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Ankylosing spondylitis and reactive arthritis in the developing world

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Spondylarthropathies revolve around the strongest known contributing factor, HLA-B27. However, the role of HLA-B27 remains unclear. Its subtypes are reported here in the particular context of developing countries. Non-MHC factors are also being described. The role of immunity is being elucidated. Cytokine expression has been proved to play a major role in ankylosing spondylitis (AS). Recently shown are IL23R, which encodes a critical cytokine receptor in the TH17 subset of T cells, and ARTS1, loss of function of which could have pro-inflammatory effects. This constitutes a major breakthrough in the understanding of AS which could potentially lead to a therapy. New imaging techniques and therapies have substantially improved the earlier diagnosis and management of the disease. However, criteria for an early diagnosis remain to be settled. Such criteria are particularly important for developing countries where they could help in decreasing the socioeconomic burden of the disease.

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Age of onset and overall prevalence

About 80% of AS patients develop the first symptoms at <30 years of age; <5% of patients present at >45 years.3 The overall prevalence of AS is 0.2–1.1%, and the incidence of AS is 0.5–14 per 100 000 people per year according to studies from different countries.4

Familial forms and heritability

Familial forms of AS are frequent. The risk of developing the disease is 40–60-fold higher in families with AS patients.5 Moreover, two studies now formally estimate heritability as over 90%.6, 7 Age of symptom onset, Bath Ankylosing

Main clinical features of as in the developing world

AS remains the most recognized form of SpA observed in the developing countries. The overall clinical features in adults are rather similar to those reported in white Caucasoids. However, some of them are worth mentioning. A higher rate of involvement of the cervical spine, atlantoaxial subluxation, and ossification of the longitudinal posterior ligament are reported.52 Moreover, one of the commonest and most particular features is the higher frequency of juvenile-onset AS (JoSA).*23, *24, *52

Reactive arthritis in the developing countries

Infections, particularly gastrointestinal infections, are one of the most important medical problems in developing countries. Gastrointestinal infections are linked to water and food contamination as a consequence of a poor urban development. Children are especially susceptible to viral infections and infections by bacteria that might potentially trigger ReA. Such is the case of gastrointestinal infection by species of Salmonella, Shigella, Campylobacter, and less frequently Yersinia, which

Diagnosis

Early diagnosis in SA is a major matter of concern in which the key point is an early identification of sacroiliitis. Sacroiliitis is not always included in diagnosis and classification criteria70, 71 because structural changes in the sacroiliac joints might only become apparent later. A systematic approach to early diagnosis of predominantly axial spondyloarthritis has been developed.72 Such a diagnosis is predictable in every third to fifth patient with chronic (>3 months) low-back pain that

Conclusion

AS and SpA occur in developing countries roughly according to HLA-B27 distribution. But it is certainly not the only factor to consider. The current better understanding of these diseases and their earlier diagnosis would be a major step in their management on a worldwide scale, but would have a particular impact in developing countries. Indeed, in these countries the main problem is poor access to expensive means of diagnosis and/or treatment. Because of the major socioeconomic burden of SpA

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