Enhanced jejunal production of antibodies to Klebsiella and other Enterobacteria in patients with ankylosing spondylitis and rheumatoid arthritis

OBJECTIVE: To measure gut immunity directly in jejunal fluid in patients with ankylosing spondylitis (AS) and rheumatoid arthritis (RA). METHODS: Antibodies against three different Enterobacterias were measured in jejunal perfusion fluids (collected by a double balloon perfusion device) of 19 patients with AS, 14 patients with RA, and 22 healthy controls using enzyme linked immunosorbent assay. RESULTS: The AS patients had significantly increased jejunal fluid concentrations of IgM, IgG, and IgA class antibodies against Klebsiella pneumoniae, and IgM and IgA class antibodies against Escherichia coli and Proteus mirabilis compared with healthy controls. When compared with the patients with RA, the AS patients had higher concentrations of IgA and IgG class antibodies only against K pneumoniae. The RA patients had higher IgM class antibody concentrations against all three studied Enterobacterias, when compared with the healthy controls, suggesting an enhanced mucosal immune response in these patients. A three month treatment with sulphasalazine did not decrease enterobacterial antibody concentrations in the 10 patients with AS. CONCLUSION: There is strong direct evidence for an abnormal mucosal humoral immune response particularly to K pneumoniae in patients with AS.     

Quality of life in patients with ankylosing spondylitis

Quality of life encompasses the net effects that a patient perceives an illness to have on his or her life. Quality of life commonly includes symptoms, physical functioning, work ability, social interaction, psychological functioning, treatment side effects, and financial costs. In ankylosing spondylitis, although symptoms of pain, stiffness, and fatigue are common and moderately severe, few patients develop severe functional disability and most remain employed. The limited information available suggests that most patients with ankylosing spondylitis have few problems with social interactions, although depression is not uncommon. Direct medical costs of ankylosing spondylitis are low, compared with those of other rheumatic diseases.     

Prevalence of antiphospholipid antibodies in patients with ankylosing spondylitis

OBJECTIVE: To establish the prevalence of antiphospholipid antibodies (aPL) in a group of patients with ankylosing spondylitis (AS). The relation of the antibodies with different clinical and analytical features was studied. METHODS: Eighty-four patients with AS (71 men) and 40 age and sex matched controls were studied. aPL determinations included: anticardiolipin antibodies (aCL) of the IgM, IgG, and IgA classes, the presence of lupus anticoagulant (LAC), and a false positive serologic test for syphilis. Comparisons between variables were done by Student t test, Mann-Whitney test and Chi squared test. Correlations between aPL and clinical variables were performed by Pearson coefficients. RESULTS: Twenty-four patients with AS (29%) has positive IgG aCL, compared with only 2 cases in the control group (5%) (p < 0.002). There were no differences in other aPL determinations between patients and controls. There was no correlation between the presence of aCL (IgG, IgM, or IgA) and LAC and the different aspects of the disease. Two patients fulfilled the criteria for antiphospholipid syndrome. CONCLUSION: Our results indicate the presence of IgG aCL in patients with AS higher than in the normal population but their relation with thrombosis and other systemic manifestations seems weak.     

IgA class serum antibodies against three different Klebsiella serotypes in ankylosing spondylitis

BACKGROUND: Over the past decade, the 585-nm pulsed dye laser (PDL) has been used successfully to treat a variety of cutaneous vascular lesions as well as hypertrophic scars. Laser scar revision has been revolutionized by the recent development of high-energy, pulsed carbon dioxide (CO2) laser systems. These new CO2 lasers allow controlled vaporization of thin layers of skin while minimizing damage to surrounding dermal structures. OBJECTIVE: To determine the effect of a high-energy, pulsed CO2 laser alone and in combination with a 585-nm PDL on nonerythematous hypertrophic scars. METHODS: Twenty patients with nonerythematous hypertrophic scars were treated with a high-energy, pulsed CO2 laser. One-half of each scar was additionally treated with the 585-nm PDL laser. Sequential clinical and photographic analyses were performed independently by two blinded assessors. In addition, erythema reflectance spectrometry measurements were obtained from the scars before and at regular postoperative intervals. RESULTS: Global assessment scores and erythema spectrometry measurements were significantly improved after laser treatment. Combination CO2 and PDL laser treatment resulted in more significant improvement than CO2 laser irradiation alone. CONCLUSION: Concomitant use of the high-energy, pulsed CO2 and PDL laser systems was superior to CO2 laser vaporization alone for revision of nonerythematous hypertrophic scars. Once again, the vascular specificity of the 585-nm PDL has been linked to improvement in hypertrophic scar tissue.     

Cardiac impairment detected by echocardiography in patients with ankylosing spondylitis

The authors subjected to complete echocardiographic examination 40 patients with ankylosing spondylitis (AS) in order to assess pathological changes of the heart (changes of the structure and function of valves, myocardial function of the left ventricle and the pericardium) and compare their incidence with clinical characteristics of the patients (age, duration, stage, form and activity of the disease) as well as with the presence of ECG changes. Based on the results and their statistical analysis they revealed that structural changes of the aorta and its valves associated with dilatation of the root of the aorta, its mild insufficiency and the possible finding of a typical bump on its posterior wall is found in half the patients with AS, being more frequent when the disease develops early, when it persists for a long time or is in an advanced stage. A similar relationship is found also in the presence of mild diastolic dysfunction of the left ventricle. The authors did not observe a more frequent incidence of other pathological changes of the heart in patients with AS. None of the detected changes were clinically severe and did not call for aimed treatment or surgery. In the conclusion the authors compare the assessed facts with data in the literature and confront data in the literature.     

Autoimmunity to cartilage link protein in patients with rheumatoid arthritis and ankylosing spondylitis

OBJECTIVE: To determine whether patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) express cellular immunity to cartilage link protein (LP). METHODS: LP was purified from human fetal epiphyseal and bovine adult nasal cartilage. It was used in proliferation assays with the peripheral blood lymphocytes (PBL) isolated from 83 patients with RA, 21 patients with AS, and 30 healthy controls. RESULTS: Patients with RA (34%) and AS (71%) expressed a significantly higher prevalence of cellular immune responses to human LP compared with the healthy control group (13%). Such significant differences were not observed for bovine LP. Half the patients with RA responding to LP exhibited cellular immunity to both human and bovine protein. In the AS group, PBL from a majority of responders to LP recognized only human LP. CONCLUSION: These data suggest that LP is a potential autoantigen in the development of RA and AS and that cellular immune reactivity to common and distinct LP epitopes in patients with RA and AS may play a role in the pathogenesis of these diseases.     

Characterization of the humoral immune response to Klebsiella species in inflammatory bowel disease and ankylosing spondylitis

This study was carried out to characterize the antibody class response by ELISA to seven Klebsiella pneumoniae serotypes (K2, K3, K17, K21, K26, K36, K50) in five different groups, 40 HLA-B27-positive ankylosing spondylitis (AS) patients, 46 patients with Crohn's disease (CD), 38 patients with ulcerative colitis (UC), 50 patients with active anti-endomysial antibody-positive coeliac disease and 40 healthy controls, using whole bacteria and capsular polysaccharide. IgG antibody levels were significantly elevated in AS patients to K17, K36, K50; IgA to K2, K3, K21, K26, K36 and K50; and IgM to serotype K21 when compared to normal controls. Furthermore, IgG antibody levels were significantly elevated in CD patients to K2, K17, K21, K26, K36 and K50; IgA to K2, K3, K21, K26, K36 and K50; and IgM to K2, K3, K17, K21 and K50. Increased IgG antibody levels in the UC group were limited only to K17, K36 and K50. No antibody class was increased to any of the K. pneumoniae serotypes in the coeliac disease group. The immune responses in AS patients also involve Klebsiella bacteria having capsular serotypes other than K26, K36 and K50. The similarity in the immune responses between CD and AS groups suggests that many AS patients may have occult bowel inflammation.     

Serum testosterone levels are not elevated in patients with ankylosing spondylitis

OBJECTIVE: Studies in patients with ankylosing spondylitis (AS) describe slightly elevated serum testosterone levels, but these studies were not properly controlled for possible confounders. METHODS: In a case-control study serum levels of sex steroids, luteinizing hormone, and sex hormone binding globulin (SHGB) were measured in patients with AS and in age and sex matched controls. The body mass index, smoking status, use of alcohol, and fat intake were recorded. RESULTS: Testosterone levels measured in serum extracts did not differ in 50 male patients with AS compared to controls (mean +/- SD 16 +/- 4 vs 15 +/- 5 nmol/l, respectively; p = 0.54). In unextracted serum, however, male patients showed elevated testosterone (p < 0.001) and dehydroepiandrosterone sulfate levels (p = 0.003), even after controlling for confounders (p < 0.001). One of 10 female patients had an elevated testosterone level in unextracted serum. The 17 male users and one of the 2 female users of phenylbutazone had the highest testosterone levels in unextracted serum, and all showed a significant decline after extraction. Serum levels of other sex steroids, luteinizing hormone, and SHGB did not differ significantly between patients and controls. CONCLUSION: Serum testosterone levels are not elevated in male patients with AS. Spuriously elevated testosterone levels in unextracted serum might be related to the use of phenylbutazone in our patient sample.     

Disability in ankylosing spondylitis

PURPOSE: This study was designed to examine the functional loss in ankylosing spondylitis and explore the relationship between disability and various factors such as age, disease duration, disease activity, spinal mobility, chest expansion, peripheral joint involvement, radiological changes, and psychosocial well-being. METHOD: Forty-two patients were included in this cross-sectional study. RESULTS: The results showed that 37 patients had mild to moderate disability, two patients had severe disability, and three patients did not report any functional loss. Spearman correlation analyses showed that disability was strongly correlated with spinal mobility measures, disease activity measures, and disease duration. Also, patients with peripheral joint involvement had greater disability. When the predictive effect of five independent variables was studied by multiple regression analysis, it was found that the most powerful predictors of functional loss in AS patients were cervical rotation, modified Schober's test, and pain. CONCLUSIONS: These data suggest that functional consequences of AS are constituted by multiple impairments and each needs to be managed by an integrated physiatric approach.     

Hip involvement in ankylosing spondylitis

Hip involvement in ankylosing spondylitis (AS) is a common and disabling problem. The clinical and x-ray records of 87 patients with definite AS (Rome criteria) were examined to define and characterize their hip disease. Clinical hip disease was present in 33 cases (38%), was usually bilateral (91%), and tended to begin early in the disease course; it was the cause of 50% of the Class III and IV disability in the entire study group. Typical findings included regional pain, limitation of motion, muscle atrophy, and flexion contractures. Radiologic hip abnormalities occurred in 42 cases (48%). The radiographic pattern was distinctive when compared to that in two control groups and included axial migration of the femoral head (63%), concentric joint space narrowing (50%), rufflike femoral osteophytosis (36%), and protrusio acetabuli (30%). Eight patients required bilateral hip surgery. Para-articular ossification occurred in 8 of 16 replaced hips; in 5 of 8 hips it caused clinical immobility. This potentially serious complication may limit the usefulness of hip arthroplasty in some AS patients.     

Collagen-specific cytotoxic T lymphocyte responses in patients with ankylosing spondylitis and reactive arthritis

Both ankylosing spondylitis (AS) and reactive arthritis (ReA) are strongly associated with HLA-B27 although the mechanism for this association is still unknown. Here we examine the hypothesis that B27-restricted, joint antigen-specific cytotoxic T lymphocytes (CTL) may be the driving force of AS and ReA. Type II and type XI procollagens (CII and CXI, respectively), expressed almost exclusively in the articular cartilage of the joints, were chosen as the possible targets of autoimmune CTL. Type I procollagen (CI), expressed in many different tissues, was also included as control. Nineteen nonamer peptides bearing appropriate HLA-B27 binding motifs from human CI, CII and CXI were identified and synthesized. When analyzed for binding affinity to HLA-B27 in assembly assays, four (two from CII, two from CXI) were found capable of binding to HLA-B27 with high affinity. These B27-binding collagen peptides were then used to stimulate peripheral blood lymphocytes from eight B27-positive AS and three ReA patients for identification of possible B27-restricted autoimmune CTL. HLA-B27-restricted CTL specific for one of the CII peptides, P109 were found in one of the ReA patients, but in none of the others.     

Dysphagia due to cervical spine involvement in ankylosing spondylitis

Here we present a case of a patient with a massive ossification of annulus fibrosus and longitudinal ligament at the level C3-C4, C4-C5 and C5-C6, also called the Van Swaay bridge. One can observe a propulsion of the pharingeal tissue at the level of the massive Van Swaay bridge between C5 and C6 which caused pressure and dysphagia.     

Clinical comparison of patients with ankylosing spondylitis, Reiter's syndrome and psoriatic arthritis

Between 1976 and 1989, 160 cases of seronegative spondyloarthropathy (SNSA) were admitted to the Department of Medicine at Chulalongkorn Hospital. The prevalence of idiopathic ankylosing spondylitis (IdAS) was 52 cases (32.5%), Reiter's syndrome (RS) 68 cases (42.5%), psoriatic arthritis (PsA) 28 cases (17.5%), reactive arthritis eight cases (5.0%) and Behcet's disease four cases (2.5%). Clinical comparison of the patients with IdAS, RS and PsA showed a male predominance in IdAS (90.2%), RS (97.1%) and PsA (71.4%). There was a significant difference (p < 0.01) between IdAS and PsA, and RS and PsA. The initial articular manifestation usually occurred in the younger age group (IdAS, 22.15; RS, 22.91; and PsA, 30.86 years); however, there was a significant difference (p < 0.05) between IdAS and PsA, and RS and PsA. Initial peripheral arthritis was found in IdAS (51.9%), RS (91.2%) and PsA (92.6%); there was a significant difference (p < 0.001) between IdAS and RS, and IdAS and PsA. The symptom of back pain was found in IdAS (78.8%), RS (38.2%) and PsA (21.4%); there was a significant difference (p < 0.001) between IdAS and RS, and IdAS and PsA. During physical examination, peripheral arthritis was evident in the IdAS (42.2%), RS (88.2%) and PsA (92.2%) patients; likewise sacroiliitis was found in the IdAS (100%) RS (54.4%), and PsA (57.2%) patients. Evidence of ankylosing spondylitis was found in the IdAS (100%), RS (22.1%) and PsA (46.4%) patients. These findings show a significant difference (p < 0.001) between patients with IdAS and RS, IdAS and PsA. Other associated symptoms were similar, particularly evidence of enthesopathy (tendonitis, heel pain, plantar fasciitis), the polyarticular pattern was more common than the mono-articular pattern. Hip joint was significantly (p < 0.05) more commonly involved in patients with IdAS than in those with RS and PsA. Associated symptoms, particularly genital lesion or skin lesion, are specific symptoms for RS and PsA, respectively.     

Serum IgA1 and IgA2 subclass antibodies against collagens in patients with ankylosing spondylitis

Clear cell papulosis is a newly described skin disease characterized by multiple white papules. Histopathologically, diagnostic clear cells were seen among the basal cells of the epidermis. We report clear cell papulosis on the lumbar area and buttocks of a 1-year-old girl.     

The outcome of ankylosing spondylitis: a study of 100 patients

The outcome was studied in 100 patients with adult-onset primary ankylosing spondylitis (AS). After a mean disease duration of 16 yr, 51.5% of the patients were employed in full-time work. Cessation of work occurred at a mean disease duration of 15.6 yr, and was significantly associated with female sex, low levels of education, acute anterior uveitis, 'bamboo spine' and the co-existence of non-rheumatic diseases. Functional outcome was studied by analysing activities of daily living, and revealed similar findings in males and females. Most of the loss of function occurred during the first 10 yr of disease, and correlated significantly with the occurrence of peripheral arthritis, spinal X-ray changes of AS and development of 'bamboo spine'. After > 20 yr of disease, > 80% of the patients still complained of daily pain and stiffness, and > 60% reported daily use of drugs.