The classification of HLA B27 positive inflammatory rheumatic disease

Kidd, Bruce Lindsay (1990) The classification of HLA B27 positive inflammatory rheumatic disease. University of Southampton, Doctoral Thesis.

Abstract

The object of the thesis was to investigate the hypothesis that many HLA B27 positive patients followed in a rheumatology clinic with unclassified rheumatic disease are suffering from atypical and unrecognised forms of spondarthritis. A total of 263 subjects were reviewed in a clinical study which compared the features of HLA B27 positive patients with unclassified rheumatic disease (n= 111) to the features of patients with a spondarthritic disorder defined by conventional standards (n= 152). In many cases a prolonged diagnostic delay had occurred, often resulting in inappropriate investigation and therapy. Seventy two (65%) of the unclassified subjects had clinical features resembling the features of subjects with defined spondarthritis. Forty eight unclassified subjects had symptoms of an inflammatory spinal disorder (spondylitic spondarthritis). The features of these subjects differed from a control group with mechanical back pain but were qualitatively similar to subjects with ankylosing spondylitis. Twenty four unclassified subjects had relapsing oligoarthritis and enthesitis (palindromic spondarthritis) which resembled one of three patterns of peripheral disease found in subjects with defined spondarthritis. An immunocytochemical study compared the histological features of the synovial membrane in subjects with either spondarthritis or rheumatoid arthritis. Differences were apparent between the disorders as regards the relative concentrations of various T lymphocyte populations. These were indicative of distinct pathological mechanisms but were not sufficiently marked as to have value in distinguishing between spondarthritis and other inflammatory rheumatic diseases. A method for classification and diagnosis of HLA B27 positive spondarthritis is proposed which recognises many previously unclassified subjects as having spondarthritis and includes the novel diagnostic categories spondylitic and palindromic spondarthritis. The quantitative approach adopted has the advantage of overcoming the `all or nothing phenomenon' inherent in conventional diagnostic standards, which though appropriate for epidemiological surveys is limiting in clinical practice.

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