Identifying genes that cause disease: HLA-B27, the paradigm, the promise, the perplexity

Unilateral granulomatous post-streptococcal uveitis with elevated tension

PURPOSE

We document a presumptive case of unilateral post-streptococcal uveitis. The affected eye manifested a granulomatous anterior uveitis with elevated intra-ocular pressure (IOP) compared with the contra-lateral eye. This presentation was preceded by a recent streptococcal pharyngitis.

CASE REPORT

An asymptomatic, otherwise healthy 13-year-old black female presented with anterior chamber cells, mutton fat resembling keratic precipitates, and elevated IOP in the left eye relative to the right eye. The patient had been diagnosed with streptococcal pharyngitis approximately 1 week before her eye examination. A blood chemistry analysis, rheumatoid profile panel and antistreptolysin antibody titer were requested. The patient was prescribed predinisolone acetate 1% ophthalmic suspension in the left eye.

RESULTS

Anti-streptolysin antibody titers were significantly elevated (291 IU/ml). The patient responded favorably to topical ophthalmic steroid treatment with a reduction of IOP and inflammation.

CONCLUSIONS

Unilateral, granulomatous anterior uveitis may be a variant manifestation of post-streptococcal uveitis. The IOP elevation in these cases may result secondary to concurrent trabeculitis.

Prevalence and levels of serum antibodies to gram negative microorganisms in Turkish patients with HLA-B27 positive acute anterior uveitis and controls

PURPOSE

Acute anterior uveitis (AAU), seronegative spondyloarthropathies such as ankylosing spondylitis and reactive arthritis form the group of "HLA-B27-associated diseases." The aim of this study was to analyze the prevalence and levels of serum antibodies against gram negative bacteria in Turkish patients with AAU.

METHODS

Twenty-five patients each with previously diagnosed HLA-B27 positive and negative AAU and 25 age-and sex-matched healthy control subjects were included in the study. Serum IgM, IgG and IgA antibodies to Yersiniae enterocolitica, Campylobacter jejuni and Chlamydia trachomatis were measured using enzyme linked immunosorbent assay (ELISA). Categorical data were analyzed by chi-square test. Serum levels were analyzed using the Kruskal-Wallis test.

RESULTS

The prevalence of serum IgM, IgG and IgA antibodies did not differ significantly between the HLA-B27 positive AAU, HLA-B27 negative AAU and control groups with the exception of serum IgA antibodies against Yersiniae enterocolitica. IgA antibody against Yersiniae enterocolitica was found to be more frequently positive in the control group. Comparison of serum IgM, IgG and IgA antibody levels did not significantly differ between three groups.

CONCLUSIONS

Serum antibody positivity against Yersiniae enterocolitica, Campylobacter jejuni and Chlamydia trachomatis is not frequent in the HLA-B27 positive and negative AAU patients. Serum levels of IgM, IgG, and IgA antibodies also did not show significant difference between three groups. No association between these microorganisms and the etiology of AAU was evident.

Ocular involvement in connective tissue disorders

Connective tissue disorders have well-known ocular associations that may be presenting features of the disease or occur as complications during the course of the disorder. Keratoconjunctivitis sicca, keratitis, scleritis, uveitis, retinal vasculitis, choroidopathy, and their associations with rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, psoriatic arthritis, juvenile idiopathic arthritis, and polymyositis are reviewed.

Choroiditis, Pigment Epithelial Detachment, and Cystoid Macular Edema as Complications of Poststreptococcal Syndrome

PURPOSE

Two cases of poststreptococcal uveitis are presented. One patient developed nongranulomatous anterior uveitis (case 1). A second patient developed nongranulomatous anterior uveitis followed by granulomatous uveitis with concurrent choroiditis, retinal pigment epithelial detachment, and cystoid macular edema (case 2). Current concepts regarding the pathogenesis of poststreptococcal syndrome and its ocular sequelae are also discussed.

CASE REPORTS

Case 1: A 31-year-old female patient presented with bilateral nongranulomatous uveitis after a recent onset of sore throat. A past diagnosis of rheumatic fever was revealed during acquisition of the patient's history. Blood chemistry analysis indicated elevated anti-streptolysin O antibody titers as the only significant elevated result. Case 2: A 33-year-old female presented initially with bilateral nongranulomatous uveitis. A history of recurrent sore throat was reported. Blood chemistry analysis revealed elevated anti-streptolysin O antibody titers only. "Mutton fat" keratic precipitates eventually developed; however, the bilateral uveitis resolved after topical cycloplegic and corticosteroid treatment. An anterior granulomatous uveitis with concurrent choroiditis, retinal pigment epithelial detachment, and cystoid macular edema ensued during a recurrent episode. Blood chemistry analysis was unremarkable at that time.

CONCLUSIONS

: Anterior nongranulomatous/granulomatous and posterior uveitis should be considered clinical manifestations of poststreptococcal syndrome in patients with a clinical history and/or serological evidence indicating possible past streptococcal infection. A variation of host-genetic-predisposed immune response, the patient's human leukocyte antigen haplotype, pathogen virulence, and/or deposition location of immune circulating complexes may give rise to the diverse spectrum of clinical ocular sequelae in poststreptococcal syndrome. Poststreptococcal uveitis may comprise a similar immunologic pathogenesis to that of acute rheumatic fever, acute glomerulonephritis, and other autoimmune diseases.

HLA-B27-associated uveitis: overview and current perspectives

PURPOSE OF REVIEW

To review current knowledge about the pathogenesis, clinical presentation, and treatment of HLA-B27-associated uveitis, which is the most commonly identified cause of uveitis in community-based practice and an important cause of ocular morbidity.

RECENT FINDINGS

Significant advances have been made in understanding the pathogenesis of HLA-B27-associated ocular and systemic disease, especially with regard to the genetic underpinning of these diseases. Increasing attention has also been focused on the use of alternative therapies in the treatment of HLA-B27-associated uveitis, with special attention to sulfa class antibiotics, historically have been used to treat the articular manifestations of the spondyloarthritides, and newer drugs that inhibit tumor necrosis factor-alpha.

SUMMARY

The next several years promise to yield exciting new advances in understanding of the genetic epidemiology and treatment of HLA-B27-associated uveitis.

Anterior uveitis: current concepts of pathogenesis and interactions with the spondyloarthropathies

Anterior uveitis describes inflammation that involves the iris or ciliary body. Anterior uveitis may be part of a systemic illness such as a spondyloarthropathy. It may also arise from an infection such as herpes simplex; be part of an ocular syndrome, such as Fuchs' heterochromic iridocyclitis; be part of trauma, as in cataract surgery; or result from an idiopathic eye disease with a presumed immune pathogenesis. During 2001, progress has been made understanding uveitis in general, as well as specifically, in association with spondyloarthropathy. Here, we review recent insights into anterior uveitis with regard to clinical presentation, immune mechanisms, genetics, and anti-tumor necrosis factor therapy.