Objectives Uveitis, psoriasis and inflammatory bowel disease (IBD) are common extra-articular manifestations (EAM) in patients with ankylosing spondylitis (AS); however, summary data of reported prevalence are lacking. The aim of the present study was to summarise the prevalence of EAMs among patients with AS and to identify underlying factors to explain potential heterogeneity of prevalence. Methods A systematic literature search was performed (Medline, Embase and Cochrane Library) to identify relevant articles. Risk of bias was assessed and data were extracted. Pooled prevalences were calculated. Potential sources of any observed clinical or methodological heterogeneity in the estimates were explored by subgroup and metaregression analysis. Results In the 156 selected articles, 143 reported the prevalence of uveitis (44 372 patients), 56 of psoriasis (27 626 patients) and 69 of IBD (30 410 patients). Substantial heterogeneity was observed in prevalence estimates among all EAMs (I 2 =84–95%). The pooled prevalence of uveitis was 25.8% (95% CI 24.1% to 27.6%), and was positively associated in multivariable metaregression with disease duration (β 0.05, 95% CI 0.03 to 0.08) and random selection of patients (β −0.24, 95% CI −0.43 to −0.04). The pooled prevalence of psoriasis was 9.3% (95% CI 8.1% to 10.6%). The pooled prevalence of IBD was 6.8% (95% CI 6.1% to 7.7%) and was positively associated with the percentage of women in the studies (β 0.02, 95% CI 0.00 to 0.03). Geographical area was associated in multivariable metaregressions with prevalence of all EAMs. Conclusions EAMs are common in patients with AS. The large heterogeneity between studies can be partly explained by differences in clinical as well as methodological characteristics.

Prevalence of extra-articular manifestations in patients with ankylosing spondylitis : a systematic review and meta-analysis

Objective. The Assessment of Spondyloarthritis international Society (ASAS) classification criteria for axial spondyloarthritis (axSpA) have added nonradiographic axSpA (nr-axSpA) to the classic ankylosing spondylitis (AS) as defined by the modified New York criteria. However, some confusion remains about differences between classification and diagnosis of axSpA. Our objective was to analyze differences between classification and diagnostic criteria by discussing each feature of the classification criteria based on real cases. Methods. The clinical features of the ASAS classification criteria were evaluated in relation to their significance for an expert diagnosis of axSpA. Twenty cases referred to our tertiary center outpatient clinic were selected because of an incorrect diagnosis of axSpA: 10 cases in which axSpA had been excluded initially because the classification criteria were not fulfilled, and 10 patients who had been previously diagnosed with axSpA because the classification criteria were fulfilled. Upon reevaluation, the former were diagnosed with axSpA while the latter had other diseases. Results. All items that are part of the classification criteria show some variability related to their relevance for a diagnosis of axSpA. There are clinical features suggestive of axSpA that are not part of the classification criteria. Misinterpretation of imaging procedures contributed to false-positive results. Rarely, other diseases may mimic axSpA. Conclusion. Because the sensitivity and specificity of the axSpA classification criteria have been around 80% in clinical trials, some false-positive and false-negative cases were expected. It is hoped that their detailed description and discussion will help to increase the understanding of diagnosing axSpA in relation to the ASAS classification criteria.

https://www.jrheum.org/content/jrheum/42/1/31.full.pdf

Classification and Diagnosis of Axial Spondyloarthritis — What Is the Clinically Relevant Difference?

Background/Purpose Uveitis can be a local eye disease or a manifestation of systemic rheumatologic disorders. However, the differences of clinical manifestations between uveitis patients with or without systemic rheumatologic disease have been seldom described in literature. We investigated the clinical features and complications of rheumatic disease-related uveitis, and compared the characteristics in patients with and without rheumatic disease in a Chinese population in Taiwan. Methods A retrospective review was performed for all patients who had been diagnosed with uveitis between January 2009 and June 2014 at the Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan. Results A total of 823 uveitis patients were enrolled in the study, including 123 patients with rheumatic diseases. The most frequent rheumatic diseases included ankylosing spondylitis (5.8%), followed by Behcet's disease (2.8%), sarcoidosis (1.4%), psoriasis (1.1%), and juvenile idiopathic arthritis (1.1%). Compared with patients without rheumatic disease, those with rheumatic disease-related uveitis had a lower mean age at onset (35.1 ± 15.8 years vs. 44.0 ± 17.5 years), a longer follow-up period (27.1 ± 25.3 months vs. 22.2 ± 23.0 months), a higher incidence of anterior uveitis (69.0% vs. 46.3%), less frequent posterior uveitis (4.9% vs. 21.4%), a higher incidence of recurrence (26.8% vs. 14.1%), more frequent bilateral involvement (53.7% vs. 38.8%), and more frequent posterior synechiae (17.2% vs. 9.4%). Conclusion The disease course and clinical manifestations of rheumatic disease-related uveitis were different from those unrelated. Patients with rheumatic disease-related uveitis had a higher recurrent rate and more frequent posterior synechiae than patients without rheumatic diseases.

/pdf/clinical-manifestations-in-uveitis-patients-with-and-without-16jlkpymuh.pdf

Clinical manifestations in uveitis patients with and without rheumatic disease in a Chinese population in Taiwan

Importance Understanding the role of vitamin D—which regulates inflammatory responses—in noninfectious uveitis (an inflammatory disease) may provide insight into treatment and prevention of this disease. Objective To investigate whether there is an association between hypovitaminosis D and incident noninfectious uveitis. Design, Setting, and Participants In a retrospective case-control study, data from a health care claims database containing deidentified medical claims from a large private insurer were used to identify 558 adults enrolled from January 1, 2000, to December 31, 2016, who received a diagnosis of noninfectious uveitis from an eye care clinician (with receipt of a confirmatory diagnosis within 120 days of the initial diagnosis) and who had a vitamin D level measured within 1 year before the first diagnosis. Exclusion criteria included having systemic disease or receiving medication known to lower vitamin D levels, having undergone intraocular surgery, and having infectious uveitis. Each case patient was matched with 5 controls on the basis of age, sex, race/ethnicity, and index date (2790 controls). The controls had vitamin D level determined either within 1 year before or within 6 months after receiving an eye examination with normal findings. Multiple logistic regression models were used to examine the association between hypovitaminosis D and noninfectious uveitis. Main Outcomes and Measures The primary, prespecified analysis assessed the association of noninfectious uveitis with hypovitaminosis D (vitamin D level ≤20 ng/mL). Results The 558 cases and 2790 controls were matched on age, and each group had a mean (SD) age of 58.9 (14.7) years. Among the cohort of 3348 patients, 2526 (75.4%) were female, and the racial/ethnic distribution in the matched samples was 2022 (60.4%) white, 552 (16.5%) black, 402 (12.0%) Hispanic, 162 (4.8%) Asian, and 210 (6.3%) unknown. Patients with normal vitamin D levels had 21% lower odds of having noninfectious uveitis than patients with low vitamin D levels (odds ratio [OR], 0.79; 95% CI, 0.62-0.99;P = .04). In a race-stratified analysis, an association between vitamin D and uveitis was found in black patients (OR, 0.49; 95% CI, 0.30-0.80;P = .004) and was qualitatively similar but nonsignificant in white patients (OR, 0.87; 95% CI, 0.62-1.21;P = .40) and Hispanic patients (OR, 0.60; 95% CI, 0.33-1.10;P = .10). Conclusions and Relevance This and other reports have found an association between hypovitaminosis D and noninfectious uveitis. However, these studies cannot establish a causal relationship. Prospective studies are warranted to evaluate whether hypovitaminosis D causes increased risk of uveitis and the role of vitamin D supplementation in prevention and treatment of uveitis.

Association of Hypovitaminosis D With Increased Risk of Uveitis in a Large Health Care Claims Database.

A cross-sectional study was made on 89 inhabitants and their dogs from a rural community of Yucatan, Mexico, to determine the serological prevalence of some zoonotic parasitic agents. Samples were taken to monitor the presence and intensity of infection with gastrointestinal parasites in dogs. In humans, the serological prevalence of T. canis, T. gondii, and T. spiralis was 29.2%, 91.0%, and 6.7%, respectively. No associations were found between positive cases and studied variables. From the total of blood samples taken from dogs, 87 (97.6%) were seropositive to T. gondii; only 52 viable fecal samples were collected from dogs of which 46.2% had the presence of gastrointestinal parasites with low to moderate intensity; from those, 12% had the presence of T. canis. This study demonstrates the presence of the studied zoonotic agents in the area particularly T. gondii which suggest a common source of infection in dogs and humans and a high number of oocyts present in the environment. Preventive measures must be designed towards good prophylactic practices in domestic and backyard animals (T. canis and T. spiralis). Contaminated sources with T. gondii (food and water) should be further investigated in order to design effective control measures.

/pdf/parasitic-zoonoses-in-humans-and-their-dogs-from-a-rural-53s3uvqpb7.pdf

Parasitic Zoonoses in Humans and Their Dogs from a Rural Community of Tropical Mexico

Objective. Our aim is to describe the frequency of uveitis associated with rheumatic inflammatory autoimmune diseases (RIAD) in adult patients admitted to the Rheumatology Department at a tertiary-care hospital in Mexico City. We also describe the clinical features, seasonal distribution, treatment, and ocular complications associated with this disease. Methods. We reviewed 1332 charts of patients with RIAD and selected those that had a diagnosis of uveitis. We obtained the following data: age, sex, type of uveitis and relationship with diagnosis of RIAD, recurrences, seasonal distribution, treatment, and residual visual deficit. Results. We found 57 (4.27%) cases of uveitis in 1332 charts, including 38 men and 19 women (M:F ratio 2:1), aged 47 ± 16 years. Nongranulomatous acute anterior uveitis (NGAAU) comprised 90.52% of cases (52/57). In 64.91% of cases (37/57), uveitis preceded the diagnosis of RIAD by 12 ± 9 years, more frequently in winter (35.96%; p = NS). Uveitis was found in 40/93 patients with ankylosing spondylitis (AS), in 7/11 patients with relapsing polychondritis (RP), in 8/16 patients with Behcet’s disease, in 1/16 patients with polyarteritis nodosa, and in 1/590 patients with rheumatoid arthritis (RA). Ninety-six percent of the patients were treated with steroids. Upon a mean followup of 60 days (range 7–4745 days), reduction of visual acuity (≤ 20/200) was associated with recurrence of uveitis in 3/7 cases with AS, in 4/8 cases with Behcet’s disease, in 3/7 with RP, and in 1 case of uveitis and seronegative RA. Conclusion. NGAAU frequently precedes RIAD and is found predominately in men, with a tendency to occur in winter.

https://www.jrheum.org/content/jrheum/38/2/325.full.pdf

Uveitis in adult patients with rheumatic inflammatory autoimmune diseases at a tertiary-care hospital in Mexico City.

Acute anterior uveitis is the most common form of uveitis and is also a common cause of vision loss in most regions of the world, but the exact etiology cannot be elucidated in some cases. Uveitis is a sight-threatening inflammation inside the eye that affects both the uveal tract and adjacent structures and is the most frequent extra-articular manifestation of ankylosing spondylitis (AS). The prevalence of acute non-granulomatous anterior uveitis (ANGAU) in AS patients has been reported to be as high as 25% to 40% during the course of the rheumatic disease [1,2,3]. In our experience, only 2% of patients are accurately diagnosed by an ophthalmologist at the onset of AS, although 22% of chronic AS patients develop uveitis, thus the availability of correctly characterized biological samples for further analysis is limited. The pathogenesis of AS with ANGAU usually has a strong genetic linkage with human leukocyte antigen (HLA)-B27 [4]. In addition, a genetic association of HLA with human infection by helminthes has been reported [5].

Infection with Toxocara canis is among the most common zoonotic infections worldwide and is a well-recognized cause of uveitis worldwide [6,7]. Humans can be infected with these parasites by ingestion of soil or contaminated meat containing Toxocara eggs. Ocular toxocariasis causes permanent vision loss in many patients and Toxocara is an important causative agent of posterior and diffuse uveitis [7]. However, Toxocara should be considered as a possible causative agent of ANGAU. There is some evidence that the occurrence of helminthes and the prognosis of rheumatic disease are linked [8,9]. In this context, Peng [10] has reported that potential parasitosis must be considered in patients with rheumatic diseases. Williams and Roy [11] have reported a case of arthritis associated with toxocaral infestation. Furthermore, an association of arthritis with infection due to helminthes, such as Strongyloides stercoralis, has been reported [12,13]. A study conducted by Kuk et al. [14] reported Toxocara seropositivity in AS patients.

Reports regarding the influence of toxocariasis in patients with AS-associated uveitis are limited and the relationship between toxocariasis and AS-associated uveitis is unclear. Thus, the aim of this work was to determine the presence of antibodies against T. canis in AS patients with ANGAU. To our knowledge, this is the first report showing the relationship between Toxocara and Mexican AS patients with uveitis.

/pdf/isolation-of-igg-antibodies-to-toxocara-in-ankylosing-lgo303273v.pdf

Isolation of IgG Antibodies to Toxocara in Ankylosing Spondylitis Patients with Acute Anterior Uveitis

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Uveitis in adult patients with rheumatic inflammatory autoimmune diseases at a tertiary-care hospital in Mexico City.

Isolation of IgG Antibodies to Toxocara in Ankylosing Spondylitis Patients with Acute Anterior Uveitis