpose of this review is to explore the strengths and limitations as well as the use in clinical trials of the different imaging modalities and to offer guidance on selecting the most suitable imaging techniques for assessing both disease activity and structural progression in clinical trials.

Real-World Insights From Türkiye: Biologic DMARDs Usage in Spondyloarthritis Patients With Chronic Kidney Disease

AIM

The objective was to evaluate biologic disease-modifying antirheumatic drugs (DMARDs) and their side effects that hindered the continuation of treatment in a patient population diagnosed with spondyloarthritis (SpA) with a glomerular filtration rate (GFR) ≤ 60 mL/min, and to compare these side effects between patients with chronic kidney disease (CKD) and those without.

METHODS

This multicenter, observational cohort study utilized data from the TReasure database, which records SpA patients in a web-based system across Türkiye. A total of 6052 patients being included. SpA patients were categorized into two main groups: non-CKD patients and CKD patients. The clinical characteristics, disease activity, treatment options, drug retention rates, reasons for drug discontinuation, and types of adverse effects were compared between the groups.

RESULTS

Biologics prescription pattern varied between CKD and non-CKD patients. Etanercept was prescribed more frequently (53.1%) in CKD patients. Regarding the number of side effects and drug discontinuations in CKD patients, no statistically significant differences were found between the non-CKD and CKD groups for any of the bDMARDs (adalimumab, etanercept, golimumab, infliximab, ustekinumab, secukinumab, and certolizumab). No statistically significant differences were observed in the duration of drug retention based on CKD status for bDMARDs.

CONCLUSION

This study offers preliminary evidence supporting the effective and safe use of bDMARDs in patients with SpA and CKD.

MR Imaging Approach to Arthritides and Spondyloarthropathies

MR imaging is a valuable imaging tool in the assessment of spinal arthritides, allowing the radiologist to formulate a rational differential diagnosis and construct a meaningful radiologic report. Of this, spondyloarthritis has garnered the most attention over the years given its debilitating symptoms and disabling effect. MR imaging depicts both inflammatory and structural lesions in the spine and SI joints and a systematic anatomic approach in appraising these lesions can aid in proper diagnosis. Combined with careful correlation with clinical findings and biomarkers, MR imaging is an instrumental tool in the diagnosis and treatment planning of spinal arthritides, particularly spondyloarthritis.

[James Joyce. Chronic recurrent iritis resulting from postvenereal reactive arthritis]

The Irish author James Joyce (1882-1941) suffered from chronic recurrent iritis with a variety of complications that led to almost complete blindness. Syphilis and a rheumatic disease, such as Reiter's syndrome were discussed as the main causes. The coincidence of a venereal infection, arthritis and the characteristic medically documented features of iritis, including typical complications, together with the chronic recurrent course of the eye disease, are convincing arguments for postvenereal reactive arthritis. A familial predisposition and smoking could have been responsible for the unfavorable course of the iritis. There is no reliable evidence of syphilis and, above all, the multiple recurrences of the iritis are not compatible with a syphilitic infection. Even after the medical publications in which the rheumatic genesis was convincingly discussed and in the knowledge of these, art historians have held on to the diagnosis of syphilis. It is therefore to be hoped that in the future the art historical literature will accurately reflect Joyce's illness in accordance with the medical knowledge.

Characteristics, risk factors, and disease course of musculoskeletal manifestations in patients with inflammatory bowel disease: a prospective longitudinal cohort study

BACKGROUND

Musculoskeletal manifestations occur in half of the patients with inflammatory bowel disease (IBD) and contribute to a reduced quality of life (QoL) and increased work disability. We aimed to evaluate the natural disease course, characteristics, and risk factors of musculoskeletal manifestations in patients with IBD.

METHODS

We performed a prospective longitudinal cohort study in patients with IBD with and without musculoskeletal manifestations with a 1-year follow-up. Primary outcome was the proportion of patients with resolution of musculoskeletal manifestations. Secondary outcomes included the proportion of patients with IBD that developed new musculoskeletal manifestations during follow-up; the correlation among IBD activity, baseline characteristics, and musculoskeletal disease course; and the difference in QoL between patients with and without musculoskeletal manifestations.

RESULTS

In total, 243 patients with IBD were included (124 with and 119 without musculoskeletal manifestations). In the majority of patients (62.2%), musculoskeletal manifestations were of noninflammatory nature. Overall, peripheral and axial manifestations were persistent in 85.7 and 44.6% at 1 year, respectively. The QoL at baseline and at 1 year was lower in the group with musculoskeletal manifestations compared with patients without these manifestations. Female sex and age above 40 were associated with the presence of musculoskeletal manifestations.

CONCLUSION

Musculoskeletal manifestations in patients with IBD are mostly noninflammatory disorders, persist at 1 year of follow-up, and occur more frequently in patients of age above 40 and female sex. Overall, patients with musculoskeletal manifestations have lower QoL compared with patients without musculoskeletal manifestations.

[Reactive arthritis]

Reactive arthritis (ReA) is a disease caused by an extra-articular infection that manifests as a sterile joint inflammation. In contrast to bacterial septic arthritis no pathogens can be cultured from the joint in ReA but pathogen components, such as antigens or DNA are more frequently detectable in the joint, suggesting an intra-articular culture-negative persistent infection or at least an intra-articular interaction between the host and pathogen components. The primary extra-articular infection in classical ReA is of bacterial origin and usually affects either the urogenital, gastrointestinal or, less frequently, the respiratory tract. Chlamydia (C. trachomatis and less frequently C. pneumoniae) and enterobacteria are among the most common pathogens causing ReA. The prevalence of ReA is estimated at 40/100,000 and the incidence at 5/100,000. Typical clinical manifestations are mostly self-limiting peripheral arthritis (monoarticular or oligoarticular), dactylitis and, more rarely, axial involvement and in half of the cases, there is an association with HLA-B27. Due to these similarities, classical ReA is categorized as a form of spondyloarthritis (SpA). The diagnosis is made on the basis of a typical clinical picture, evidence of a previous or persistent infection and the exclusion of other causes of arthritis. Treatment includes physical measures, the use of anti-inflammatory agents such as nonsteroidal anti-inflammatory drugs (NSAID) or glucocorticoids, in the case of persistent arthritis, immunomodulating substances such as sulphasalazine, methotrexate and in individual cases biologics and Janus kinase inhibitors (JAKi) are used. In general, antibiotic treatment of ReA does not shorten the duration of the disease.

Expanding the Genetic Framework: Insights into Non-HLA-B27 Contributions to Axial Spondylarthritis

Background and Objectives: Spondylarthritis is a complex group of inflammatory diseases closely associated with the HLA-B27 antigen. However, the role of non-HLA-B27 alleles in the disease's pathogenesis has gained significant scholarly attention in recent years. Case presentation: This case study presents a 49-year-old male with a history of progressive inflammatory back pain, characterized by morning stiffness and restricted spinal mobility developed over several years. Initially presenting with non-specific symptoms, the patient eventually experienced persistent axial pain and deteriorating functional limitations, which required further evaluation. Radiographic imaging supported the diagnosis of ankylosing spondylitis (AS) by identifying bilateral sacroiliitis. HLA genotyping revealed a negative result for HLA-B27 but positive results for HLA-B13 and HLA-B37. This finding serves as a foundation for exploring alternative genetic factors contributing to spondylarthritis (SpA). HLA-B13 and HLA-B37 exhibit structural and functional similarities to HLA-B27, particularly in their peptide-binding grooves. This resemblance may lead to overlapping peptide repertoires and increased T cell cross-reactivity. Moreover, these alleles belong to overlapping cross-reactive groups (CREGs) and share the Bw4 epitope. This suggests that they may contribute to disease pathogenesis via similar mechanisms, such as molecular mimicry and the dysregulation of natural killer (NK) cell interactions, as observed in HLA-B27. Conclusions: This case emphasizes the necessity of expanding diagnostic criteria to incorporate non-HLA-B27 markers, particularly for patients who are HLA-B27-negative. Enhancing our understanding of the roles of alternative genetic markers can improve diagnostic accuracy, enable personalized treatment approaches, and enhance outcomes for the diverse SpA patient population.

Minimally invasive ultrasound-guided biopsy of the common extensor tendon enthesis: a cadaveric study to standardise the technique

OBJECTIVE

To develop and validate a minimally invasive ultrasound (US)-guided biopsy technique to collect entheseal tissue from the common extensor tendon (CET) enthesis at the lateral humeral epicondyle.

METHODS

Seven sonographers performed a US examination of the CET on six human cadaveric upper limbs to locate the enthesis using an anatomical landmark-based approach. An adapted mini-arthroscopic system was introduced under US guidance to the target site for sample collection. At the end of the procedure, a dye was injected through the guide needle, followed by dissection, to confirm the sampling location. Histology and immunohistochemistry analyses were performed to assess the quality and representativeness of the samples. The reliability of the procedure among operators was evaluated by analysing the rate of successful sampling.

RESULTS

24 samples were collected. The target site to be biopsied was identified as the insertion of the extensor carpi radialis brevis component of the CET. On dissection, the stain used to verify sampling accuracy was confirmed within the defined target area, with no damage to adjacent structures. Histology and immunohistochemistry indicated that most of the samples exhibited characteristics consistent with entheseal tissue (21 out of 24). All participants identified the CET and successfully completed the procedure, demonstrating reliable sample quality across operators.

CONCLUSION

We developed a landmark-based approach to perform a minimally invasive full controlled US-guided biopsy of the CET enthesis that showed to be feasible and reproducible. We believe that this standardised, minimally invasive technique will widespread a reliable collection of entheseal tissue for future clinical and translational studies.

Musculoskeletal Symptoms and Clinical Findings in Bio-naïve Patients with Inflammatory Bowel Disease Prior to Biological Treatment Initiation: A Prospective Cohort Study

BACKGROUND

Musculoskeletal involvement in inflammatory bowel disease (IBD) patients contributes to poorer outcomes and reduced quality of life (QoL). We aimed to describe the prevalence and distribution of peripheral and axial musculoskeletal symptoms and clinical findings in patients with IBD prior to biological treatment.

METHODS

Bio-naïve patients with IBD were consecutively recruited. Musculoskeletal symptoms were assessed using questionnaires and a structured interview. A rheumatologist conducted a clinical evaluation of peripheral joints and entheses, spine mobility, and considered various differential diagnoses.

RESULTS

Of 82 patients (ulcerative colitis (UC): 33, Crohn's disease (CD): 49, mean age 46 years, 55% male), 51 (62.2%) had musculoskeletal symptoms and 51 (62.2%) had clinical findings. Peripheral joint pain was reported by 39 (47.6%) patients, entheseal pain by 15 (18.3%), and back pain by 33 (40.2%) patients. Clinical evaluation revealed arthritis in 24 (29%) patients and enthesitis in 50 (61%); enthesitis was asymptomatic in 72% of the cases. The Assessment of Spondyloarthritis international Society (ASAS) classification criteria for peripheral spondyloarthritis were met in 36 (44%) patients, and for fibromyalgia in 7 (8.5%) patients. Being female was associated with more frequent musculoskeletal symptoms and clinical findings. Significantly more patients with CD reported joint pain, but no differences in clinical findings were observed between UC and CD, nor between those with active and inactive IBD.

CONCLUSION

Two-thirds of patients with IBD scheduled for their first biological treatment exhibited musculoskeletal involvement, sometimes asymptomatically. Axial and peripheral symptoms were equally common. A multidisciplinary approach is crucial for early detection and integrated treatment aiming for remission in all disease domains to improve patients' QoL.

Ex vivo cell-based assay for assessment of response to TNF inhibitors in patients with rheumatic diseases

OBJECTIVE

There are five TNF inhibitors (TNFis), whose structure and signalling differ. An individual patient with a rheumatic disease may respond to one TNFi but not to another. In addition, 30-40% of patients with rheumatic diseases may respond inadequately to TNFis. The downstream signalling of the various TNFis may determine their clinical efficacy. Several reports have shown that the different TNFis exhibited differential effects on Th17 cells. We analysed the effects of the various TNFis on IL-17A expression in peripheral blood mononuclear cells (PBMCs) of patients with rheumatic diseases, in order to evaluate the possibility of predicting responses in an ex vivo setting.

METHODS

PBMCs were co-cultured with the various TNFis or medium (control), and IL-17A mRNA levels were analysed by quantitative PCR. IL-17A expression levels in response to four TNFis (not including certolizumab pegol) were compared with that of the control. The IL-17A expression level as determined by the assay was correlated with the clinical response. The assay sensitivity and specificity for distinguishing responders from non-responders was calculated by receiver-operating characteristic (ROC) analysis.

RESULTS

The results of the assay for a retrospective cohort of patients with rheumatic diseases (n = 82) correlated with their therapeutic responses to the various TNFis with 89.5% accuracy. Our results indicated that the assay predicted the responses of a prospective cohort (n = 54) to specific TNFis with 79% accuracy.

CONCLUSION

This functional assay could assist in predicting the odds for response to TNFi therapy, indicating whether a given patient is likely to respond to a specific TNFi.

Neural networks for predicting etiological diagnosis of uveitis

BACKGROUND/OBJECTIVES

The large number and heterogeneity of causes of uveitis make the etiological diagnosis a complex task. The clinician must consider all the information concerning the ophthalmological and extra-ophthalmological features of the patient. Diagnostic machine learning algorithms have been developed and provide a correct diagnosis in one-half to three-quarters of cases. However, they are not integrated into daily clinical practice. The aim is to determine whether machine learning models can predict the etiological diagnosis of uveitis from clinical information.

METHODS

This cohort study was performed on uveitis patients with unknown etiology at first consultation. One hundred nine variables, including demographic, ophthalmic, and clinical information, associated with complementary exams were analyzed. Twenty-five causes of uveitis were included. A neural network was developed to predict the etiological diagnosis of uveitis. The performance of the model was evaluated and compared to a gold standard: etiological diagnosis established by a consensus of two uveitis experts.

RESULTS

A total of 375 patients were included in this analysis. Findings showed that the neural network type (Multilayer perceptron) (NN-MLP) presented the best prediction of the etiological diagnosis of uveitis. The NN-MLP's most probable diagnosis matched the senior clinician diagnosis in 292 of 375 patients (77.8%, 95% CI: 77.4-78.0). It achieved 93% accuracy (95% CI: 92.8-93.1%) when considering the two most probable diagnoses. The NN-MLP performed well in diagnosing idiopathic uveitis (sensitivity of 81% and specificity of 82%). For more than three-quarters of etiologies, our NN-MLP demonstrated good diagnostic performance (sensitivity > 70% and specificity > 80%).

CONCLUSION

Study results suggest that developing models for accurately predicting the etiological diagnosis of uveitis with undetermined etiology based on clinical information is feasible. Such NN-MLP could be used for the etiological assessments of uveitis with unknown etiology.

Peripheral Spondyloarthritis: Conceptualization and Diagnosis as a Distinct Rheumatologic Subset of Disease

Peripheral spondyloarthritis (pSpA) encompasses multiple entities affecting the musculoskeletal system with classic findings of synovitis, enthesitis, and tenosynovitis. It remains poorly defined when compared with the axial spondyloarthritides due to nonspecific symptoms, ill-defined imaging findings, and lack of specific testable biomarkers. Previous research has tried to distinguish between the two disease entities using clinical presentations, scoring systems, and radiographic findings; however, overlap remains. We summarize the current classification of pSpA, imaging findings, and the distinction between these entities and axial spondyloarthritis.

HLA-B5 prevalence in patients with spondyloarthritis and impact on disease phenotype: a multicentric case-control study

OBJECTIVE

The study aimed to estimate the prevalence of HLA-B51 and HLA-B52 in Lebanese patients with spondyloarthritis (SpA) compared with healthy controls (HC). We further aimed to evaluate the impact of HLA-B51 on phenotype and identify the distribution of the alleles in the HLA-B locus.

METHODS

A case-control study enrolled consecutive SpA patients from three rheumatology clinics in Lebanon, including axial (axSpA), peripheral SpA (pSpA), and psoriatic arthritis (PsA) and HCs from blood donors. Demographic and disease data were collected through interviews and file reviews, with testing of the entire HLA-B locus using molecular techniques. The prevalence of HLA-B51 and B52 was estimated in SpA patients vs controls. Prevalence comparisons were made, and logistic regression identified factors associated with HLA-B51 in patients.

RESULTS

Data from 120 HCs and 86 SpA patients (65 axSpA, 15 pSpA, 6 PsA), mean age 25.6 and 46.4 years, respectively, showed a higher HLA-B51 prevalence in SpA (25.6%), especially axSpA (29.2%) vs HC (12.5%) (P = 0.016), and a numerically higher HLA-B52 prevalence (8.1% vs 4.2%, P = 0.230). HLA-B51 correlated with recurrent oral ulcerations (OR 7.99; 95% CI: 2.14, 29.84) and radiographic juxta-articular erosions (OR 7.65; 95% CI: 1.14, 38.03). HLA-B35 was the most dominant allele in both groups (18.7%), followed by HLA-B27 (15.7%) and HLA-B51 (13.4%) in SpA.

CONCLUSION

HLA-B51 was identified more frequently in patients with SpA compared with HC and was associated with recurrent oral ulcerations and juxta-articular radiographic erosions. Longitudinal studies are needed to determine whether this association indicates a disease overlap or might correlate with a specific SpA phenotype.

The history of ankylosing spondylitis/axial spondyloarthritis - what is the driving force of new knowledge?

The history of (axial) spondyloarthritis has started several centuries ago. Since the end of the 19th century major achievements have been made. This historical review tries to show how closely the advances in clinical medicine in rheumatology have been related to advances made in basic sciences.

Prevalence, Clinical Features, and Extraintestinal Manifestations in Patients with Familial Inflammatory Bowel Diseases

BACKGROUND

A positive family history is considered the strongest recognizable risk factor for developing inflammatory bowel diseases (IBD) and is present in 8-12% of cases.

AIMS

To determine the prevalence of familial IBD and also to compare the clinical characteristics and extraintestinal manifestations between familial and sporadic cases.

METHODS

We conducted a cross-sectional study based on retrospectively-prospectively collected data from a cohort of IBD patients followed in daily clinical practice. Patients with biopsy-confirmed familial and sporadic IBD aged 16-90 years old were included in the study. A comprehensive questionnaire was used to collect data on each site visit. Logistic regression analysis and chi-squared test were used.

RESULTS

In total, 265 patients with IBD were included. 12.1% had a first-degree relative with IBD present (16.4% in Crohn's disease and 5.7% in the ulcerative colitis group, P < 0.05). Familial IBD patients were mainly females, were more frequently diagnosed with Crohn's disease and had a higher risk for hospitalization due to an IBD flare (P < 0.05), to undergo a surgical procedure (P < 0.001), to require treatment with biologic agents (P < 0.05), to develop perianal disease (P < 0.05), and extraintestinal manifestations (P < 0.05), mainly spine joint complications, erythema nodosum, and anterior uveitis.

CONCLUSION

In this study, a positive family history of IBD was present in 16.4% of Crohn's disease and 5.7% of ulcerative colitis patients and was associated with a greater risk for hospitalization, surgical procedures, occurrence of perianal disease, need for treatment with biologic agents, and development of extraintestinal manifestations.

Axial Spondyloarthritis: Updates in Concepts and Reporting in Radiology

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease primarily affecting the axial skeleton, historically termed "human leukocyte antigen B27 positive spondyloarthropathy" or ankylosing spondylitis. Improved understanding of the underlying pathologic mechanisms has led to an ongoing redefinition of this disease state, a recognition of the substantial phenotypic and biological variation, and an emphasis on earlier detection. Magnetic resonance imaging has become central to identifying and confirming early axSpA, critical to fulfilling the promise of slowing disease progression and preventing irreversible structural abnormalities. We review the clinical background and current role of medical imaging in axSpA, with a focus on Assessment of SpondyloArthritis International Society consensus definitions, to improve radiology reporting and facilitate discussion between radiologists and other clinical experts in spondyloarthritis.

[Russian Cross-disciplinary Consensus on the diagnosis and treatment of spondyloarthritis associated with inflammatory bowel diseases]

The Russian Cross-disciplinary Consensus on the diagnositic and treatment of spondyloarthritis (SpA) in inflammatory bowel diseases (IBD) was prepared on the initiative of the Loginov Moscow Clinical Scientific Center, using the Delphic system. Its purpose was to consolidate the opinions of experts on the most actual issues of diagnosis and treatment of concomitant immuno-inflammatory diseases (SpA and IBD). An interdisciplinary approach is provided by the participation of leading gastroenterologists and rheumatologists. The working group analyzed domestic and foreign publications on the problem of curation of patients with SpA and IBD. There have been 17 statements and 2 treatment algorithms formulated. Statements 1-3 reflect the fundamental principles of management of patients with SpA and IBD. The principles of early diagnosis of SpA and IBD, including the diagnosis of complications of therapy, are described below. Eleven statements are devoted to current methods of treatment, on the basis of which 2 treatment algorithms have been developed. The statements of the Consensus were submitted to the Expert Council for consideration, edits were made, after which an online vote took place. This paper presents current recommendations for the management, diagnosis and treatment of patients with SpA and IBD.

Evaluation of instruments assessing peripheral arthritis in spondyloarthritis: an analysis of the ASAS-PerSpA study

OBJECTIVES

To assess construct validity, including known-group discrimination, of the currently available disease activity instruments assessing peripheral arthritis in spondyloarthritis (SpA).

METHODS

In this analysis from the Assessment of SpondyloArthritis International Society (ASAS)-PerSpA study, patients with a diagnosis of axial SpA, peripheral SpA, or psoriatic arthritis (PsA) were included. The disease activity instruments evaluated were the Patient Global Assessment (PGA), Bath Ankylosing Spondylitis Disease Activity Index, Axial Spondyloarthritis Disease Activity Score, Disease Activity Index for PsA (DAPSA), Swollen Joint Count (SJC), Tender Joint Count, Disease Activity Score (DAS) 28, DAS44, and C-reactive protein (CRP). Construct validity was assessed through correlations with external constructs (Bath Ankylosing Spondylitis Functional Index, ASAS Health Index, and Euro Quality of Life 5 Dimensions) and known-group discrimination (active/inactive disease based on a combination of PGA [≥5/<5]), and SJC (≥1/0 and ≥2/<2) was analysed using standardised mean differences (SMDs).

RESULTS

In total, 4121 patients were included (mean age 45 [SD, 14] years, 61% males). When assessing the construct validity through correlations with external constructs, all instruments performed excellently (100% hypotheses confirmed). When assessing known-group discrimination, all disease activity measures, except CRP, presented SMDs ≥ 0.8 (good discrimination), with higher SMDs observed for DAS28 followed by DAPSA. Results were similar across disease phenotypes. Considering all combinations of PGA and SJC to discriminate between active/inactive disease, a better performance was observed for the composite scores, including joint counts.

CONCLUSIONS

In our construct validity analysis, all disease activity instruments assessing peripheral arthritis had a good performance as reflected in the correlations with external constructs and the known-group discrimination. The highest discriminatory capacity to distinguish between 'active/inactive disease' was observed for composite scores, including joint counts, like DAS28 and DAPSA.

Assessment of sarcopenia in young patients with inflammatory arthritis: a cross-sectional study

Sarcopenia is a disease characterized by decreasing muscle mass and strength or performance. The prevalence of sarcopenia in rheumatic diseases has been evaluated in single diseases using various diagnostic approaches, generating conflicting data. The study aims to investigate sarcopenia prevalence in young adults with inflammatory arthritis (IA) and to detect factors associated with low muscle mass and strength. The single-center, cross-sectional study included 138 young adults with IA. Dynamometry with a Jamar hand dynamometer was used to determine handgrip strength. Thresholds for reduced muscle strength were < 27 kg for males and < 16 kg for females. To determine skeletal mass index (SMI), dual photon X-ray absorptiometry (DXA) was done with such cut-off points < 5.67 kg/m2 in females and < 7.0 kg/m2 in males. Patients with both reduced muscle mass and strength were considered as sarcopenic. Logistic regression analyses estimated between sarcopenia and associated factors. Statistical significance was defined as a p-value < 0.05. The prevalence of sarcopenia was about 47% in all IA and was significantly different between juvenile idiopathic arthritis (JIA), spondyloarthritis (SpA), and rheumatoid arthritis (RA) groups (p = 0.006). At multivariable analysis, body mass index (BMI) (OR 0.84; CI 95% 0.72-0.86, p = 0.02), bone mineral density (BMD) at femur neck (OR 0.01; CI 95% 0.001-0.268, p = 0.01), 25-hydroxyvitamin D (25(OH)D) (OR 0.96; CI 95% 0.93-0.98, p = 0.001), and disability by Health Assessment Questionnaire (HAQ) (OR 14.54; CI 95% 4.92-51.77, p < 0.001) were associated with a significantly increased risk of sarcopenia. The results of our study demonstrate a high prevalence of sarcopenia among young patients with IA. In these participants, lower BMI, lower BMD, 25(OH)D concentration, and higher HAQ were linked to sarcopenia.

Clinical characterization of aortitis and periaortitis: study of 134 patients from a single university hospital

Aortitis and periaortitis refer to the inflammation of the aortic wall and the surrounding tissues. Both conditions are associated with various diseases and express nonspecific manifestations. Early diagnosis and treatment are crucial to improve the prognosis of the disease. This study aimed to assess the causes and main clinical features of aortitis and periaortitis in patients from a single centre in Spain. Observational, retrospective study of patients diagnosed with aortitis or periaortitis at a Spanish referral center over the last decade. 134 patients (87 female; mean age of 55.1 ± 9.1 years) were recruited, 132 of which had aortitis and two periaortitis. Aortitis was associated with giant cell arteritis (n = 102), Takayasu's arteritis (n = 6), IgG4-related disease (n = 6), infectious diseases (n = 3), malignancy (n = 1), drugs (n = 1), isolated aortitis (n = 1), and other immune-mediated inflammatory diseases (IMIDs) (n = 12). IMIDs included were Sjögren's syndrome (n = 2), sarcoidosis (n = 2), rheumatoid arthritis (n = 2), axial spondyloarthritis (n = 2), inflammatory bowel disease (n = 1), primary biliary cirrhosis (n = 1), idiopathic pulmonary fibrosis (n = 1), and polyarteritis nodosa (n = 1). Periaortitis was due to idiopathic retroperitoneal fibrosis in both cases. Imaging techniques used for diagnosis included 18F-FDG PET/CT scan (n = 133), CT-angiography (n = 44), and/or MRI-angiography (n = 33). Polymyalgia rheumatica (52.2%) and asthenia (53.7%) were the most common manifestations, followed by limb claudication (23.9%) and inflammatory back pain (26.9%). Acute-phase reactants were typically increased. Aortitis is a common condition and may be associated with multiple non-infectious diseases. Its clinical presentation is often unspecific, requiring a high level of suspicion to get an early diagnosis and treatment.

Diagnosis of Inflammatory Bowel Disease-Associated Peripheral Arthritis: A Systematic Review

BACKGROUND

Inflammatory bowel disease (IBD)-associated peripheral spondyloarthritis (pSpA) decreases quality of life and remains poorly understood. Given the prevalence of this condition and its negative impact, it is surprising that evidence-based disease definitions and diagnostic strategies are lacking. This systematic review summarizes available data to facilitate development and validation of diagnostics, patient-reported outcomes, and imaging indices specific to this condition.

METHODS

A literature search was conducted. Consensus or classification criteria, case series, cross-sectional studies, cohort studies, and randomized controlled trials related to diagnosis were included.

RESULTS

A total of 44 studies reporting data on approximately 1500 patients with pSpA were eligible for analysis. Data quality across studies was only graded as fair to good. Due to large heterogeneity, meta-analysis was not possible. The majority of studies incorporated patient-reported outcomes and a physical examination. A total of 13 studies proposed or validated screening tools, consensus, classification, or consensus criteria. A total of 28 studies assessed the role of laboratory tests, none of which were considered sufficiently accurate for use in diagnosis. A total of 17 studies assessed the role of imaging, with the available literature insufficient to fully endorse any imaging modality as a robust diagnostic tool.

CONCLUSIONS

This review highlights existing inconsistency and lack of a clear diagnostic approach for IBD-associated pSpA. Given the absence of an evidence-based approach, a combination of existing criteria and physician assessment should be utilized. To address this issue comprehensively, our future efforts will be directed toward pursuit of a multidisciplinary approach aimed at standardizing evaluation and diagnosis of IBD-associated pSpA.

Reducing diagnostic delays of extraintestinal manifestations in inflammatory bowel disease: a comparative study of a multidisciplinary outpatient clinic versus conventional referral specialists

Background

Managing extraintestinal manifestations (EIMs) in inflammatory bowel disease (IBD) patients remains challenging due to considerable heterogeneity in diagnostic criteria and the lack of a standardised definition and validated diagnostic pathways. Delays in recognising and treating EIMs can lead to significant disease progression. Therefore, early detection and treatment are crucial.

Objectives

We aimed to assess the effectiveness of a dedicated immune-mediated inflammatory diseases (IMIDs) clinic in reducing EIM diagnostic delays and improving patients' outcomes.

Design

A single-centre observational study was conducted, including IBD patients presenting with EIMs red flags.

Methods

We compared the EIMs diagnostic delay between patients who attended a multidisciplinary IMID outpatient clinic (IMID-G) and those who attended individual referral specialists representing the standard outpatient clinic group (SOC-G). We further evaluated the impact of diagnostic timing on 18-month clinical outcomes, including therapeutic changes, steroid and immunosuppressant use and biological therapy switch/swap.

Results

We enrolled 238 IBD patients, 127 in the IMID-G and 111 in the SOC-G. The average time to EIM diagnosis was 2.48 ± 1.8 and 5.36 ± 2.3 months for the IMID and SOC-Gs (Δ = 2.88 months, p = 0.005). The majority of patients received a diagnosis of peripheral arthritis (IMID-G = 37.5%; SOC-G = 33.7%) and spondyloarthropathy (IMID-G = 32.1%; SOC-G = 33.7%). No significant difference was observed in the rates of EIMs between the two groups (88.2% in IMID-G vs 92.8% in SOC-G, p = 0.27). Regarding therapeutic changes, the IMID-G reported a mean time to the first therapeutic change driven by the specialist referral of 2.96 ± 1.8 months, compared to 6.09 ± 2.5 months in the SOC-G, showing a significant difference (p = 0.007). The IMID-G had a higher frequency of biological therapy switching/swapping and adding immunosuppressive treatment than the SOC-G (p = 0.008 and p = 0.04, respectively). Survival curves revealed a significant reduction in diagnostic delay and time to treatment in the IMID-G compared to the SOC-G (log-rank test, p < 0.001).

Conclusion

Attending a dedicated IMID clinic can enhance the diagnostic process for EIMs in IBD patients, thereby reducing diagnostic delays and allowing early interventions to avoid disease progression.

1995-2025: thirty years of ASAS and its contribution to the understanding of spondyloarthritis

OBJECTIVE

To describe the role of the Assessment of SpondyloArthritis interntational Society (ASAS) over the past 30 years in the understanding of the field of spondyloarthritis.

METHODS

A narrative review of the achievements.

RESULTS

A summary of the role of ASAS in defining nomenclature, definition of and criteria for SpA, outcome assessments, recommendations, and education.

CONCLUSION

ASAS played an important role in shaping the field of SpA.

Metabolic musculoskeletal disorders in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD), which includes Crohn's disease and ulcerative colitis, is a chronic inflammatory disorder that affects not only the gastrointestinal tract but also extraintestinal organs, leading to various extraintestinal manifestations and complications. Among these, musculoskeletal disorders such as osteoporosis, sarcopenia, and axial and peripheral spondyloarthritis are the most commonly observed. These conditions arise from complex mechanisms, including chronic inflammation, malnutrition, gut dysbiosis, and glucocorticoid use, all of which contribute to reduced bone density, muscle loss, and joint inflammation. Osteoporosis and sarcopenia may co-occur as osteosarcopenia, a condition that heightens the risk of fractures, impairs physical performance, and diminishes quality of life, particularly in elderly patients with IBD. Holistic management strategies, including lifestyle modifications, calcium, and vitamin D supplementation, resistance training, and pharmacological interventions, are essential for mitigating the impact of these conditions. Spondyloarthritis, which affects both axial and peripheral joints, further complicates disease management and significantly compromises joint health. Timely diagnosis and appropriate medical interventions, such as administration of nonsteroidal anti-inflammatory drugs and biologics, are critical for preventing chronic joint damage and disability. Moreover, a multidisciplinary approach that addresses both metabolic and inflammatory aspects is essential for optimizing physical function and improving treatment outcomes in patients who have IBD with musculoskeletal involvement.

Modulation of IL-6 receptor/STAT3 downstream signaling in rheumatoid arthritis patients

Interleukin-6 (IL-6) is a relevant cytokine in rheumatoid arthritis (RA) pathogenesis, potentially activating Janus kinases (JAK)-1, -2, and tyrosine kinase 2 (TYK2), and thus, three signal transducer and activator of transcription (STAT)-1, -3 or - 5 pathways. This pilot study aims to explore differences in phosphorylated (p)STAT3 levels among patients with RA, those not classified as RA (nRA), and healthy donors (HD), providing some clues on the relative contribution of each JAK protein to the downstream of the IL-6-induced STAT3 pathway. Clinical data and blood samples from 80 subjects (41 RA, 14 nRA, and 25 HD) were collected. The activity of the JAK-STAT3 pathway was assessed by Western Blot and Real Time-PCR analysis for the quantification of STAT3 in peripheral blood mononuclear cells (PBMC). Furthermore, the impact of JAK-1, -2, and TYK2 inhibitors on pSTAT3 was assessed in vitro by FACS, with and without IL-6 stimulation in RA patients naïve to treatment with DMARD and steroids. The pSTAT3 (%) was significantly higher in PBMC from RA compared to nRA patients and HD. Furthermore, pSTAT3 (%) was significantly associated with inflammation and disease activity (ESR, CRP, and DAS28). The JAK-1 inhibitor was more effective in reducing pSTAT3 expression in CD14pos cells of RA patients, while the JAK-2 selective compound was more effective in CD4pos cells of RA patients. On the contrary, the TYK2 selective agent showed no significant effects. This study highlights the importance of the JAK/STAT3 pathway in RA. Some differences among various JAK proteins have been pointed out, with JAK1 and JAK2 standing as the most relevant mediators of the STAT3 pathway in this in-vitro model after IL-6R activation.

Inflammatory back pain as an unusual manifestation of Takayasu arteritis: a case report

Takayasu arteritis and spondyloarthritis are two rheumatological diseases whose co-existence is well-documented in the literature. Data on the presence of inflammatory back pain in Takayasu arteritis without a diagnosis of spondyloarthritis, however, is scarce. Here, we present a 33-year-old man who was admitted to the emergency department with acute-onset chest pain associated with left carotidynia, carotid bruit, and left arm claudication, normal electrocardiogram and computed tomography angiographic features suggesting Takayasu arteritis, including stenosis and occlusion of the aorta and its branches. Two years prior, he had undergone a clinical work-up for inflammatory back pain accompanied by alternating buttocks pain, morning stiffness lasting more than half an hour, and heel pain. HLA-B27 status and magnetic resonance imaging of the sacroiliac joints were both negative. He was prescribed non-steroidal anti-inflammatory drugs and was placed on adalimumab 40 mg subcutaneously every 2 weeks but had to switch to etanercept 2 months before his emergency admission due to supply issues. Oral prednisolone was initiated at a dose of 60 mg/day with symptomatic improvement in both his inflammatory back pain and his chest pain, but he had to be switched to methotrexate and infliximab due to steroid side effects. Inflammatory aortitis should be considered as a possibility during the assessment of inflammatory back pain to mitigate the risks of delayed diagnosis.

Cytotoxic Response of CD4+ T Cells Orchestrated by SLAMF4 in Rheumatoid Arthritis

OBJECTIVE

This study aimed to assess whether signaling lymphocytic activation molecule family receptors (SLAMFs) are involved in the shaping of the pathologic response of CD4+ T cells in rheumatoid arthritis (RA).

METHODS

Peripheral blood (PB) and synovial fluid (SF) mononuclear cells from patients with RA were freshly isolated. In RA, we used a multimodal approach to determine the involvement of numerous subpopulations of CD4+ T cells expressing SLAMFs. Experimentally, multiple flow cytometry panels, RNA sequencing, and stimulations were used. Analyses involved high-dimensional unsupervised clustering of flow cytometry data and pathway enrichment analyses of transcriptomic data.

RESULTS

In PB of patients with RA with active disease, SLAMF4+ effector memory CD4+ T cells (Tem) represented the only overrepresented subpopulation of CD4+ T cells expressing SLAMFs. This positive correlation between RA activity and SLAMF4+ Tem was restricted to those coexpressing the intracellular molecule SLAM-associated protein (SAP) and the tissue-homing receptor CCR5. Gene Set Enrichment Analysis of RNA sequencing data reveals that SLAMF4+ CCR5+ Tem display a cytotoxicity-related gene signature. Moreover, based on the differential expression of cytotoxicity markers (GPR56, CX3CR1, granzyme-B, perforin, and granulysin), unsupervised clustering of flow cytometry data identified distinct subpopulations of PB cytotoxic Tem. Among them, only SLAMF4high SAP+ CCR5+ Tem (Cytotox-F4high Tem) were correlated with RA activity. Remarkably, Cytotox-F4high Tem emerged as the only cytotoxic population of CD4+ T cells (CD4+ CTLs) present in SF of patients with active disease.

CONCLUSION

This study emphasizes that Cytotox-F4high Tem represent a significant CD4+ CTL subpopulation involved in RA, suggesting that their inhibition represent a promising therapeutic interest.

Psoriatic arthritis phenotype clusters and their association with treatment response: a real-world longitudinal cohort study from the psoriatic arthritis research consortium

OBJECTIVES

To identify phenotype clusters and their trajectories in psoriatic arthritis (PsA) and examine the association of the clusters with treatment response in a real-world setting.

METHODS

In the multicentre PsA Research Consortium (PARC) study, we applied factor analysis of mixed data to reduce dimensionality and collinearity, followed by hierarchical clustering on principal components. We then evaluated the transition of PsA clusters and their response to new immunomodulatory therapy and tumour necrosis factor inhibitor (TNFi).

RESULTS

Among 627 patients with PsA, three clusters were identified: mild PsA and psoriasis only (PsO) (Cluster 1, 47.4%), severe PsA and mild PsO (Cluster 2, 34.3%) and severe PsA and severe PsO (Cluster 3, 18.3%). Among 339 patients starting or changing, significant differences in response were observed (mean follow-up of 0.7 years, SD 0.8), with Cluster 3 showing the largest improvements in cDAPSA and PsAID. No differences were found among those starting TNFi (n=218). cDAPSA remission and PsAID patient acceptable symptom state were achieved in 10% and 54%, respectively. Clusters remained stable over time despite treatment changes, though some transitions occurred, notably from Cluster 3 to milder clusters.

CONCLUSION

Data-driven clusters with distinct therapy responses identified in this real-world study highlight the extensive heterogeneity in PsA and the central role of psoriasis and musculoskeletal severity in treatment outcomes. Concurrently, these findings underscore the need for better outcome measures, particularly for individuals with lower disease activity.

16s RNA-based metagenomics reveal previously unreported gut microbiota associated with reactive arthritis and undifferentiated peripheral spondyloarthritis

OBJECTIVES

Reactive arthritis (ReA) provides a unique opportunity to comprehend how a mucosal infection leads to inflammatory arthritis at a distant site without the apparent invasion of the pathogen. Unfortunately, conventional stool cultures after ReA provide limited information, and there is a dearth of metagenomic studies in ReA. The objective of this study was to identify gut microbiota associated with the development of ReA.

METHODS

Patients with ReA or undifferentiated peripheral spondyloarthritis (UpSpA) were included if they presented within 4 weeks of the onset of the current episode of arthritis. Metagenomic DNA was extracted from the stools of these patients and of 36 age- and sex-similar controls. Sequencing and analysis were done using a standard 16S ribosomal pipeline.

RESULTS

Of 55 patients, there was no difference between the gut microbiota of postdiarrheal ReA (n = 20) and of upSpA (n = 35). Comparing the gut microbiota of patients vs healthy controls, the patients had significantly higher alpha and beta diversity measures. After stringency filters, Proteobacteria had high abundance while Firmicutes had lesser as compared with the controls. Six families were overexpressed in patients, while another five were overexpressed in controls. Sixteen genera and 18 species were significantly different between patients and controls. At the species level there was strong association of Staphylococcus aureus, Clostridium septicum Klebsiella pneumoniae, Escherichia coli, Empedobacter brevis, Roseburia hominis, Bacillus velezensis and Crassaminicella with ReA.

CONCLUSION

The microbiota of classical gut-associated ReA and upSpA is similar. Patients have higher diversities in their gut microbiota compared with healthy controls. Both known and previously unreported species associated with ReA/upSpA were identified.

Arthralgia and Extraintestinal Manifestations in Crohn's Disease Elevate the Risk of IBD-Related Arthritis over Sacroiliitis

INTRODUCTION

Inflammatory bowel disease (IBD) related arthritis is the most prevalent extraintestinal manifestation (EIM) of IBD, ranging between 10 and 39%. Magnetic resonance enterography (MRE) is used to assess small bowel disease involvement in Crohn's disease (CD) and can detect signs of sacroiliitis in up to 23.5% of patients. The predicting role of sacroiliitis detected on MRE is still unknown. The aim of this study is to evaluate the predictive role of sacroiliitis at MRE and other clinical features for IBD-related arthritis development in a cohort of adult patients with CD.

METHODS

Between December 2012 and May 2020, consecutive patients with CD who performed MRE were enrolled in the study. Patients with a previous diagnosis of IBD-related arthritis were excluded. A baseline demographics and clinical characteristics of the patients were retrospectively collected. The identification of new-onset IBD-related arthritis events during the follow-up was based on rheumatological clinical diagnosis and fulfillment of the ASAS classification criteria.

RESULTS

Ninety-five patients, mean age 43.9 years (standard deviation [SD] ± 16.6), 52.6% female were enrolled in the study with a median follow-up of 83 months (Q25:75 25:143). Six out 95 (6.3%) developed IBD-related arthritis with a mean time of 11 months (SD ± 16.8). Sacroiliitis detected on MRE was not associated with an increased risk of IBD-related arthritis (odds ratio [OR] = 2.12 [95% confidence interval (CI) 0.36, 12.53, p = 0.408]). In contrast, the presence of arthralgia and EIMs were found to be a predictor for IBD-related arthritis development (OR = 84.0 [95% CI 8.18, 862.39, p < 0.0001] and OR = 7.37 [95% CI 1.25, 43.32, p = 0.027], respectively).

CONCLUSIONS

This study highlights that sacroiliitis, as assessed by MRE, was not associated with the development of IBD-related arthritis, whereas extraintestinal manifestations and arthralgia were significantly associated with later IBD-related arthritis development in patients with CD.

Dysregulation of amino acid and lipid metabolism in patients with spondyloarthritis

OBJECTIVE

To conduct a metabolomics analysis in patients with spondyloarthritis (SpA) and compare results with those from healthy controls. The overall goal was to identify small-molecule substances that may have potential pathogenic and diagnostic significance in SpA.

METHODS

This was an observational, cross-sectional, single-centre study that included patients with axial (ankylosing spondylitis [AS]), peripheral (psoriatic arthritis [PsA]) and healthy controls.

RESULTS

The study included 50 patients with AS, 50 patients with PsA, and 164 controls. When compared with healthy controls, patients with SpA showed significant differences in 35 metabolites, primarily associated with amino acid and lipid metabolism. However, only two differences were found between the AS and PsA cohorts (glucose and glycerol).

CONCLUSIONS

Our data suggest that patients with SpA exhibit significant disruptions in amino acid and lipid metabolism. The large number of identified metabolites offers promising opportunities, both for discovering new SpA biomarkers and for gaining a deeper understanding of the pathophysiology of these chronic inflammatory diseases.

Fast, Present and Future of the Concept of Spondyloarthritis

PURPOSE OF REVIEW

Axial spondyloarthritis (axSpA) is a rather prevalent chronic inflammatory rheumatic disease that affects already relatively young patients. It has been known better since the end of the nineteenth century but quite a lot has been learned since the early 60ies when the first classification (diagnostic) criteria for ankylosing spondylitis (AS) were agreed on. I have been part of many developments in the last 30 years, and I'm happy to have been able to contribute to the scientific progress in terms of diagnosis, imaging, pathophysiology and therapy. When I was asked to write a manuscript about the SpA concept I felt honored. Thus, the purpose of this extensive review was, on the one hand, to describe the history of AS and axSpA, and on the other hand, to reason about the concept and the gestalt of axSpA, and finally to deliver some ideas what future researchers could possibly do to further study the disease.

RECENT FINDINGS

The last 3 decades were full of innovations for both, classification and treatment of axSpA which also helped us to learn about the pathophysiology. Thus, TNFa, IL-17, IL-23 and Janus kinase are established targets to reduce inflammation. IL-17 and IL-23 are very special in that regard because they both work for psoriasis but only anti-IL-17 agents which don't work in IBD are approved for axSpA, while IL 23 inhibitors are approved for both, psoriasis and IBD, but they don't work in axSpA. New imaging techniques such as low dose CT and synthetic MRI are likely to improve the detection of both active and structural lesions of axSpA. This manuscript tries to describe the most important findings about axSpA. The main aim of research remains to discover the pathophysiology and to further improve treatment options in order to reduce and abolish inflammation and prevent new bone formation to increase the quality of life of our patients. The differences between male and female disease and the role of the immune system in axSpA are now the main challenges, and the role of special T-cell receptors seem to deserve special interest.

Analysis of ASAS health index and its influencing factors in ankylosing spondylitis: a prospective study based on the population of Chaoshan region

Objective

This study aimed to evaluate the health-related quality of life (HRQoL) in ankylosing spondylitis (AS) patients in the Chaoshan region and identify factors influencing the ASAS Health Index (ASAS-HI) to enhance comprehensive AS treatment strategies.

Methods

A survey of ASAS-HI was conducted on 82 AS patients from the rheumatology outpatient department of the First Affiliated Hospital of Shantou University Medical College. The Bath Ankylosing Spondylitis Global Score (BAS-G) assessed overall health status, the Ankylosing Spondylitis Quality of Life Questionnaire (AS-QOL) evaluated quality of life, the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) measured disease activity, and the Bath Ankylosing Spondylitis Functional Index (BASFI) assessed functional difficulties. Inflammatory markers and patient data were collected, and univariate/multivariate logistic regression analyses were used to explore influencing factors of ASAS-HI.

Results

The mean ASAS-HI score was 3.52 ± 3.12. ASAS-HI was positively correlated with BASDAI (r = 0.478, p < 0.001), ASDAS-CRP (r = 0.406, p < 0.001), BASFI (r = 0.338, p < 0.002), and BAS-G (r = 0.335, p < 0.002). Patients with ASDAS-ESR ≥ 2.1, ASDAS-CRP ≥ 2.1, and spinal tenderness had significantly higher ASAS-HI scores than others (p < 0.001). Spinal tenderness and radiographic grading were identified as key influencing factors.

Conclusion

ASAS-HI is significantly impacted by disease activity and functional limitations. Early assessment of ASAS-HI is crucial for optimizing disease management in AS patients.

A review on anterior uveitis and spondyloarthritis with a focus on the interdisciplinary approach between ophthalmologists and rheumatologists

Anterior uveitis (AU) is characterized by the inflammation of the iris and ciliary body and is the most frequent extra-articular manifestation of spondyloarthritis (SpA). In SpA patients, AU is typically described as unilateral alternating acute AU (AAU). Moreover, as AAU can be the initial clinical manifestation of SpA, ophthalmologists could play a key role in the early diagnosis of SpA. The diagnostic delay in SpA is associated with poorer outcomes, including functional impairment, reduced response to treatment, and lower quality of life. A well-structured screening of patients with AAU could facilitate the early diagnosis. Consequently, the interdisciplinary collaboration between ophthalmologists and rheumatologists is fundamental to reduce the diagnostic delays. A correct and early diagnosis of SpA, together with early treatment initiation is important prognostic factors. These measures are associated with better treatment responses and may help retard the development of structural damage, particularly in the era of biological therapies, which have significantly improved the care of patients with SpA. Although various algorithms have been proposed to guide the selection of appropriate candidates for rheumatology referral, to date, there are no formal guidelines or universally recognized criteria for referral. This review aimed to summarize the epidemiological, pathogenetic, clinical, and therapeutic aspects of AU associated with SpA as well as the ophthalmology-rheumatology interdisciplinary approach.

Factors associated with dietary practices and beliefs on food of patients with rheumatic and musculoskeletal diseases: A multicentre cross-sectional study

OBJECTIVES

To investigate dietary practices and beliefs of patients with rheumatic and musculoskeletal diseases (RMDs) and associated factors.

METHODS

In 2019-2020, a cross-sectional multicentre study enrolled patients with inflammatory arthritis (IA) (rheumatoid arthritis [RA], axial spondyloarthritis [axSpA]) or hand osteoarthritis (HOA) from secondary- and tertiary-care centres. A self-administered questionnaire explored dietary practices and patients' perceived effects of diet, foods and beverages on symptoms. Univariable and multivariable analyses investigated factors associated with diets and patients' views.

RESULTS

Of 448 included patients, data for 392 were analysed (123 with RA, 161 with axSpA, 108 with HOA), 26% were on or had been on at least one exclusion diet (mostly cow's milk- and gluten-free diets in IA, mostly cow's milk-free diet and detox/fasting in HOA). Only 5% of patients followed the Mediterranean diet. Among patients who had tried a diet, 51% reported a decrease in pain. Overall, 42% of patients identified at least one food or beverage that increased or decreased pain. On multivariable analyses, dieting or the perceived effect of food on pain was associated with health beliefs (positive or negative), the use of complementary and alternative medicines, and lack of support or information from healthcare professionals. Patients had received little dietary information from their physicians.

CONCLUSIONS

This study provides insights into patients' dietary practices and factors associated with these practices, including patients' health beliefs and insufficient support by health professionals, in RMDs.

The 'Tree trunk and root' model: key imaging findings may anatomically differentiate axial psoriatic arthritis and DISH from axial spondyloarthropathy

Variable axial skeleton inflammation and axial skeleton tissue remodelling with aberrant ligamentous soft-tissue ossification occurs across the axial spondyloarthritis (ax-SpA) axial psoriatic arthritis (ax-PsA) and the diffuse idiopathic skeletal hyperostosis (DISH) spectrum. In this article, we show how imaging has resulted in an enthesis-centric model for different disease pathology compartmentalisation or a 'root and trunk' model for pathological process development. Whilst ankylosing spondylitis is predominantly characterised by early entheseal bony anchorage-related osteitis (root inflammation) and DISH is characterised by ligamentous soft-tissue ossification, ax-PsA is more heterogenous. Whilst ax-PsA may share an identical osteitis pattern to ax-SpA, a substantial proportion of ax-PsA cases have a soft tissue or tree trunk pathology that manifests as back pain with lack of osteitis but prominent ligamentous trunk ossification at later stages. We illustrate this using different imaging modalities to create a base for imaging research to elucidate this pattern of pathology.

Spine and Sacroiliac Joint Involvement in Newly Diagnosed Patients With Inflammatory Bowel Disease: Clinical and MRI Findings From a Population-Based Cohort

INTRODUCTION

In patients with inflammatory bowel disease (IBD), co-occurring spondyloarthritis (SpA) leads to poorer outcomes and impaired quality of life, highlighting the importance of early detection and effective treatment. This is the first study to assess the prevalence and distribution of axial symptoms and magnetic resonance imaging (MRI)-detected involvement of the spine and sacroiliac joints (SIJs) in early IBD.

METHODS

Newly diagnosed patients with IBD from a prospective, population-based cohort were consecutively recruited. Rheumatological interview, clinical, ultrasound, and MRI assessment for SIJ and spine inflammatory and structural lesions were made using validated scoring methods and consensus definitions of axial SpA (axSpA).

RESULTS

Of 110 patients (ulcerative colitis: 70, Crohn's disease: 40, mean age of 42 years, and 40% male), 48 (44.9%) reported back and/or buttock pain, and 10 (9.1%) had inflammatory back pain. Seventeen (16.7%) patients had MRI findings indicative of axSpA; only 10 of these patients had axial symptoms. Inflammatory MRI lesions were present in SIJs and the spine of 27 (26.5%) and 30 (30.3%) patients, respectively. The Assessment of SpondyloArthritis International Society classification criteria for axSpA were met in 11 (10%) cases. MRI findings typical of axSpA were associated with peripheral joint and entheseal inflammation detected by ultrasound ( P = 0.04). No differences in clinical or imaging findings were found between patients with ulcerative colitis and Crohn's disease.

DISCUSSION

One-in-6 newly diagnosed patients with IBD had MRI findings indicative of axSpA. As 40% of these patients were asymptomatic, this suggests that axSpA is underdiagnosed in early IBD. Multidisciplinary collaboration is essential to ensure early detection of axial inflammation and to enable optimal therapy preventing future structural damage and disability.

Diagnosis and Management of Inflammatory Bowel Disease-Associated Spondyloarthritis

Inflammatory bowel disease (IBD)-associated spondyloarthritis (SpA) is common but remains poorly understood. In this review article, we aimed to provide guidance regarding the diagnosis and management of this condition. For diagnosis of IBD-associated peripheral SpA (IBD-pSpA), we recommend collaboration with rheumatology for incorporation of clinical symptoms, physical examination findings, joint imaging if applicable, and available diagnostic criteria. For the management of IBD-pSpA, we first recommend assessment and treatment of underlying luminal IBD disease activity. We provide guidance regarding positioning of advanced therapies for IBD in patients with IBD-pSpA based on the limited available literature. For diagnosis of IBD-associated axial SpA, we recommend rheumatology referral to make the diagnosis based on incorporation of symptoms, laboratory data, imaging findings (sacroiliitis), and available diagnostic criteria. For the management of axial SpA, we recommend comanagement with rheumatology and use of either antitumor necrosis factor agents or Janus kinase inhibitors, when applicable.

Different disease activity trajectories in early axial spondyloarthritis lead to significantly different long-term outcomes: a trajectory-based analysis of the DESIR cohort over 10 years

INTRODUCTION

The study aimed to identify and describe disease activity trajectories over 10 years in patients with recent-onset axial spondyloarthritis (axSpA) and determine their impact on long-term outcomes.

METHODS

This prospective, multicentre study (Devenir des Spondylarthropathies Indifférenciées Récentes cohort, ClinicalTrials.gov NCT) followed patients with early axSpA for 10 years. Only patients with at least three Axial Spondylitis Disease Activity Score (ASDAS) values were included. Long-term outcomes assessed were TNF inhibitors (TNFi) exposure, structural progression, function (Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Metrology Index), quality of life (36-items Short Form Survey), sick leave days and cardiovascular (CV) events. ASDAS trajectories were identified using k-means clustering. Multinomial multivariable regression estimated associations between baseline characteristics and trajectories. Long-term outcomes for each trajectory were described.

RESULTS

Among 601 patients, five ASDAS trajectories were identified: persistent low disease activity/remission (tA), clinically important improvement (tD) and persistent moderate (tB), high (tC) or very high (tE) disease activity. Patients in tA were more likely to be male, have a university degree, have white-collar jobs, have positive HLA B27 status and have less fibromyalgia. Trajectory tE was linked to poorer function (BASFI 50/100 vs 7/100 for lower ASDAS trajectory), higher TNFi exposure (74% vs 29%) and more CV events (5.7% vs 0). Structural progression was low but comparable across trajectories, except for higher sacroiliac joint progression in tB.

CONCLUSION

The k-means method revealed distinct disease activity trajectories in axSpA. Higher disease activity trajectories were associated with a higher prevalence of fibromyalgia and poorer outcomes, except for structural progression, which was comparable across trajectories.

Treatment of Reactive Arthritis with Biological Agents

PURPOSE OF THE REVIEW

Reactive arthritis (ReA) is an inflammatory joint condition triggered by an infection elsewhere in the body, and this review aims to provide a comprehensive synthesis of recent studies including case reports and case series to determine whether biologics are a treatment option.

RECENT FINDINGS

Recent studies indicate that biological agents, including anti-TNF agents (infliximab, adalimumab, etanercept), anti-IL17 (secukinumab), and anti-IL6 (tocilizumab), are effective in treating refractory cases of ReA. Evidence suggests these agents are associated with significant clinical improvement. Notably, the data reveal that these biologics are generally well-tolerated, with a low incidence of major adverse events, which supports their safety profile for use in ReA. Biological agents, including anti-TNF, anti-IL17, and anti-IL6 therapies, can be safely and effectively used in the treatment of ReA when conventional therapies fail. It further emphasizes the need for a well-designed controlled trial to provide scientific basis for better informed clinical decisions in cases not responding to conventional treatment.

Current Concepts and Medical Management for Patients with Radiographic Axial Spondyloarthritis

Radiographic axial spondyloarthritis (r-axSpA), a chronic inflammatory disease, can cause significant radiographic damage to the axial skeleton. Regarding the pathogenic mechanism, association of r-axSpA with tumor necrosis factor (TNF) and the interleukin-23/17 (IL23/ IL17) pathway has been reported. Development of extraarticular manifestations, including uveitis, inflammatory bowel disease, and psoriasis, has been reported in some patients. The pivotal role of human leukocyte antigen-B27 in the pathogenesis of r-axSpA remains to be clarified. Symptoms usually start in late adolescence or early adulthood, and disease progression can vary in each patient, with clinical manifestations ranging from mild joint stiffness without radiographic changes to advanced manifestations including complete fusion of the spine, and severe arthritis of the hip, and could include peripheral arthritis and extraarticular manifestations. The modified New York criteria was used previously in diagnosis of r-axSpA. However, early diagnosis of the disease prior to development of bone deformity was required due to development of biological agents. As a result of Assessment of SpondyloArthritis international Society (ASAS), the classification was improved in part for diagnosis of spondyloarthritis prior to development of bone deformity. The diagnosis is based on comprehensive laboratory findings, physical examinations, and radiologic findings. Medical treatment for r-axSpA involves the use of a stepwise strategy, starting with administration of nonsteroidal anti-inflammatory drugs and physiotherapy, and progressing to sulfasalazine or methotrexate and biologics including TNF-α inhibitors or IL-17 inhibitors as needed. Use of Janus kinase inhibitors has been recently reported.