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Delay in the radiographic detection of sacroitiitis in ankylosing spondylitis

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... Sacroiliitis findings on radiological imaging develop nearly 5 to 10 years after the onset of IBP in almost half of the patients [22]. Therefore, although direct radiography assessed using modified New York criteria remains the initial imaging modality for detection of sacroilitis in the ASAS criteria, magnetic resonance imaging may be needed as second-line method of choice when modified New York criteria are not met [16]. ...
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Introduction The prevalence of Sjögren's syndrome (SS) in patients with the diagnosis of SpA has been reported to be higher than normal population. Yet, the vice-versa is unclear. In this study, we aimed to investigate the prevalence of IBP, radiologic sacroiliitis and SpA in patients with primary SS. Methods 85 patients followed at the rheumatology clinics of the Marmara and Kocaeli Universities with the diagnosis of primary SS between November 2011 and August 2012 were included in this study. The control group consisted of 100 age-and gender-matched patients. Inflammatory back pain and axial SpA were diagnosed according to the assessment of spondylo arthritis International Society (ASAS) criteria. Results 83 patients were (97%) female and 2 (3%) were male. Mean age of the patients was 49.1 (±11) years. Mean disease duration was 7.3 (±4) years. The patient and control groups were comparable in terms of age and gender (p > 0.05). Inflammatory back pain was observed in 21 (24.7%) of 85 primary SS patients and in 4 (4%) of 100 control subjects (p < 0.001), radiographic sacroiliitis was demonstrated in 9 (10.5%) of primary SS patients and 2 (2%) of the control subjects (p = 0.025). Remaining SpA findings were not encountered in either group. Conclusion inflammatory back pain and radiologic sacroiliitis is increased in patients with primary SS. Whether IBP, SI joint inflammation and radiologic sacroiliitis is due to the co-existence of SpA and primary SS or IBP is an underdiagnosed clinical feature of SS deserves further studies of large patient numbers.
Article
This study was designed to assess the relative values current of locally available investigations in the early diagnosis of inflammatory sacroiliitis. Consecutive patients attending routine rheumatology clinics in Aberdeen clinically considered by consultant rheumatologists to have inflammatory back disease but with insufficient criteria to firmly establish a diagnosis of ankylosing spondylitis were included. Patients were assessed using a standard questionnaire, clinical examination of spinal movements, plain radiology of the sacroiliac joints, computerised tomographic scanning of the sacroiliac joints and HLA-B27 typing. Patients were systematically followed up using repeated clinical and radiological examination for five years. Plain film evidence of grade 2 radiological sacroiliitis (bilateral or unilateral) was found to be the most reliable predictor for the development of ankylosing spondylitis satisfying the New York criteria at 5 year follow up. CT scanning and HLA-B27 typing were of no added value in this series and the clinical questionnaire lacked specificity. It is concluded that the combination of clinical history, examination and plain film radiology are currently reliable criteria for diagnosing the subsequent development of ankylosing spondylitis satisfying established criteria.
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The association of HLA-B27 with ankylosing spondylitis and related spondyloarthropathies has been known for two decades and has provided a great impetus to the epidemiologic studies and also helped broaden the clinical spectrum of these diseases. The etiology of these diseases is likely to be multifactorial and include genetic, immunologic, and environmental mechanisms. The detailed three-dimensional x-ray crystallographic structure of B27 has now been reported. It has revealed electron density compatible with oligopeptides that are nine amino acid-long (nonamers) bound in the antigen-binding cleft of the molecule. Microsequence analysis of 11 peptides eluted from the antigen-binding cleft has confirmed that all are nonamers. The most restricted position in the bound peptide is the second position, where all the 11 peptides contain arginine. The side chain of arginine extends into the B pocket ("45 pocket"), which seems to act as a specificity side pocket in the antigen-binding cleft of the B27 molecule. It is very likely that an understanding of the detailed structure of B27, including the peptide-binding motif and the structural domains recognized by cytotoxic T cells, along with the recent development of the B27 transgenic rat model for spondyloarthropathies, will further enhance our understanding of the immunogenetics of these diseases. It is hoped that this will lead to the source of the arthritogenic triggers and possibly disease prevention by antigen-specific immunomodulation. Because T-cell activation is initiated by the formation of antigen-MHC complexes that are the ligands that are recognized by the antigen-specific T-cell receptor (TCR), it might be possible to inhibit this activation by blocking the antigen-binding cleft of MHC molecules by using high-affinity MHC-binding peptides (MHC blockade) or by a novel, new, and more efficient method of TCR antagonism.
Article
AND PERSPECTIVES The frequency of uSpA has been ignored in previous epidemiologic studies because of the inadequacy of the existing classification criteria. With the use of the recently developed ESSG criteria,29a the real prevalence may be better defined in the future and may also lead to early recognition of such patients in clinical practice. But even more challenging is the issue to elucidate the suspected infectious etiology in most patients with uSpA. Extensive microbiologic diagnostic investigations and the use of new molecular biologic methods for detecting microbes or microbial antigens will advance our understanding over the next years. The term uSpA is only a working label with the implicit demand to solve these clinical conundra by follow-up or even better by identifying the causative or triggering agents.
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Ankylosing spondylitis and related spondyloarthropathies form a family of rheumatic diseases that are characterized by inflammatory peripheral and axial arthritis, with predilection for sacroiliitis, and a remarkably strong association with a genetic marker, HLA-B27. The association with B27 has provided a great impetus to the epidemiologic studies of spondyloarthropathies and also helped broaden the clinical spectrum of these diseases. There are at least six subtypes of B27, and the x-ray crystallographic structure of the common B27 subtype (B*2705) is now known. Endogenous peptides bound in the B27 antigen-binding cleft have been isolated and all seem to be nonamers (i.e., nine amino acids long).
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The Second International Simmons Center Conference on HLA-B27-Related Disorders presented a number of new observations related to the molecular biology of the HLA-B27 molecule, its functional biology as a peptide-binding molecule, and the clinical implications of the association of B27 with the spondylarthropathies, as well as new clinical information concerning these diseases. As a result of the rapid developments in these fields, new insights into the pathogenesis of the B27-related spondylarthropathies will emerge.
Article
Eighty-eight patients with possible ankylosing spondylitis (AS) were selected for this followup study. They showed normal or at most suspicious radiographic findings of the sacroiliac joints. After 5 years' followup, 24, and after 10 years 32 patients (59% of the 54 finally available, 36% of the 88 original patients) had definite AS. In 12 individuals, AS could be excluded. Of the 10 remaining patients, 6 still had possible, and 4 had undifferentiated spondyloarthropathy. A comparison between HLA-B27 positive and negative patients showed a significantly increased frequency of definite AS or possible and undifferentiated spondyloarthropathy (p less than 0.05) in the group of HLA-B27 positive patients. The development of AS was characterized by a prolonged course: radiological sacroiliitis became evident after at least 9 +/- 6 years, radiological signs of spinal involvement after 11 +/- 6 years mean disease duration. After 18 +/- 6 years 25 (78%) of 32 patients with AS still maintained good or sufficient functional capacity, indicating a good functional prognosis in the great majority of the patients.