Inflammatory bowel disease in ankylosing spondylitis

Bones and Crohn's: problems and solutions

Inflammatory bowel disease may manifest in various extra intestinal manifestations. Osteopenia and various arthropathies may be debilitating. These may be related to the disease itself, patient genetics, lifestyle, or disease treatment. Calcium and vitamin D malabsorption, vitamin K deficiency, malnutrition, corticosteroid and other immunosuppressive medications, smoking, lack of exercise and postmenopausal state may all play important roles. Treatment may be undertaken to correct nutrient deficiencies, inhibit bone resorption and increase bone formation.

Reactive arthritis: the role of bacterial antigens in inflammatory arthritis

For more than 100 years it has been suspected that bacteria or products derived from them are deposited in joints and cause arthritis without suppuration. Over this time a vast amount of evidence, much of which is still unchallenged, has accumulated to demonstrate that whole bacteria and subcellular bacterial elements do pass, under certain circumstances, from sites of mucosal colonization or infection into the circulation and thence into joints. Similarly, experimental studies have demonstrated that the deposition of both inert material and bacterial components within synovium is sometimes, but not always, associated with the development and persistence of synovitis. In human reactive arthritis aseptic synovitis follows localized bacterial infection in the gut or genitourinary tract. A genetic predisposition, associated with the HLA B27 antigen, is recognized, and interaction between class I HLA determinants and bacteria-derived antigens may underlie the development of arthritis. Although much remains to be learned about the dissemination of antigens from the primary site of infection in reactive arthritis, strong evidence implicates the deposition of antigenic elements of Chlamydia, Yersinia, Salmonella and perhaps other micro-organisms within the synovium. Immunological findings support the notion that such antigens are being presented within the joint and participating in the induction and/or maintenance of synovitis. It is not yet clear whether such bacteria are complete or viable or whether persistence at an extra-articular site is important to the persistence of arthritis. The possibility that reactive arthritis, and perhaps other forms of seronegative arthritis also, is caused and perpetuated by bacterial antigens within the joint poses new questions about the role of HLA B27 in pathogenesis. It also raises important and exciting issues regarding treatment. Already, studies of antimicrobial therapy have yielded encouraging initial findings, and it is now possible to design and evaluate therapies aimed at blocking specific antigen recognition within the joint.

The relationship between Klebsiella infection and ankylosing spondylitis

Ankylosing spondylitis (AS) is probably produced by repeated episodes of Klebsiella-reactive arthritis, usually in HLA-B27-positive individuals. This concept is based on immunological, microbiological and serological considerations. Immunological studies based on anti-B27 tissue typing sera and anti-B27 monoclonal antibodies indicate that HLA-B27 cross-reacts with antigens found in Klebsiella, Salmonella, Shigella and Yersinia micro-organisms. Salmonella, Shigella and Yersinia gut infections are associated with a reactive arthritis that occurs predominantly in HLA-B27-positive individuals. However, microbiological studies indicate that only Klebsiella, but not Salmonella, Shigella or Yersinia, can be isolated in faecal cultures obtained from AS patients. Furthermore, serological studies involving a number of different techniques demonstrate that only antibodies against Klebsiella, but not against Salmonella, Shigella or Yersinia, can be identified in active AS patients. The evidence is sufficiently extensive to warrant long-term studies involving Klebsiella reduction in the bowel flora of AS patients, in an attempt to reduce the severity and modify the development of the disease. It would appear that Klebsiella-reactive arthritis is the precursor stage occurring in the early and active phases of AS. Only future studies can determine whether this disease will remain a taxonomic curiosity or provide guidelines for therapeutic sequelae which will be of benefit to AS patients.

Seronegative spondarthritides

We have attempted to review the epidemiology of a group of diseases collectively termed the seronegative spondarthritides. In discussing environmental influences on these diseases we have reviewed shared aetiological hypotheses and how these have been, and may be, manipulated to influence disease development. The socioeconomic impact of disease has been discussed, together with some of the strategies we might adopt to prevent further disability and handicap. Recent developments, particularly in the laboratory, promise imminent advances in the aetiopathogenesis of this group of chronic inflammatory disorders.

Increased numbers of IgG-containing cells in rectal lamina propria of patients with ankylosing spondylitis

Using an indirect immunoperoxidase technique we found the numbers of IgG-containing cells in the rectal lamina propria to be increased in patients with ankylosing spondylitis compared with controls, but not in patients with acute anterior uveitis or rheumatoid arthritis, or in the first-degree relatives of patients with ankylosing spondylitis. No differences between diagnostic groups were detected in the numbers of cells containing IgA, IgM, IgD, or IgE. The total numbers of plasma cells in the rectal lamina propria were not significantly increased. Similar increases of IgG-containing cells were not found in the duodenal lamina propria of patients with ankylosing spondylitis.

Cauda equina syndrome complicating ankylosing spondylitis: use of electromyography and computerised tomography in diagnosis

A case of the cauda equina syndrome complicating ankylosing spondylitis (AS) is described. An unusual feature of this case was the relapsing and remitting nature of the condition, but there is sufficient evidence to explain the clinical picture on the basis of a recurrent intraspinal inflammatory process. The clinical and radiological features are similar to those of a further 28 reported in the literature. An electromyogram (EMG) proved important in defining the extent of neurological involvement. Computerised tomography (CT) showed marked laminar erosion and no bony exit foramen encroachment. We believe that the clinical diagnosis of this condition can be adequately confirmed with plain radiology, EMG, and CT scan.

The spondylitis of inflammatory bowel disease. Evidence for a non-HLA linked axial arthropathy

Of 12 patients with inflammatory bowel disease (IBD) and ankylosing spondylitis (AS) or sacroiliitis (SI), only 4 (32%) had HLA-B27. Family studies revealed 3 B27-negative relatives with AS, 1 with SI, 1 with SI and IBD, and 1 with IBD alone. HLA haplotypes did not segregate with disease. These data suggest a non-HLA linked genetic predisposition to IBD which also confers susceptibility to spondylitis, even in the absence of expression of bowel disease.

Association of inflammation with raised serum IgA in ankylosing spondylitis

Serum immunoglobulins were measured in 122 patients with ankylosing spondylitis (AS) during various phases of disease activity and compared to those in 58 healthy subjects. The mean serum IgA was 38% higher in patients (306.9 mg/dl) than in controls (222.7 mg/dl) (P < 0.005), but there was no significant difference in IgG and IgM levels. Increased IgA was associated with laboratory parameters of active inflammatory disease. The mean IgA in patients having an erythrocyte sedimentation rate (ESR) equal to or greater than 15 mm/h was 369 mg/dl, 65% higher than in controls (P < 0.001), whereas there was no significant difference between controls and patients with an ESR of less than 15 mm/h. The mean IgA in patients having a C-reactive protein (CRP) level equal to greater than 15 micrograms/ml (15 mg/l) was 387.8 mg/dl, 74% higher than in controls (P < 0.001), and again there was no significant difference between controls and patients with CRP levels less than 15 micrograms/ml. (SI conversion: g/l = mg/dl x 0.01). It is suggested that selective increase of serum IgA occurs predominantly during phases of active inflammatory disease in AS, and this finding is compatible with the concept of a microbial triggering agent acting across an IgA secreting organ such as the gut.

Prevalence of occult inflammatory bowel disease in ankylosing spondylitis

Fifty-five patients with ankylosing spondylitis and 16 control patients matched for sex and age were examined for evidence of occult inflammatory bowel disease. In all patients evaluation included history and physical examination, barium enema, sigmoidoscopy, and rectal biopsy. The results of this study suggest that there is no increased prevalence of occult inflammatory bowel disease in patients with ankylosing spondylitis.

Ankylosing spondylitis and inflammatory bowel disease. III. Clinical characteristics and results of histocompatibility typing (HLA B27) in 50 patients with both ankylosing spondylitis and inflammatory bowel disease

A study was made, in co-operation with several gastroenterology and rheumatology centres, of the clinical and genetic characteristics (HLA B27) of 50 patients suffering from both inflammatory bowel disease (38 Crohn's disease (CD), 12 ulcerated colitis (UC)) and ankylosing spondylitis (AS), the latter diagnosis being established according to the New York criteria. 20 CD (52.6%) and 8 UC (66.7%) patients were HLA B27 positive. The presence of HLA B27 was studied in relation to clinical parameters, such as first occurrence of symptoms of AS or inflammatory bowel disease (IBD), a history of peripheral arthritis, iridocyclitis, and a positive history of AS or IBD. Our patients were found to have heterogeneous clinical features: on one side of the spectrum a group of cases was distingiushed with the typical characteristics of idiopathic AS, often being HLA B27 positive. On the other side a smaller group of HLA B27 negative patients was observed, with severe intestinal inflammatory pathology, lacking most of the typical clinical features of idiopathic AS ('secondary' form of AS). Finally, between these two extremes a group of patients was found with less pronounced clinical or genetic characteristics. These different clinical and histocompatibility patterns suggest a mixed aetiopathogenesis of AS in IBD patients. Such a 'syndrome' of AS might harbour both idiopathic AS and forms of AS 'secondary' to the intestinal inflammatory pathology.

Histocompatibility antigens and other genetic markers in ankylosing spondylitis and inflammatory bowel diseases

Of 118 Dutch patients suffering from ankylosing spondylitis (AS) 81-4% were found to be positive for the HLA antigen B27. The B27 frequency proved to be significantly higher in patients in whom the disease had an early onset. In addition to B27, another HLA antigen may be associated with AS; the antigen Bw 16 was found to be significantly increased in B27 negative AS patients. HLA phenotype frequencies were also determined in 109 patients with idiopathic inflammatory bwel disease (IBD). In fifty-eight ulcerative colitis (UC) patients a raised incidence of A 11 was noticed. In fifty-one patients with Crohn's disease (CD) the antigen B18 showed an increased frequency. Both deviations were statistically significant. In thirty-nine patients suffering from both AS and IBD 50% proved to be B27 positive, which is significantly diffrent from B27 frequency in patients with AS alone. In the B27 negative patients with AS and IBD and increased frequency of Bw16 was also shown.

Amyloidosis and Crohn's disease

Amyloidosis associated with Crohn's disease was found in 7 patients among 85 subjected to intestinal resection for granulomatous enterocolitis. Most of the patients had symptoms of inflammatory bowel disease of relatively short duration before the diagnosis of amyloidosis was made and were without suppurative complications. Systemic involvement was seen in 6 of the patients. One died postoperatively from renal failure, and in 2 other patients kidney transplantation was performed because of deterioration of a pre-existent renal insufficiency. Six patients were alive 6 months to 10 years after amyloidosis was diagnosed. There is great risk of rapid deterioration of kidney function postoperatively in these patients. However, our experience suggests that in some cases the progression of amyloidosis may be delayed or even brought to a halt after surgical treatment of Crohn's disease.