Abstract
Spondyloarthritis (SpA) is generally uncommon in sub-Saharan Africa, in part because of the rarity of HLA-B27 in this region. However, the relationship between HLA-B27 and SpA, particularly ankylosing spondylitis (AS), is complex. Despite the HLA-B*27:05 risk allele occurring in some West African populations, associated AS is not seen. In fact, most patients with AS are HLA-B27-negative, although there is emerging evidence that another class I HLA molecule, HLA-B*14:03, is associated with AS in black Africans. The Assessment of SpondyloArthritis International Society criteria for detecting early axial disease are of limited value in sub-Saharan Africa, because of both the rarity of HLA-B27 and very limited access to magnetic resonance imaging. Reactive arthritis (ReA), psoriatic arthritis, and undifferentiated SpA are seen mainly in the context of HIV infection, although the exact effect of the virus in the pathogenesis of arthritis is unclear. In Zambia, ReA is associated with the HLA-B*57:03 allele, which is paradoxically also associated with slow progression of HIV infection. HIV-associated ReA has a more protracted and aggressive course than standard ReA. Enthesitis-related arthritis is more common in children infected with HIV by vertical mother-to child transmission. Use of TNF inhibitors for axial disease is problematic, mainly because of cost, but also because of potential safety problems, especially reactivation of tuberculosis.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Rachid B, El Zorkany B, Youseif E, Tikly M. Early diagnosis and treatment of ankylosing spondylitis in Africa and the Middle East. Clin Rheumatol. 2012;31:1633–9. An overview of some of the challenges of early diagnosis and cost-effective treatment of ankylosing spondylitis in the developing world.
Mijiyawa M, Oniankitan O, Khan MA. Spondyloarthropathies in sub-Saharan Africa. Curr Opin Rheumatol. 2000;12:281–6.
Khan MA. Polymorphism of HLA-B27: 105 subtypes currently known. Curr Rheumatol Rep. 2013;15:362. An excellent update of the HLA-B27 subtypes.
Dean LE, Jones GT, Macdonald AG, Downham C, Sturrock RD, Macfarlane GJ. Global prevalence of ankylosing spondylitis. Rheumatology (Oxford). 2014;53:650–7. A comprehensive review of the variation in prevalence of ankylosing spondylitis by continent, based on published data and estimates based on HLA-B27 population prevalence figures.
Cao K, Moormann AM, Lyke KE, et al. Differentiation between African populations is evidenced by the diversity of alleles and haplotypes of HLA class I loci. Tissue Antigens. 2004;63:293–325.
Solomon L, Beighton P, Valkenburg HA, Robin G, Soskolne CL. Rheumatic disorders in the South African Negro. Part I. Rheumatoid arthritis and ankylosing spondylitis. S Afr Med J. 1975;49:1292–6.
Malemba JJ, Mbuyi-Muamba JM. Clinical and epidemiological features of rheumatic diseases in patients attending the university hospital in Kinshasa. Clin Rheumatol. 2008;27:47–54.
Ntsiba H, Bazebissa R. Four first Congolese cases of pelvic ankylosing spondylitis. Bull Soc Pathol Exot. 2003;96:21–3.
Allsopp CE, Harding RM, Taylor C, et al. Interethnic genetic differentiation in Africa: HLA class I antigens in The Gambia. Am J Hum Genet. 1992;50:411–21.
Kalidi I, Fofana Y, Rahly AA, et al. Study of HLA antigens in a population of Mali (West Africa). Tissue Antigens. 1988;31:98–102.
Brown MA, Jepson A, Young A, Whittle HC, Greenwood BM, Wordsworth BP. Ankylosing spondylitis in West Africans–evidence for a non-HLA-B27 protective effect. Ann Rheum Dis. 1997;56:68–70.
Khan MA, Kushner I, Braun WE. Comparison of clinical features in HLA-B27 positive and negative patients with ankylosing spondylitis. Arthritis Rheum. 1977;20:909–12.
Feldtkeller E, Khan MA, van der Heijde D, van der Linden S, Braun J. Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatol Int. 2003;23:61–6.
Belachew DA, Sandu N, Schaller B, Guta Z. Ankylosing spondylitis in sub-Saharan Africa. Postgrad Med J. 2009;85:353–7.
Ouedraogo DD, Tieno H, Kabore H, Palazzo E, Meyer O, Drabo JY. Ankylosing spondylitis in rheumatology patients in Ouagadougou (Burkina Faso). Clin Rheumatol. 2009;28:1375–7.
Khan MA, Braun WE, Kushner I, Grecek DE, Muir WA, Steinberg AG. HLA B27 in ankylosing spondylitis: differences in frequency and relative risk in American Blacks and Caucasians. J Rheumatol Suppl. 1977;3:39–43.
Diaz-Pena R, Ouedraogo DD, Lopez-Vazquez A, Sawadogo SA, Lopez-Larrea C. Ankylosing spondylitis in three Sub-Saharan populations: HLA-B*27 and HLA-B*14 contribution. Tissue Antigens. 2012;80:14–5. Excellent paper challenging the old assumption regarding the lack of association of HLA-B27 with ankylosing spondylitis in sub-Saharan Africa.
Lopez-Larrea C, Mijiyawa M, Gonzalez S, et al. Association of ankylosing spondylitis with HLA-B*1403 in a West African population. Arthritis Rheum. 2002;46:2968–71.
Diaz-Pena R, Blanco-Gelaz MA, Njobvu P, Lopez-Vazquez A, Suarez-Alvarez B, Lopez-Larrea C. Influence of HLA-B*5703 and HLA-B*1403 on susceptibility to spondyloarthropathies in the Zambian population. J Rheumatol. 2008;35:2236–40.
Mijiyawa M. [Ankylosing spondylitis in Togolese patients]. Med Trop (Mars). 1993;53:185–9.
Rudwaleit M, van der Heijde D, Landewe R, et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009;68:777–83.
Tam LS, Leung CC, Ying SK, et al. Risk of tuberculosis in patients with rheumatoid arthritis in Hong Kong - the role of TNF blockers in an area of high tuberculosis burden. Clin Exp Rheumatol. 2010;28:679–85.
Cepeda EJ, Williams FM, Ishimori ML, Weisman MH, Reveille JD. The use of anti-tumour necrosis factor therapy in HIV-positive individuals with rheumatic disease. Ann Rheum Dis. 2008;67:710–2.
Doe PT, Asiedu A, Acheampong JW, Rowland Payne CM. Skin diseases in Ghana and the UK. Int J Dermatol. 2001;40:323–6.
Ogunbiyi AO, Daramola OO, Alese OO. Prevalence of skin diseases in Ibadan, Nigeria. Int J Dermatol. 2004;43:31–6.
Hartshorne ST. Dermatological disorders in Johannesburg, South Africa. Clin Exp Dermatol. 2003;28:661–5.
Ouedraogo DD, Meyer O. Psoriatic arthritis in Sub-Saharan Africa. Joint Bone Spine. 2012;79:17–9. A review of the current knowledge (or lack thereof) of psoriatic arthritis in sub-Saharan Africa.
Namazi MR. Paradoxical exacerbation of psoriasis in AIDS: proposed explanations including the potential roles of substance P and gram-negative bacteria. Autoimmunity. 2004;37:67–71.
Carter JD, Hudson AP. Reactive arthritis: clinical aspects and medical management. Rheum Dis Clin North Am. 2009;35:21–44.
Mbayo K, Mbuyi-Muamba JM, Lurhuma AZ, Halle L, Kaplan C, Dequeker J. Low frequency of HLA-B27 and scarcity of ankylosing spondylitis in a Zairean Bantu population. Clin Rheumatol. 1998;17:309–10.
Houzou P, Oniankitan O, Kakpovi K, et al. Rheumatic diseases profile of 13517 West African patients. Tunis Med. 2013;91:16–20.
World Health Organisation. Data on the size of the HIV/AIDS epidemic: Prevalence of HIV among adults aged 15 to 49 (%) by country. World Health Organisation; 2011 http://apps.who.int/gho/data/node.main.562?lang=en. Alarming data on the prevalence of HIV infection in central and southern Saharan Africa
Stein M, Davis P. HIV and arthritis–causal or casual acquaintances? J Rheumatol. 1989;16:1287–90.
Bileckot R, Mouaya A, Makuwa M. Prevalence and clinical presentations of arthritis in HIV-positive patients seen at a rheumatology department in Congo-Brazzaville. Rev Rhum Engl Ed. 1998;65:549–54.
Njobvu P, McGill P, Kerr H, Jellis J, Pobee J. Spondyloarthropathy and human immunodeficiency virus infection in Zambia. J Rheumatol. 1998;25:1553–9.
Stein CM, Davis P. Arthritis associated with HIV infection in Zimbabwe. J Rheumatol. 1996;23:506–11.
Njobvu P, McGill P. Human immunodeficiency virus related reactive arthritis in Zambia. J Rheumatol. 2005;32:1299–304.
Ntsiba H, Ngandeu-Singwe M, Makita-Bagamboula C, Yala F. Human immunodeficiency virus associated arthritis in Congo Brazzaville. Med Mal Infect. 2007;37:758–61.
Dougados M, van der Linden S, Juhlin R, et al. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum. 1991;34:1218–27.
Lopez-Larrea C, Njobvu PD, Gonzalez S, Blanco-Gelaz MA, Martinez-Borra J, Lopez-Vazquez A. The HLA-B*5703 allele confers susceptibility to the development of spondylarthropathies in Zambian human immunodeficiency virus-infected patients with slow progression to acquired immunodeficiency syndrome. Arthritis Rheum. 2005;52:275–9.
Trollip S, Njobvu PD, McGill P, Chipeta J, Bucala R. Spectrum of Rheumatic Diseases (RDs) in Lusaka: Then and Now. Clin Rheumatol. 2013;32 Suppl 2:S122.
Njobvu P, McGill P. Soft tissue rheumatic lesions and HIV infection in Zambians. J Rheumatol. 2006;33:2493–7.
Ekwom PE, Oyoo GO, Amayo EO, Muriithi IM. Prevalence and characteristics of articular manifestations in human immunodeficiency virus infection. East Afr Med J. 2010;87:408–14.
Adelowo OO, Umar A. Juvenile idiopathic arthritis among Nigerians: a case study. Clin Rheumatol. 2010;29:757–61.
Chinniah K, Mody GM, Bhimma R, Adhikari M. Arthritis in association with human immunodeficiency virus infection in Black African children: causal or coincidental? Rheumatology (Oxford). 2005;44:915–20.
Weakley K, Esser M, Scott C. Juvenile idiopathic arthritis in two tertiary centres in the Western Cape, South Africa. Pediatr Rheumatol Online J. 2012;10:35. Much-needed data on juvenile idiopathic arthritis in sub-Saharan Africa.
Chipeta J, Njobvu P, Wa-Somwe S, Chintu C, McGill PE, Bucala R, et al. Clinical patterns of juvenile idiopathic arthritis in Zambia. Pediatr Rheumatol Online J. 2013;11:33. Much-needed data on juvenile idiopathic arthritis in sub-Saharan Africa, revealing the relative absence of the subtype of oligoarthritis of young girls, associated with uveitis, that is relatively common in Caucasians.
Haffejee IE, Raga J, Coovadia HM. Juvenile chronic arthritis in black and Indian South African children. S Afr Med J. 1984;65:510–4.
Zaborowski AG, Parbhoo D, Chinniah K, Visser L. Uveitis in children with human immunodeficiency virus-associated arthritis. J AAPOS. 2008;12:608–10.
Compliance with Ethics Guidelines
Conflict of Interest
Mohammed Tikly, Panganani Njobvu, and Paul McGill declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is part of the Topical Collection on Spondyloarthritis
Rights and permissions
About this article
Cite this article
Tikly, M., Njobvu, P. & McGill, P. Spondyloarthritis in Sub-Saharan Africa. Curr Rheumatol Rep 16, 421 (2014). https://doi.org/10.1007/s11926-014-0421-z
Published:
DOI: https://doi.org/10.1007/s11926-014-0421-z