Education And Debate


BMJ 1995; 310 doi: (Published 20 May 1995) Cite this as: BMJ 1995;310:1321
  1. Andrew Keat

    The spondyloarthropathies are a cluster of overlapping forms of inflammatory arthritis that are distinct from rheumatoid arthritis and characteristically affect the spine and entheses (insertions of tendons and ligaments). The syndromes include ankylosing spondylitis, reactive arthritis and Reiter's syndrome, psoriatic arthritis, and enteropathic arthritis. The arthropathy of Whipple's disease and Behcet's syndrome may also be included, although these are more controversial. Less clearly defined overlap categories also exist.

    Principal clinical features associated with spondyloarthropathies


    • Peripheral arthritis

    • Ethesopathy

    • Sacroiliitis

    • Spondylitis


    • Psoriasis

    • Inflammatory bowel disease

    • Conjunctivitis and iritis

    • Genitourinary inflammation

    • Carditis

    The spondyloarthropathies are distinguished by familial clusters of cases and a strong association with the class I histocompatibility molecules HLA-B27 and, to a lesser extent, HLA-CW6. However, tissue typing for HLA-B27 is not usually helpful and is not a reliable guide to prognosis. Unlike most patients with rheumatoid arthritis, patients with spondyloarthropathies are seronegative for anti-immunoglobulins (rheumatoid factors).

    Spondyloarthropathies may present at any age, though young adults are primarily affected. In contrast with rheumatoid disease, both sexes are affected more or less equally, though with a slight male predominance. Spinal symptoms may also be more prominent in males.

    View this table:

    Estimated prevalence of spondyloarthropathies and related conditions in United Kingdom



    The characteristic lesions of entheses—such as of the plantar fascia and Achilles tendon insertion—may appear as radiographic erosions. Repair by reactive bone leads to a new, more superficial enthesis, forming a bony spur. This is remodelled with cancellous bone, which eventually leads to ankylosis. Widespread diffuse lesions in the spine or pelvis may produce insidious stiffness and generalised discomfort.

    Histological section through enthesis showing cellular infiltrate between collagen bundles of fascia and periosteum: site of attachment is replaced by granulation tissue infiltrated by lymphocytes, plasma cells, and polymorphonuclear leucocytes. Deep to the superficial lesion there is also infiltration of the marrow space with inflammatory cells and oedema. …

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