Odd Vinje

HLA antigens, psoriasis and acute anterior uveitis in Bechterew's syndrome (ankylosing spondylitis)

One hundred and twenty‐two consecutively hospitalized patients with ankylosing spondylitis (AS) were reexamined. Ninety‐two per cent were HLA B27 positive. Of the HLA B27 negative patients, 60% were found to have psoriasis, as opposed to 11 % of the HLA B27 positive patients. Acute anterior uveitis (AAU) was found only in HLA B27 positive patients, and more frequently in males than in females. The genetic and clinical heterogeneity of AS, together with the overlapping clinical criteria for AS and psoriatic spondylitis, may make the term “Bechterews syndrome” preferable. Based on these findings and previous reports, we conclude that (i) AAU is a manifestation of Bechterews syndrome in HLA B27 positive patients, (ii) HLA B27 negative patients without any obvious accompanying manifestations may suffer from psoriatic spondylitis, and (iii) genetic predisposition to psoriasis in persons who are HLA B13, B17 and B37 negative, may interact with the genetic predisposition to Bechterews syndrome in HLA B27 positive persons and produce Bechterews syndrome with psoriasis or psoriasis‐like skin eruptions.

Family Studies in Bechterew's Syndrome (Ankylosing Spondylitis): II. Prevalences of Symptoms and Signs in Relatives of HLA 827 Negative Probands

All available adult first-degree relatives of 9 probands with HLAB27 negative ankylosing spondylitis were examined. Completion rate was 90%. Prevalences of symptoms and signs and distributions of chest and spinal mobility are presented. No secondary case of Bechterews syndrome was found among the relatives, compared with 10% among the relatives of HLAB27 positive probands (p = 0.05). We conclude from this study and that of relatives of HLAB27 positive probands, that a HLAB27 negative relative runs a low risk of contracting Bechterews syndrome, irrespective of the HLAB27 status of the proband.

Arthropathy and Sacro-Iliitis in Severe Psoriasis

Fifty consecutive adult patients hospitalized for psoriasis were examined. Persistent low back pain, large joint arthropathy, phalangeal joint arthropathy and radiological sacro-iliitis were frequent findings (18-28%), but were not associated with one another. Chest expansion and spinal mobility were not reduced in the patients who had roentgenological sacro-iliitis. Low back pain at night and large joint arthropathy were positively associated. Peripheral arthropathy and roentgenological sacro-iliitis were associated. There was no sex difference in the frequency of signs or symptoms. Four patients (8%) had ankylosing spondylitis. It was concluded that in psoriatic patients, the different signs of joint affection are only partly related.

HLA B27, Sacro-Iliitis and Peripheral Arthropathy in Acute Anterior Uveitis

Thirty-four consecutively admitted patients with acute anterior uveitis (AAU) were examined. The male to female ratio was 1.8:1. Twenty-two patients (67%) were HLA B27 positive. Twelve (36%) had radiographical sacro-iliitis; all were males and were HLA B27 positive. Three of them were asymptomatic. Eighteen patients (53%) had low back pain suggestive of sacro-iliitis, but this symptom was associated neither with radiographical sacro-iliitis nor with HLA B27. Radiographical sacro-iliitis and HLA B27 occurred together more frequently in males than in females. It was concluded that the association between AAU and signs of joint affection reflects the association seen in HLA B27 positive patients, while HLA B27 negative patients suffered from low back pain as well. HLA B27 positive patients with AAU should be remitted for radiographical examination of the sacro-iliac joints.

The distribution of clinical findings in Bechterew's syndrome (ankylosing spondylitis) suggests distinct genetic subgroups

One hundred and twenty‐two consecutive patients hospitalized for ankylosing spondylitis (AS) were reexamined. The frequency of clinical signs and results of tests for associations are presented. Psoriasis was associated with a distal pattern of peripheral arthropathy. Spinal rigidity was predominantly seen in males. Males with phalangeal arthropathy exhibited preserved spinal mobility. This was the case also when HLA B27 positives and patients who did not have psoriasis were considered separately. HLA B27 positive patients in this group had frequently experienced acute anterior uveitis. It seems possible that the disease in such males is the result of combined predisposition to ankylosing spondylitis and psoriatic arthropathy. Hip arthropathy was frequently present in males with spinal rigidity. The associations observed confirm that AS is a heterogenous group of diseases. The term “syndrome” may be suitable for such a heterogenous group, and we prefer the term “Bechterews syndrome” as the name of this group. When these new findings are added to the previous observations that acute anterior uveitis probably is a clinical, sex‐influenced characteristic of HLA B27 positive Bechterews syndrome, that HLA B27 negative patients with Bechterews syndrome frequently had psoriasis and were HLA B13 and B17 negative, and that psoriasis was frequent in HLA B27 positive patients as well, we tentatively conclude that different and interacting genetic mechanisms may be involved in the etiology of Bechterews syndrome.

Laboratory Findings in Patients with Psoriasis, with Special Reference to Immunological Parameters, Associations with Arthropathy and Sacro-Iliitis

Twenty-five male and 25 female consecutive patients hospitalized because of psoriasis were examined. The clinical and radiographical findings are presented in detail elsewhere. Increased serum IgA, C3, C4, and C3PA concentrations were found in patients both with and without arthropathy and/or sacro-iliitis. Increased IgG concentrations were found in patients without arthropathy, and of C1 inhibitor concentrations in patients with arthropathy and/or sacro-iliitis. IgG and IgA concentrations were lower in patients with arthropathy than in those without, the difference being most significant in patients with arthropathy of large joints. An association was found between increased C4 concentration and sacro-iliitis, increased CRP concentration and sacro-iliitis and increased C3 concentration and phalangeal joint arthropathy. C4 and CRP concentrations were not associated. A close association between CRP and SAA was observed. Our results indicate that psoriatic arthropathy is not a single uniform joint disease, but represents different forms of arthropathy.

Radiographic Changes, HLA B27 and Back Pain in Patients with Psoriasis or Acute Anterior Uveitis

Twenty-five female and 23 male consecutive patients hospitalized because of severe psoriasis, and 34 consecutive patients hospitalized because of acute anterior uveitis (AAU) were examined. Twelve of the patients with AAU (35%) and 11 of the patients with psoriasis (23%) had definite sacro-iliitis, which was unilateral in 6 (55%) of the former and in 2 (17%) of the latter. No definite radiographic differences in sacro-iliitis between HLA B27-positive and -negative patients could be detected. The radiographic changes of the dorso-lumbar junction (Th9-L2) related to the diseases, were seen only in HLA B27 positive patients with sacro-iliitis. Scattered lateral syndesmophytes were the commonest paravertebral ossifications in patients with psoriasis, whereas more diffuse and more numerous lateral mixed osteophytes appeared most frequently in AAU patients. Parasyndesmophytes were seen both in patients with psoriasis and in those with AAU. Asymptomatic sacro-iliitis was frequently found in unilateral, psoriatic sacro-iliitis (4 out of 6 patients) but was not restricted to this group. No radiographic indications of aortic valve insufficiency or apical lung fibrosis were found.

How Does Bechterew's Syndrome (Ankylosing Spondylitis) Start?: Interrelations between Onset of Symptoms

Detailed medical histories were obtained from 122 consecutive patients with Bechterews syndrome (ankylosing spondylitis) who had been hospitalized at Oslo Sanitetsforening Rheumatism Hospital. Frequencies of symptoms, age at onset of symptoms and their interrelationships are presented. Low back pain affected more patients than any other symptom and, generally speaking, it started earlier than any other individual symptom. However, any symptom could antedate low back pain. Symptoms preceding low back pain were most frequently reported at a young age, and most often affected the extremities. The presence of psoriasis was associated with an increased frequency of symptoms in the peripheral joints. Acute anterior uveitis and chest stiffness were more common in males than in females. The influence of the selection of patients on the results is discussed.

Laboratory Findings in Chronic Prostatitis—With Special Reference to Immunological and Microbiological Aspects

Twenty-nine consecutive patients hospitalized for chronic prostatitis were examined. The HLA and radiographic findings are presented in detail elsewhere. Serum immunoglobulin levels were normal. The concentrations of IgG, IgA and IgM in prostatic fluid were significantly lower than in serum, both absolutely and as percentages of total protein concentration. Distinct bands were seen in the gamma region of agarose gel electrophoresis from prostatic fluids both in patients and in controls, and other tests also indicated that they did not reflect oligoclonal Ig responses. Growth of Chlamydia or Mycoplasma species was not detected in any of the biopsy specimens. We conclude that, with the test panel used, we have not been able to confirm that immunological factors or the presence of Chlamydia or Mycoplasma species is important in chronic prostatitis.

HLA Antigens and Sacro-Iliitis in Chronic Prostatitis

Two (7%) out of 29 patients with chronic prostatis were HLA B27 positive. They had roentgenological normal sacro-iliac joints. Two (7%) had sacro-iliitis as judged by radiological examination; one of them had never experienced low back pain. No patient had arthropathy in peripheral joints, ulcerative colitis, Crohns disease, psoriasis or anterior uveitis. It was concluded that ankylosing spondylitis is rare in patients treated for chronic prostatitis.