Similarity between chronic reactive arthritis and ankylosing spondylitis.A 32-35-year follow-up study.

OBJECTIVE: We assessed the long-term outcome of recent reactive arthritis (ReA) during 1973-2007 and ankylosing spondylitis (AS) during 1973-1997 to identify similarities in manifestations of disease. METHODS: Radiographs of the sacroiliac, hand and foot joints were taken at onset and at 8, 20, and in ReA 32 years from entry among recent-onset (<6 months) patients; 60 with ReA and 17 with AS. Sacroiliacal joints using the modified New York 1984 criteria and the Larsen score of 0-100 of 20 joints of hands and feet were assessed. The number of swollen joints, patients with orthopaedic operations or iritis or HLA-B27 or retirement because of spondyloarthritis, and ESR were recorded. RESULTS: The onset age of 60 ReA patients (34 men) was 17-54 years, mean 32 (SD 10) and 51 (85%) were HLA-B27 positive. The number of onset swollen joints was 1-5, mean 2.6 (SD 1.6), while in 40 patients at the 30-year check-up it was 0-3, mean 0.2 (SD 0.6). ESR was at onset mean 55 mm/h (SD 33) and at the 30-year check-up 15 mm/h (SD 11). Yersinia enterocolitica type 3 antibodies were raised in 22 (37%) patients at onset. The end-point Larsen score was 2-6, mean 4 in 6 patients. One ankle joint arthroplasty and five smaller operations had been performed. Bilateral grade 2-3 sacroiliitis developed in 9/60 (15%), and unilateral grade 2-4 in 3. The incidence of iritis was 12/60 (20%). Erosive arthritis or iritis or sacroiliitis developed in 24/60 (40%) participants. Thirteen (22%) retired because of arthritis while five died. Of 17 AS patients (8 men), whose age was initially 21-50 years, mean 33 (SD 10), 11 (65%) had rheumatic symptoms years before our first examination. All were HLA-B27 positive and developed grade 2-4 bilateral sacroiliitis during the 20-year follow-up. The end-point Larsen score was 2-22, mean 9 (SD 8) in 5 patients. Hip arthroplasties were performed in one and small-joint operations in 3. ESR was at onset mean 54 mm/h (SD 29), and at the last measurement mean 26 mm/h (SD 21). Iritis was found in 5/17 (29%); seven (41%) retired due to AS; five died. CONCLUSION: Our community-based inception cohorts show that with time, among a number of similarities most often sacroiliitis, peripheral arthritis and iritis developed in both chronic ReA and AS. These HLA-B27-related diseases would appear to be identical. The differences between patients depend on the chronicity of the sickness. The hypothesis that HLA-B27 is related to chronicity of disease seems to be valid.

Adalimumab in juvenile idiopathic arthritis-associated chronic anterior uveitis.

OBJECTIVE: To evaluate the efficacy of adalimumab in juvenile idiopathic arthritis (JIA)-associated uveitis. METHODS: Retrospective observational study of 20 patients with JIA and chronic uveitis on adalimumab treatment. The ocular inflammation and improvement was assessed according to the Standardization of Uveitis Nomenclature criteria. RESULTS: At the initiation of adalimumab, the mean age of patients was 13.4 yrs and the mean duration of uveitis 8.7 yrs. Seventeen (85%) patients had polyarticular JIA and 19 (95%) had previously been on anti-TNF treatment. The mean duration of adalimumab therapy was 18.7 months. Of the 20 patients, 7 (35%) showed improved activity, 1 (5%) worsening activity and in 12 (60%) no change was observed in the activity of uveitis. Those with improved activity were younger and had shorter disease duration. The mean number of flares/yr decreased from 1.9 to 1.4 during adalimumab treatment. Serious adverse events or side-effects were not observed. Seven patients discontinued adalimumab during the follow-up: six because of inefficacy and one because of inactive uveitis. CONCLUSION: Adalimumab is a potential treatment option in JIA-associated uveitis, even in patients non-responsive to previous other anti-TNF therapy.

Uveitis in young adults with juvenile idiopathic arthritis: a clinical evaluation of 123 patients.

OBJECTIVE: To examine the prevalence and characteristics of uveitis in young adults with juvenile idiopathic arthritis (JIA). METHODS: The study population consisted of 123 JIA patients born between 1976 and 1980 whose arthritis had been diagnosed and treatment first started at the Rheumatism Foundation Hospital in 1976 to 1995. A clinical re-evaluation was carried out by an ophthalmologist and a paediatric rheumatologist 16 years later on average. RESULTS: The mean age of the patients was 23.5 years, 72% were women, and 63% had oligoarthritis. During the course of the disease, diagnosis of uveitis had been made in 25 patients (20%). Arthritis in the 19 patients with asymptomatic uveitis was more often ongoing than in the 98 patients without uveitis (p = 0.032). Asymptomatic uveitis was persistent in eight of the 19 cases (42%), and arthritis was active in seven of these. Four of the six patients with attacks of symptomatic uveitis had parallel treatment for arthritis. In three of 19 patients with asymptomatic uveitis and in five of six with acute uveitis the eye inflammation had started after the age of 16. At the onset of arthritis the patients with asymptomatic uveitis were younger than those without uveitis (p = 0.002). Complications of uveitis developed in six patients but their sight remained good. CONCLUSIONS: Asymptomatic uveitis continued into adulthood in almost half the uveitis patients. Most also had ongoing arthritis. Acute uveitis was often associated with persistent arthritis.

Acute anterior uveitis in association with an outbreak of Campylobacter jejuni infection.

We report a case of acute anterior uveitis (AAU) in association with an outbreak of Campylobacter jejuni infection, with the first estimation of the incidence of AAU triggered by Campylobacter, and discuss reactive ophthalmological complications (AAU, iritis, and conjunctivitis) attributable to Campylobacter.

Severe childhood uveitis without overt arthritis.

OBJECTIVE: To look for forme fruste (incomplete) forms of juvenile idiopathic arthritis (JIA)-associated uveitis. METHODS: The study involved 6 patients (3 girls and 3 boys) without overt arthritis who had been sent for ophthalmologic and rheumatologic evaluation because of uveitis resembling that seen in JIA. RESULTS: Two patients evinced no evidence of arthritis, 3 had non-specific signs and symptoms such as pains or valgus ankle and one may have had an episode of arthritis. Five patients carried the HLA allele B27 and 4 were positive for antinuclear antibodies. The mean age at diagnosis of uveitis was 8.4 years (range 3.5-14.2 years) and the mean follow-up period was 6.2 years (range 3.8-7.3 years). All patients had obviously had their uveitis for a long period prior to the first contact with an ophthalmologist. In 3 patients uveitis was asymptomatic when diagnosed, 2 had mild conjunctival injection and one had exacerbation of the disease process. Subsequently the uveitis was asymptomatic and bilateral in all patients. Complications of uveitis were common: cataract was found in 4 patients, glaucoma in 1 patient, cystoid macular edema in 4, posterior synechiae in 5 and band keratopathy in 3. The final visual acuity was poor in one eye of 1 patient despite effective treatment of uveitis. Uveitis was still active in all patients at the close of follow-up. CONCLUSION: Asymptomatic uveitis, which is frequently positive for antinuclear antibodies, can occur in children who show no clear evidence of arthritis. Complications occur in consequence of a delay in the diagnosis of insidious uveitis.

Uveitis as a marker of active arthritis in 372 patients with juvenile idiopathic seronegative oligoarthritis or polyarthritis.

OBJECTIVE: To compare the activity of arthritis in children with recently diagnosed seronegative oligoarthritis or polyarthritis with or without uveitis. METHODS: The study covered 372 JIA children with recently diagnosed seronegative oligoarthritis or polyarthritis. The mean prospective follow-up period was 4.5 years. Asymptomatic anterior uveitis was found in 96 cases. The activity of arthritis in all 372 patients was assessed clinically and by laboratory parameters. RESULTS: The erythrocyte sedimentation rate was significantly higher (p = 0.001) at the diagnosis of arthritis and at the end of the follow-up (p = 0.02) in the 96 JIA patients with uveitis than in the 276 JIA patients without uveitis. The hemoglobin value was significantly lower (p = 0.008) at the diagnosis of arthritis in patients with uveitis, but not at the end of the follow-up. The number of inflamed joints was significantly greater at the end of the follow-up in patients with persistent polyarthritis and uveitis (p = 0.01) compared to those polyarthritis patients without uveitis. Patients with uveitis were significantly more often treated with oral prednisolone (p < 0.001), glucocorticoid joint injections (p < 0.001), and with methotrexate (p = 0.003) compared to patients without uveitis. Clinical remission of arthritis was achieved significantly less frequently in patients with uveitis than in patients without uveitis (21% versus 42%, p<0.001). CONCLUSION: The inflammatory activity of arthritis seems to be increased in patients with seronegative oligo- or polyarthritis and uveitis compared to those without uveitis.

Occurrence of uveitis in recently diagnosed juvenile chronic arthritis: a prospective study.

OBJECTIVE: To examine the occurrence and characteristics of uveitis in patients with recently diagnosed juvenile chronic arthritis (JCA). DESIGN: A prospective observational case series. PARTICIPANTS/METHODS: The study covered the new cases detected with JCA (426 children), all of whom were referred to an ophthalmologic consultation during 1989 to 1996 at the Pediatric Department of the Rheumatism Foundation Hospital, Heinola, Finland. MAIN OUTCOME MEASURES: The children with JCA were followed by ophthalmologic and pediatric examinations two to four times a year. The type and course of arthritis and presentation and characteristics of uveitis were examined prospectively. RESULTS: Uveitis was detected in 104 of 426 children (24%). Two thirds of all patients and the same proportion of those with uveitis were girls. Proportionally, uveitis was found to be as common among children with oligoarthritis (27%) as among those with seronegative polyarthritis (25%). Antinuclear antibodies (ANA) were detected significantly more frequently in patients with uveitis (66%) than among those without uveitis (37%) (P < 0.001). The uveitis was asymptomatic in 99 cases; only 5 children had episodes of acute anterior symptomatic uveitis. Uveitis was found before or within 3 months from the onset of recent arthritis in 51 of 104 children (49%) and later on in 53 of 104 children (51%). The mean age at diagnosis of uveitis was 5.9 years (range, 1.1-17.7; median, 4.9 years). The mean period from the diagnosis of JCA to the diagnosis of uveitis was 1.1 years (range, -2.4-6.5; median, 0.3 years). The mean age at diagnosis of JCA was 4.8 years (range, 0.6-15; median, 3.2 years) among those with uveitis and 7.3 years (range, 0.9-16; median, 6.7 years) among those who did not have it (P < 0.001). Uveitis was ongoing in 63 children at the end of the follow-up period. The mean follow-up time was 4.5 years (range, 0-9.7) for all children and 5.6 years (range, 1.3-9.6) for those with uveitis. In most instances, the visual prognosis was good. In 25 of 104 patients (24%) one or more complications of uveitis were found, but in only three children did the visual acuity decrease to 20/60 or less, and none became blind. All the other patients had visual acuity > or = 20/40. CONCLUSIONS: In this patient group, uveitis in JCA frequently appeared very early after the onset of arthritis. The uveitis was significantly more common in patients with an early onset of arthritis combined with ANA positivity. The proportion of children with uveitis was as large in those with polyarthritis as in those with oligoarthritis, with no predilection to girls.

Juvenile idiopathic arthritis in multicase families.

OBJECTIVE: To characterize juvenile idiopathic arthritis (JIA) patients from multicase families. METHODS: The study series comprised 80 affected siblings belonging to 37 families. Comparisons were made with a population-based series of JIA patients from Finland and with a sibling series from the United States. RESULTS: The distribution of cases according to onset type was similar in the sibling and population-based series. The age at diagnosis was significantly lower in the sibling series (4.8 years vs 7.4 years; p < 0.001). There was more intra-pair similarity in onset and course types in the United States series compared to the Finnish series and the proportion of girls was higher in the former. CONCLUSION: The only significant difference between familial and sporadic cases with JIA is an earlier onset of disease in familial cases. There is no essential difference in clinical features of the disease between patients in the multicase and sporadic groups. Differences between the Finnish and US series may be due to selection bias in the latter.

Uveitis in sibling pairs with juvenile idiopathic arthritis.

OBJECTIVE: To ascertain the occurrence and characteristics of uveitis in sibling pairs affected with juvenile idiopathic arthritis (JIA). METHODS: The sibling series comprised 80 JIA patients from 37 families with two or three JIA children, seen at the paediatric department of the Rheumatism Foundation Hospital in Heinola, Finland. An ophthalmologist examined the children for uveitis two to four times a year and the course of the condition was recorded during the follow-up. RESULTS: Uveitis was diagnosed in 21 of the 80 patients (26%). Three pairs (3.4 pairs expected) were concordant for the presence of asymptomatic uveitis. Two patients with enthesitis-related arthritis had acute unilateral uveitis. Among the remaining cases, uveitis was chronic and continuously active at the end of follow-up in 13 instances, but in spite of this only one patient had impaired vision. HLA allele B27 occurred more frequently in patients with uveitis than in those without uveitis (52 vs 30%, P=0.073) and all six subjects in the pairs concordant for chronic uveitis carried this allele. CONCLUSIONS: The observed concordance rate for uveitis did not differ from that expected. Although the uveitis was chronic in most instances, its course was usually mild.

Uveitis as a cause of visual loss in arthritides and comparable conditions.

OBJECTIVE: To examine the role of inflammatory rheumatic diseases and comparable conditions in the etiology of severe uveitis leading to visual impairment and blindness. METHODS: A retrospective study based on the Finnish Register of Visual Impairment. At the end of 1996, the Finnish Register of Visual Impairment included 296 uveitis patients in whom uveitis was the main cause of visual impairment. The patient records were examined retrospectively to investigate the etiology of severe uveitis. Due to the incompleteness of data obtained of the patients blinded a long time ago, we included only 174 uveitis patients whose visual handicap (best corrected visual acuity in the better eye < 20/60 or severe visual field loss) was stated during 1980-1996. RESULTS: A total of 174 uveitis patients were found, 72 male and 102 female. A diagnosed or presumed inflammatory rheumatic disease or comparable condition was found in 38/174 (22%) patients: juvenile rheumatoid arthritis in 14 (8%), spondyloarthropathy (ankylosing spondylitis or reactive arthritis) in 10 (6%), sarcoidosis in 5 (3%), seronegative rheumatoid arthritis in 4 (2%); Behçet's disease was diagnosed in 2 (1%), 1 patient had polymyositis, 1 polyarteritis nodosa, and 1 juvenile systemic lupus erythematosus. In addition to the above, 10 (6%) patients had chronic back pain and 5 (3%) patients various noninflammatory joint problems. Diverse other ophthalmologic or systemic disease was detected in 38 (22%) cases. Trauma or surgery caused uveitis in 9 (5%) patients. For 74/174 (43%) uveitis patients no specific associating condition could be shown. Legal blindness was documented in 65/174 (37%) patients, including 8 totally blind persons. CONCLUSION: This study provides first data on the relative importance of inflammatory rheumatic diseases and comparable conditions in the etiology of severe uveitis leading to visual handicap and blindness.

A population-based study on uveitis in juvenile rheumatoid arthritis.

OBJECTIVE: To obtain information on the occurrence and characteristics of uveitis in a population-based survey of patients with juvenile rheumatoid arthritis (JRA). METHODS: The subjects in this study were entitled, under the nationwide sickness insurance scheme, to receive specially reimbursed medication for JRA in 5 of the 21 central hospital districts in Finland (population base about 270,000 children < 16 years of age) in 1980, 1985 and 1990. RESULTS: A total of 114 incident cases (34 boys and 80 girls) satisfied the criteria for JRA. Uveitis was diagnosed in 18 of these patients (16%). The mean age of uveitis patients at the diagnosis of JRA was 6.8 years (median 5.4 years) and the mean interval from the diagnosis of JRA to the detection of uveitis was 2.9 years. Silent (asymptomatic) anterior uveitis was found in 4 boys and 11 girls and acute anterior uveitis in 2 boys. One girl had marginal corneal ulceration with mild anterior uveitis. Uveitis was chronic (> 6 months) in 9 cases. Uveal inflammation was most severe in the 3 children whose uveitis was detected at the time of the diagnosis of JRA. CONCLUSION: The study provides population-based information on the occurrence and characteristics of uveitis associated with JRA.

Late onset uveitis in juvenile-type chronic polyarthritis controlled with prednisolone, cyclosporin A and methotrexate.

A female with seronegative polyarthritis since early adulthood developed silent chronic uveitis 15 years after the onset of her arthritis. The patient was antinuclear antibody positive and carried the HLA B27 haplotype. Arthritis was refractory to conventional anti-rheumatic medication and severe uveitis did not respond to either topical corticosteroid treatment or to oral corticosteroid plus cyclosporine. Finally, a combination therapy with oral corticosteroids, cyclosporin A and methotrexate calmed down the sight-threatening uveitis and aggressive polyarthritis within three months. The collaboration of ophthalmologists with rheumatologists is important in treating patients with arthritis and uveitis in order to determine the optimal management strategy early in the disease course.

Rheumatoid arthritis in identical twins: a clinical and immunogenetic study of eight concordant pairs derived from a nationwide twin panel.

The nationwide Finnish Twin Cohort was linked with the national Sickness Insurance Register. Eight identical twin pairs concordant for rheumatoid arthritis (RA) fulfilling the American Rheumatism Association criteria were identified. All 16 cases were known to be seropositive. Four pairs had at least one additional first-degree relative with RA, and the prevalence of RA among all the first-class relatives was 9%. HLA-typing was performed for 15 patients representing the eight pairs; six pairs carried the DR4 allele, and three of these pairs were putative homozygotes. Nodules and Sjögren syndrome occurred fairly frequently (in 7 of 16 and 6 of 13 cases examined, respectively), but concordance within pairs was no higher than that expected by chance. The course of the disease was fulminant in one patient and in several others the disease had led to marked joint destructions. The findings pointed out to some intrapair similarity in the progression of the joint damage and in the type of complications caused by gold.