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Spondyloarthritides (SpA) are inflammatory rheumatic diseases affecting the axial skeleton, peripheral joints and entheses, and also manifest at extraskeletal sites. According to the more recently introduced nomenclature, predominant axial SpA is distinguished from predominant peripheral SpA. Axial SpA is further divided into radiographic and nonradiographic axial SpA. Genetic factors are relevant, with HLA-B27 being most important. The interleukin 23/17 pathway seems to be relevant and points towards new therapeutic targets. Inflammatory back pain is the leading symptom in axial SpA and has certain characteristics. In addition, HLA-B27 and sacroiliitis on imaging are important for diagnosis. Therapy consists of physiotherapy, nonsteroidal anti-inflammatory drugs (first line) and biologicals (second line). Conventional disease-modifying antirheumatic drugs are effective only in peripheral arthritis.

Impairments of the immune system play an important role in all immun-mediated rheumatic diseases. Recently, the following news were reported: · Early aging of the immune system with thymus insufficiency has now been reported for both patients with rheumatoid arthritis and axial spondyloarthritis, without prethymic lack of progenitors at least in rheumatoid arthritis.. · For giant cell arteritis, the most frequent vasculitis in the elderly, an increased expression of IL-17A in temporal artery biopsies coincides with good prognosis and reponse to glucocorticoids.. · Concerning immunosenescence in systemic lupus erythematosus, BAFF appears to have an important role for relapses after B-cell depletion.. For the future it can be anticipated that the use of unified classification criteria for rheumatic diseases (as with the new 2012 EULAR / ACR classification criteria for polymyalgia rheumatica) will ensure better comparability of immunological studies also in the elderly., (© Georg Thieme Verlag KG Stuttgart · New York.)

The special program "Osteoimmunology" under the leadership of the Universities of Erlangen, Jena, Gießen and Münster, is investigating in 27 projects clarification approaches on the causes of inflammatory rheumatic diseases, such as rheumatoid arthritis and ankylosing spondylitis with the aim of developing new forms of treatment. The molecular mechanisms involved in bone damage and the interaction between the immune system and bone and cartilage are topics of research.

The spondyloarthritides (SpA) are an interrelated group of rheumatic diseases that are characterized by common clinical symptoms and genetic similarities. The most important subtype is ankylosing spondylitis (AS), which is now considered part of axial spondyloarthritis. Important clinical features of the SpA are inflammatory back pain (IBP), asymmetric peripheral oligoarthritis, predominantly of the lower limbs, enthesitis, and specific organ involvement such as anterior uveitis, psoriasis and chronic inflammatory bowel disease. For clinical purposes, five subgroups are differentiated: AS, psoriatic SpA (PsSpA), reactive SpA (ReSpA), SpA associated with inflammatory bowel disease (SpAIBD) and undifferentiated SpA (uSpA). AS usually starts in the sacroiliac joints at a mean age of 26 years, affecting men slightly more frequently than women. SpA are genetically linked (90% of cases), the strongest contributing factor being HLA B27.Conventional radiography remains the gold standard for diagnosis in the axial skeleton. The new ASAS classification criteria have helped to improve the early diagnosis of SpA, with MRI and early HLA B27 determination playing an important role.

The most frequent extraarticular manifestation in spondyloarthropathies (SpA) is eye involvement, which is found in 30%-50% of patients. HLA B27 positive patients in particular--mostly those in the subgroup with ankylosing spondylitis--are affected. Prevalence of uveitis increases with duration of disease. Typical eye involvement is sudden-onset unilateral anterior uveitis (iridocyclitis). Most cases respond well to topical corticosteroids. Frequently relapsing or chronic cases may require oral corticosteroids in addition to classical immunosuppressive drugs and, to an increasing extent, also TNF-alpha inhibitors. In the case of the latter, monoclonal antibodies are preferred over receptor antagonists. Acute anterior uveitis may occur as a minimal variation or initial symptom of SpA. These patients should also be seen by a rheumatologist since undiagnosed SpA may be present in a significant percentage and should be included in therapeutic considerations.

Aim: Secondary osteoporosis with subsequent fractures are well-known symptoms in ankylosing spondylitis. As a possible genetic component of osteoporosis, an association between bone mineral density (BMD) and polymorphisms of the vitamin D receptor (VDR) gene has been reported., Method: In the present study, we investigated relationships between these polymorphisms, BMD, biochemical markers of bone metabolism and markers of disease activity in ankylosing spondylitis., Results: AS patients showed osteoporosis more frequently than healthy controls. A mapping of activity indices and BMD showed an association of lumbar and peripheral BMD as well as of the current and median C-reactive protein over the last 3 years with the used FokI-genotypes of the VDR in male patients with AS. Female AS patients showed no significant association., Conclusion: The pathophysiological mechanisms of this association are unclear, especially with respect to the inflammatory activity. An early assessment of the risk for osteopenia/osteoporosis in AS patients using molecular biological tests could make possible timely preventive measures or therapy.

The analysis of cytokines (i.e. interleukins, interferons and colony-stimulating factors) has only flourished in the last 25 years subsequently revealing new insights into the pathogenesis of rheumatic diseases that revolutionised the management of patients with chronic rheumatic disorders. Tumour necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1) and interleukin-6 (IL-6) have been found to play a pivotal role in rheumatic inflammation. As early as in 1992 the first proof of concept study with a monoclonal antibody against TNF was able to demonstrate positive effects in rheumatoid arthritis. Since the approval of the first anti-TNF-alpha therapy, further agents against TNF and other proinflammatory cytokines were approved and even more biological drugs are under development aimed at modulating the disturbed immune system in patients with rheumatic diseases. To date the following biologics are approved for therapy of chronic rheumatic diseases: the TNF antagonists Etanercept, Infliximab and Adalimumab; Anakinra as an IL-1 receptor antagonist; the anti-CD20 monoclonal antibody Rituximab and the anti-CD80/86 fusion protein Abatacept. In the present article, we report on biological therapy modalities in rheumatic diseases as well as the recommendations for initiation of these agents.

Background and Purpose: Local as well as whole-body cryotherapy is used to relieve pain and inflammation in rheumatic diseases. In comparison with a chamber-based whole-body cryotherapy, the novel criostream whole-body therapy (single-person cabin with cold air cooled by liquid nitrogen) as an innovative technique offers not only a rapid therapeutic effect but also a considerable reduction in costs. The aim of this study was to compare the effect of whole-body cryotherapy in the criostream on pain reduction, disease activity and pro-inflammatory cytokines (tumor necrosis factor-[TNF-]alpha and interleukin-[IL-]1), and improvement in functional scores., Patients and Methods: Ten patients with different active inflammatory rheumatic diseases (four patients with rheumatoid arthritis, three patients with ankylosing spondylitis, and three patients with psoriatic arthritis/spondylitis) underwent nine sessions of whole-body cryotherapy in 5 days for a short time period (at first 90 s, with step-up in each application to 2.5 min total time)., Results: Pain and disease activity scores decreased significantly, and, subsequently, also the functional scores showed a significant amelioration. Furthermore, there was a significant reduction in TNF-alpha (p < 0.01) and IL-1 (p < 0.05). Side effects were reported only after the first application in two cases (headache and sensation of cold)., Conclusion: The criostream offers an elegant and, from the patient's point of view, attractive therapeutic agent in the multimodal treatment concept for inflammatory rheumatic diseases.

The genetic setting and immunopathogenesis of patients with ankylosing spondylitis can not be changed by the diet. Therefore, an effective pharmacological therapy always is required. As adjuvant therapy the anti-inflammatory diet can help to reduce inflammatory processes, and to delay flares of the disease. The anti-inflammatory diet is consistent with a balanced diet and prevents infirmity provoked by malnutrition. Ankylosing spondylitis is an autoimmune disease and, as such, nutrients may mimic an antigen and cause flares of the disease and increase disease activity driven by antigen reaction. This nutrient-receptor interaction occurs in the individual patient, necessitating an individual dietary counselling for the patient with ankylosing spondylitis.

The activity of a rheumatic disease can be influenced by pregnancy and puerperium. Prospective studies have shown an improvement in joint involvement in rheumatoid arthritis in two thirds to three quarters of pregnancies. After birth, an exacerbation is common. In spondylarthropathies there is no relevant change in disease activity. The fetal outcome is not impaired in patients with rheumatoid arthritis and inflammatory spondylarthropathies. Every pregnancy in women with a rheumatic disease should be considered as high-risk, and such pregnancies require close collaboration between rheumatologists and obstetricians.

Despite intensive research during the last three decades, it is still not clear which precise mechanisms determine the interactions between host factors (HLA-B27 and other genes, cytokines, T lymphocytes) and microbial factors leading to the manifestation and chronicity of ankylosing spondylitis (AS). Rheumatologists and histopathologists have focused their interest on decoding the immune-mediated inflammatory processes and on studying new bone formation and ankylosis. Concerning the genetic basis of AS, there is considerable effort in large genome-wide and candidate gene analyses to discover new genes that are associated with AS. Moreover, such genetic studies could identify genomic regions that determine clinical manifestations and the course of disease.

At present, two principles of biologic treatment for rheumatoid arthritis and other chronic inflammatory joint and spine diseases (juvenile polyarticular idiopathic arthritis, spondarthritides) are available for use in clinical practice. These are the TNF-alpha antagonists etanercept and infliximab as well as the human recombinant IL-1 receptor antagonist anakinra. All three biologics have significant short and long-term therapeutic effects on clinical and humoral inflammatory activity compared to placebo treatment in controlled clinical trials and even radiological progression of rheumatoid arthritis can be with halted. Principally, safety and tolerability of TNF- and IL-1 antagonist are good. However, local skin reactions at injection sites and infections of the upper respiratory tract and urinary tract have to be considered. Severe infections are rare except for an increased frequency of tuberculous infection observed with infliximab worldwide. The induction of autoantibodies including antibodies to double-stranded DNA and neuralizing antibodies to etanercept and infliximab themselves can occur though their clinical significance is still upon debate. It is important to notice that the advantages of the use of biologics in individual patients has carefully to be balanced against their high costs and the increased risk of infectious side effects. Therefore, guidelines of international experts recommend the clinical use of biologics mostly for patients resistant or intolerable to conventional treatment.

Objective: To assess the efficacy and tolerability of sulfasalazine in ankylosing spondylitis including a meta-analysis of comparable trials., Methods: In a prospective, randomized, double-blind, placebo-controlled trial 70 patients with established diagnosis of ankylosing spondylitis and a mean disease duration of 16.7 years were investigated in two centers for 26 weeks comparing 3 g/d sulfasalazine to placebo., Results: The main outcome parameters, pain score, fingers-to-floor test, and CRP, did not improve significantly in the sulfasalazine group compared to the placebo group. Altogether sulfasalazine was significantly superior to placebo only concerning the IgA levels. The dropout rate was 47% for the sulfasalazine group and 19% for the placebo group. Due to side effects, 38% and 11%, respectively, stopped treatment. Ten other prospective, double-blind, controlled studies were analyzed. Altogether 959 patients with a mean disease duration of 13.9 years were evaluated. Most parameters did not improve significantly in the sulfasalazine groups compared to the placebo groups. Spinal motility remained nearly unchanged (0.3-3.5% improvement). Pain, morning stiffness, functional index, and global assessment were slightly influenced (1.9-11.7%). Reduction of ESR, CRP, IgA, IgG, and IgM was more distinct (12.6-20.3%). In 4 studies SSZ had greater efficacy in patients with peripheral joint involvement., Conclusion: Sulfasalazine has no clinically relevant benefit in patients with ankylosing spondylitis. The dropout-rate due to adverse effects is high with a daily dose of 3 g. Sulfasalazine may be beneficial in peripheral joint involvement. Only few data exist about patients with a disease duration of less than 10 years.

Unlabelled: Synovial fluid (SF) analysis was a mandatory investigation in rheumatological practice. In recent time, synovial fluid analysis lost importance predominantly due to unclear defined guidelines for the practical use., Objective: To evaluate the clinical value of the determination of the complement components C'3c and C'4 and immunoglobulines IgG, IgA and IgM synovial fluid concentrations with regard to pathophysiology and currently used RA and SpA classification criteria., Methods: Synovial fluid samples were obtained from 22 patients fulfilling ACR criteria for rheumatoid arthritis (RA), and 18 patients suffering from seronegative spondyloarthropathy (SpA) according to the ESSG criteria. Sixteen osteoarthritis (OA) SF samples were used as controls. IgG, IgA, IgM, C'3c and C'4 in SF and sera were determined by nephelometry. Comparison of the diseases, and linear as well as stepwise logistic regression analyses were performed in order to determine the interrelation of the determined parameters and a ranking of their diagnostic value for the identification of RA or SpA synovial fluids., Results: SF-IgA, SF-IgG and SF-IgM concentrations were closely correlated with their corresponding serum levels (p < 0.01), while SF-C'3c and SF-C'4 depended on articular factors (p < 0.01). Determination of SF-C'3c (accuracy = 80.4%, improved chi 2 = 22.02, p < 0.001) and SF-C'4 (accuracy = 75.0%, improved chi 2 = 21.81, p < 0.001) both provided a good predictive value for the diagnosis of SpA when exceeding the cut off level of about 40 mg/dl (C'3c) or 15 mg/dl (C'4), respectively. Calculation of the C'-SF/S ratios did not provide an additional diagnostic benefit. SF-IgG, IgA and IgM as well as the calculated SF/S ratios were within the same range in RA and SpA fluids., Conclusions: SF concentration of complement components primarily depends on local articular factors. Significant differences of SF complement concentrations in established RA and SpA give reason for prospective analysis of these parameters in early undifferentiated oligoarthritis and evaluation in large studies, e.g. when re-evaluating the preliminary criteria for spondyloarthropathy.

Background: Positive effects of fasting and vegan diet in patients with rheumatic diseases are reported in the literature., Medical History: We present a 33-year-old patient with double-sided HLA B27-positive sacroiliitis, which was diagnosed by magnetic resonance tomography. Since about 10 years he therefore had pain in the iliosacral region. Numerous sessions of physiotherapy, a cure treatment, and treatment with sulfasalazine and doxycycline were not effective. The patient was dependent on the daily intake of the nonsteroidal antirheumatics meloxicam 2 x 7.5 mg and ibuprofen 400-800 mg and the analgetic tramadol 50-150 mg, but evening and night pain and morning stiffness persisted under this treatment., Treatment: We recommended a temporary vegan diet, i.e. to completely avoid animal fats and proteins., Course: 3-4 days after changing on vegan diet the complaints improved distinctly and persistently. After consumption of meat 6 weeks later, complaints worsened. Consequent vegan diet again resulted in significant improvement of the pain and morning stiffness. At follow-up 3 months after the initial contact, tramadol and ibuprofen intakes had been stopped, meloxicam had been reduced to 1 x 7.5 mg. The patient was almost completely free of complaints., Conclusions: It was demonstrated that in a single case of sacroiliitis which was refractory to other treatment, vegan diet resulted in a convincingly improvement of complaints., (Copyright 2001 S. Karger GmbH, Freiburg)

Background: Enteropathic spondylarthropathies (SpA) are the most frequent extraintestinal manifestation of the chronic inflammatory bowel disease (IBD), Crohn's disease (CD) and Ulcerative Colitis (UC). It was the aim of the present study, to analyze a large number of IBD patients for the prevalence and pattern of joint manifestation and the association of SpA with the extend of bowel involvement and HLA-haplotype., Patients and Methods: 521 patients (409 CD and 112 UC) were prospectively analyzed over a period of one year. SpA was diagnosed on the basis of an appropriate patient history as well as clinical, radiological and immunoserological parameters., Results: SpA was diagnosed in 10.7% of all CD and 14.4% of all UC patients. In 26.8% of all patients symptoms of SpA occurred prior to and in 14.4% simultaneously with IBD. 28.1% of all patients presented with isolated peripheral arthritis, 26.8% of all patients showed an isolated involvement of the spine or sacroiliic joints and 45.1% of all patients presented with combined involvement. 2/12 UC patients with SpA suffered from rectosigmoiditis, 5/12 from partial colitis and 5/12 had pancolitis. In CD patients with SpA, 8/59 had isolated colitis, 8/59 ileocolitis and 31/59 isolated small bowel involvement. There was a positive correlation between SpA and HLA-B27 (p < 0.01)., Conclusion: Enteropathic spondylarthropathies are an important extraintestinal manifestation of IBD. Spondylarthropathies occur irrespective of the extend of IBD and frequently become symptomatic prior to IBD. These and recent data describing inflammatory bowel disease in patients with SpA of unknown etiology suggest that both diseases have a common pathogenetic background.

The association of HLA-B27 with ankylosing spondylitis (AS), first described more than 20 years ago, triggered intensive research all over the world. AS is a disease model to study the interplay between genetic, immunologic, and environmental factors in the induction of rheumatic disease. Over the past years, substantial advances have taken place in the area of the molecular and cellular immunology of the HLA-B27 molecule, HLA-B27 subtype polymorphism, peptide binding and presentation to cytotoxic T cells, and their relevance to disease. New insights into the pathogenesis of the spondylarthropathies come from the development of animal models, namely HLA-B27/human beta 2-microglobulin transgenic rats, and HLA-B27 transgenic, beta 2-microglobulin knock-out mice. The role of gram-negative bacteria and gut inflammation in the development of ankylosing spondylitis continues to be the focus of interest in many studies. In this review, recent hypotheses of the pathogenesis of AS and its relationship to HLA-B27 are discussed.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a multipotent hematopoietic growth factor, which is mainly produced by T-cells and stromal cells. Beside the stimulating effects on mature granulocytes, it induces the expression of HLA class II-antigen on synovial tissue-cells in patients with rheumatoid arthritis. The concentrations of GM-CSF in the plasma of 87 patients with rheumatoid arthritis, 48 patients with spondyloarthropathy, 17 patients with systemic lupus erythematosus (SLE), and 43 healthy control persons were investigated. We used an immunoradiometric assay (IR-MA) with a detection limit of 30 pg/ml to measure the GM-CSF concentrations in plasma. The GM-CSF levels of 29 patients with severe rheumatoid arthritis (366 +/- 61 pg/ml, p less than 0.05), 58 patients with moderate rheumatoid arthritis (376 +/- 44 pg/ml, p less than 0.0001), and of 17 patients with SLE (256 +/- 41 pg/ml, p less than 0.05) were elevated compared to the control group (174 +/- 18 pg/ml). No significant differences in the mean GM-CSF plasma levels between the patients with spondyloarthropathy (190 +/- 32 pg/ml) and the control group were found. GM-CSF concentrations as high as 1300 pg/ml were detected in the synovial fluids of patients with rheumatoid arthritis. GM-CSF concentrations in the plasma of patients with severe rheumatoid arthritis were correlated with the plasma concentrations of the soluble interleukin-2-receptor (sCD25) (R = +0.53).

Epidemiological aspects of ankylosing spondylitis of the pre- and post-HLA-B27-area are shortly presented. The prevalence, the incidence and the mortality of the disease are mentioned. The non specific risk factors such as age, sex, familiar clustering and racial distribution are described. The absence of specific risk factors is regretted.

Ankylosing spondylitis is one of the oldest diseases in humans; however, it is still one of the most fascinating and mysterious in human pathology. The unusual combination of both fundamental pathological processes: inflammation and ossification (which are mostly independent in respect to time and place) is unique. Until 1973, ankylosing spondylitis did not attract much immunological research. After the detection of an association between HLA B27 and the disease, clinical and immunological research was stimulated. It was supposed that HLA B27 may be a pathogenic factor. Meanwhile, it has become well known that HLA B27 itself is not required for development of the disease; however, discovery of immunological cross-reactivity between HLA B27 and some Klebsiella antigens inspired pathogenic considerations. It is discussed that the structural similarities between enteric bacteria and HLA B27 induce autoantibodies, or that HLA B27 plays a role in antigen recognition. Possibly, HLA B27 may also act as a receptor for infectious agents and their products. Fascinating, but controversely discussed is the hypothesis that bacterial products modify the B27 molecule and, in this way, trigger the disease. All present theories about pathogenesis of ankylosing spondylitis are unsatisfactory, because many important questions cannot be answered. There are no explanations for the unusual affinity of possible pathogenic immune reactions to the spine and other organs, the induction of ossification, the merging of cartilage, or the development of sacroilitis. Especially, we do not know the important bridge (if one exists) between inflammation and ossification. The typical ossification of the spine is of dramatic consequence for the patient in respect to function and mobility.(ABSTRACT TRUNCATED AT 250 WORDS)

The opsonizing capacity of sera from 22 patients with rheumatoid arthritis (RA), from 14 with psoriatic arthritis (AP), from seven with ankylosing spondylitis, and from healthy control persons was investigated by luminol-dependent chemiluminescence, induced during yeast phagocytosis of normal polymorphonuclear leukocytes. The chemiluminescence response using opsonizing sera was compared to that induced by no-opsonized yeast and the opsonizing capacity was expressed as a percentage. For the opsonization, fresh native serum, in some experiments Mg2+-EGTA and EDTA-treated serum, was used. In RA and AP sera, a significantly diminished opsonizing capacity (p less than 0.005) was observed. In healthy controls and in SPA patients, the opsonizing capacity of their sera was over 200%, while in seronegative RA patients, it was only 175%, in seropositive RA 125%, and in AP 150% was measured. There was no correlation between opsonizing capacity and complement or immunoglobulin content of the investigated sera. The amount of C3b, IgG and IgM covalently bound to yeast particles was determined, too. Yeast particles bind significantly less (p less than 0.01) IgG when opsonized with RA and AP sera, while a higher relative amount of IgM (p less than 0.01) was bound to yeast incubated in the sera of seropositive RA patients. No significant differences in the C3b binding were observed.

The question, whether HLA-B27-negative patients with classical ankylosing spondylitis (AS) belong to a separate nosological entity, was studied by a standardized analysis of 12 clinical, 8 radiological and 6 laboratory criteria in 95 cases, including 7 with HLA-B27-negativity, who reinforced international criteria for classical AS. The results showed neither definite clinical nor radiological, or laboratory differences between the HLA-B27 negative and positive group. We conclude, that existence or absence of the tissue antigen HLA-B27 has no influence on inflammatory activity of skeletal or soft tissue manifestations of the disease. The group of HLA-B27-negative patients who fulfill the criteria of classical AS does therefore not seem to form a separate nosological entity.

151 cases of ankylosing spondylitis, arranged in clinical stages I-IV, were investigated by immunological methods (determination of HLA-B27, immunocomplexes: conglutinin-, Clq-assay; IgG-, IgM-, IgA-rheumatoid factors) and with regard to acute phase proteins (CRP, C3/C4, alpha 1-acid glycoprotein). IgA-rheumatoid factors were demonstrated as dependent upon the stage of the disease in 23-41% of cases and appeared in 20-23% of cases simultaneously with immunocomplexes. Immunocomplexes appeared in 20-23% of cases. With regard to investigations of acute phase proteins, sedimentation rate and CRP correlated best. The frequent appearance of IgA-rheumatoid factors allows a definition of ankylosing spondylitis as seronegative only as far as the determination of IgG- and IgM- rheumatoid factors is concerned.

An account is given of assessed titres of anti-streptolysin O (ASO) and antihyaluronidase (AH) in rheumatic fever, in rheumatic patients of inactive phase and in tonsillitis. The ASO titre was examined in 1739 members of the general public and in 360 patients with chronic rheumatic diseases. The author analyses 6235 examinations of ASO titres and 1210 AH examinations. In rheumatic fever the mean maximum ASO titre was 397 u, while the mean maximum AH titre was 3583 u. In inactive phase rheumatic patients the mean ASO titre was 187 u, the mean AH titre 630 u. The mean ASO titre at the onset of the disease in tonsillitis was 172 u. During the second examination after 3-4 weeks, the mean rise of the ASO titre was 205 u. A increased AH titre above 1280 u was recorded during the first examination in 35.2%, during the second examination in 52.3%. The mean ASO titre in the population group comprising 1739 subjects was 148 u. A titre increased above 200 u was recorded in 20.7%. The mean ASO titre in rheumatoid arthritis was 139 u, in ankylosing spondylitis 199 u, in systemic lupus erythematosus and diffuse scleroderma 128 u. In all groups the ASO and AH levels were inversely proportional to the age of the examined subject. Attention is drawn to the correct evaluation of the assessed antibody titres.

Synostosing ankylosis of lower limb joints was investigated radiologically and clinically in approximately 2000 patients with ankylosing spondylitis. Ankylosis was found in 8 hip joints and in 4 of the joints of the foot skeleton. Most commonly the initial picture of these diseases is that of an arthritis (sometimes specifically misinterpreted as such) years and decades before the manifestation of ankylosing spondylitis appears. The ossifying potential of the disease can apparently manifest itself early in limited areas. The radiological morphology with destruction and reconstruction is found mainly as the well known vertebral changes. Immobilization can at the most be regarded as a favourable factor in a predominantly immunological-inflammatory patho-mechanism. Additional local abnormalities of the vascular or enzymatic systems of the joints can be assumed.

Ankylosing spondylitis is a disease with clinically and radiologically very variable features. It is the intention to direct the attention from the old by orthopedists' influenced association of the stiff back to the polymorphism of the disease especially to the early stages which still frequently are recognized too late. The paper deals with the nosology, the various states of the clinical course with the numerous radiological criteria including therapeutical approaches.

The tiysue antigen HLA-B27 was present in 92.6% of 95 Swiss patients with classical ankylosing spondylitis. This tissue antigen is present in only 7.7% of healthy Swiss blood donors. 36% of all patients had one or several acute attacks of anterior uveitis. This usually follows the onset of joint symptoms. In 4% of the 95 patients the iritis was the first symptom. The combination of acute uveitis and ankylosing spondylitis with the tissue antigen HLA-B27 indicates that not only the spondylitis, but also the uveitis is in many cases genetically determined.

Antinuclear antibodies (ANA) were found in 19.1% of patients suffering from ankylosing spondylitis (n = 320). This figure is significantly higher than the results obtained in a control group. ANA were present in all stages of the disease, including the abortive form of isolated sacroiliitis. ANA were also found in different stages of activity. In addition, ANA-positive cases showed a higher inflammatory activity. In females ANA were more frequently found than in males. There was a positive correlation between ANA and HLA B27 in 87.2%.

Urogenital chlamydial infection should act as a trigger of peripheral and axial form of arthritis like sexually acquired reactive arthritis and Reiter's syndrome assumedly. HLA B-27 positive patients with rheumatic disorders, mainly M. Bechterew (55 out of 62 men and 18 out of 25 women) were investigated for serum-IgG-antibodies to Chlamydia trachomatis (ELISA). Among HLA B-27 positive men and women urogenital disorders in their history were more common as compared with controls. There were found no differences concerning the rate of antichlamydial antibodies between patients and controls. It is supposed, that urogenital bacterial infections rather others than chlamydial infection may be connected with M. Bechterew.