Rheumatol Int (2009) 29:1013–1016

DOI 10.1007/s00296-009-0902-y

ORIGINAL ARTICLE

Association of various inXammatory diseases with human leukocyte antigens B27, B7, Bw4 and Bw6 in patients with SSA

Sangeeta Singh · Gyanendra K. Sonkar · Usha Singh

Received: 25 May 2008 / Accepted: 25 March 2009 / Published online: 26 April 2009© Springer-Verlag 2009

Abstract Seronegative spondyloarthropathies (SSA) area group of inXammatory disorders, which clinically involvethe axial skeleton and the sacroiliiac and shoulder joints.The aim of the present study was to study the association ofHLA B27, B7, Bw4 and Bw6 with some inXammatory dis-eases, in SSA patients in our area. A total of 220 SSApatients were studied and HLA typing for these antigenswere done by the complement-mediated microcytotoxicitymethod. The total positivity of B27 was found to be 68.64%in SSA patients. Tubercular infection (�2 = 8.06) and acuteanterior uveitis (�2 = 6.19) were found to be statisticallysigniWcant (P < 0.05) in B27-positive SSA patients. Tuber-culosis was also found to be signiWcantly (�2 = 6.40)associated with Bw4. In SSA urinary tract infection, gastro-intestinal infection and streptococcal infection were notsigniWcantly associated with B27, B7, Bw4 or Bw6 anti-gens. Our study concludes that microbial infections do havesome pathogenic role in causing SSA.

Keywords Seronegative spondyloarthopathy · HLA antigens · Tuberculosis · Acute anterior uveitis · Urinary tract infection · Gastrointestinal infection · Streptococcal infection

Introduction

Seronegative spondyloarthropathies (SSA) are a group ofinXammatory disorders, which clinically involve the axialskeleton and the sacroiliiac and shoulder joints. The

patients usually complain of low back pain with prominentmorning stiVness [1]. HLA B 27 is associated with AS inall racial groups [2, 3], but it must be noted that a majorityof HLA B27 carriers are free from disease. Two theorieshave been proposed to explain HLA B27 with AS: thereceptor theory and molecular mimicry theory. The recep-tor theory states that the T cell receptor recognizes foreignor self-peptide in association with MHC class I or class IImolecule, forming a trimolecular complex [4, 5]. The HLAB27 binding groove could present a peptide of arthritogenicorigin to T cells, which may be similar to a foreign peptidebound to an HLA molecule. Molecular mimicry theory sug-gests that disease is caused by the antigenic component ofmicroorganisms, which partially resemble or cross-reactivewith HLA molecules. Once antibacterial/antiviral antibod-ies have been produced as a result of infection, they willbind to HLA molecules. Activation of the complement cas-cade will lead to inXammatory and clinical symptoms of thedisease [6]. An alternative explanation for pathogenic auto-reactive responses is through the presence of “cryptic epi-tope”. The principle of this theory is that each self-proteinhas a small number of well-presented dominant epitope,which are involved in negative selection of T cells [7].Cryptic determinants may be present in the synovium andany similarity with antigenic sequences in an infectingorganism could induce an auto-reactive response, which inturn could lead to inXammation and tissue damage.

Mycobacterium tuberculosis is the causative pathogenfor tuberculosis. One-third of the world population isinfected with M. tuberculosis. Among the infected, onlyaround 10% will ever develop clinical disease [8]. RacialdiVerences in susceptibility to tuberculosis are well known.Several studies revealed the association of various HLAantigens with the disease susceptibility in diVerent ethnicpopulations [9–11].

S. Singh · G. K. Sonkar · U. Singh (&)Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Indiae-mail: usha_ugcitrc@rediVmail.com

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Anterior uveitis is among the most common manifesta-tions of eye disease in patients with seronegative spond-yloarthropathies. A strong correlation between uveitis andthe presence of the HLA B27 gene has been reported [12].

Reactive arthritis is triggered by infections in gut or inthe urogenital tract by various bacteria [13, 14]. Streptococ-cus and Staphylococcus have also been implicated in somecases [15] of SSA.

Very few studies on the association of these antigenswith various infections seen in SSA have been carried outin India and abroad. Hence, the aim of the present studywas to study the association of HLA B27, B7, Bw4 andBw6 with some inXammatory diseases in SSA patients inour area.

Materials and methods

The study included 220 patients suspected for SSA fromthe Out and Inpatient Department of Orthopaedics andDivision of Rheumatology of Sir Sunderlal Hospital, Ban-aras Hindu University, Varanasi, India over a period of2 years. Clinical details regarding acute anterior uveitis(AAU), gastrointestinal infection (GI) and urinary tractinfection (UTI) were taken in all cases. Clinical examina-tion done by the clinician was recorded. Diagnosis of SSAwas done by the European Spondyloarthropathy StudyGroup (ESSG) criteria [16]. Diagnosis of tuberculosis wasdone by the ELISA technique and acid-fast bacilli (AFB)staining of smear culture from sputum or urine; culture wasdone in some cases. Test for antistreptolysin O (ASO) forGroup A streptoccocal infection (SI) was done by the latexWxation method, kit of Spinreact Company, Spain, suppliedby Awadh ScientiWc, Lucknow, India. Typing for HLAB27, B7, Bw4 and Bw6 was done by complement-mediatedmicrocytotoxicity method of Terasaki and McClelland [17],as described in detail by Mehra [18]. Antisera B27, B7,Bw4 and Bw6 of BAG Company, Germany were suppliedby Shiva ScientiWc, New Delhi, India.

Statistical analysis

Values are given as mean § SD. Analysis was performedusing �2 test done on SPSS for Windows (version 10.0) sta-tistical package (SPSS Inc., Chicago, IL, USA) computerstatistics programme. P values less than 0.05 were consid-ered to be signiWcant.

Results

A total of 220 cases, which clinically presented as SSA,were studied. The total positivity of B27 was found to be68.64% (151/220). The common infection in our study wasthat of gastrointestinal infection (GI), which was found tobe 36.36%, followed by streptococcal infection (SI;20.45%) and tuberculosis (TB; 20%). ELISA for TB forIgG/IgM antibody and Mantoux test were positive in 20%(44/220) of cases. A total of 37 cases of SSA (24.50%),which were reported to be positive for tuberculosis, werealso positive for HLA B27 antigen. The association of HLAB27 with tuberculosis was found to be statistically signiW-cant (�2 = 8.06, P < 0.05; Table 1). AAU was less commonin our patients (14.50%). Only 18.54% (28/151) of B27-positive SSA patients were diagnosed to have AAU, but itwas found to be statistically signiWcant as compared toHLA B27 negative cases (�2 = 6.19, P < 0.05). UTI, GIinvolvement and SI were also higher in B27-positivepatients compared to negative groups, but statistically non-signiWcant between the two groups (Table 1).

A total of 33 cases of SSA (15%) were B7-positive.Among the most common infections associated with B7-positive cases was GI (36.36%), followed by UTI, SI, TBand AAU (27.27, 24.24, 18.18 and 12.12%, respectively).However, all these infections were statistically nonsigniW-cant between B7-positive and negative groups (P > 0.05;Table 2).

A majority of our SSA patients (75.45%) were Bw4-pos-itive. Out of Bw4-positive SSA cases, only TB was found

Table 1 Association of various infections with HLA B27

TB tuberculosis, AAU acute anterior uveitis, UTI urinary tract infection, GI gastrointestinal infection, SI streptococcal infection, S statisticallysigniWcant, NS statistically nonsigniWcant

Infection B27-positive (n = 151) B27-negative (n = 69) Total (n = 220) �2

No. Percentage No. Percentage No. Percentage

TB 37 24.50 7 10.14 44 20.00 8.06 (S)

AAU 28 18.54 4 05.80 32 14.55 6.19 (S)

UTI 33 21.85 9 13.04 42 19.09 2.38 (NS)

GI 59 39.07 21 30.44 80 36.36 1.53 (NS)

SI 35 23.18 10 14.50 45 20.45 2.20 (NS)

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to be statistically signiWcant (�2 = 6.40, P < 0.05), whilethe rest of the infections were nonsigniWcant between thetwo groups. GI was higher in Bw4-positive cases of SSA(Table 3).

About half of the SSA patients (54.54%) were positivefor Bw6. None of the infections was found to be signiW-cantly associated with the Bw6 antigen. GI was found morefrequently, followed by UTI and other infections (Table 4).

Discussion

M. tuberculosis is the causative pathogen for tuberculosis.Host resistance and hereditary susceptibility along withenvironmental and socio-economic factors are responsiblefor the spread of the disease [19]. In our study 44 (20%)cases were found to be positive for tuberculosis. A Chinesestudy [20] reported 23 AS cases out of 69 cases (33.33%)positive for PPD reaction, including two pulmonary TBcalcinosis and two active TB. A study from India by Guptaet al. [21] reported out of 10 cases of AS with B27-positiveonly one case was having active pulmonary tuberculosis.Skeleton tuberculosis is common in developing countries.The sacroiliac joint was involved in 3–9.7% of the patients.Tubercular sacroiliitis is usually unilateral and clinicallypresent with pain in the buttock and low backache for ashort duration. A study from Netherlands [22] conducted onthe synovial Xuid of various arthritis by PCR found no evi-dence for the pathogenetic role of mycobacteria in spondyl-oarthritis, undiVerentiated arthritis or rheumatoid arthritis.

Gogea et al. [23] also reported a case of tubercular sero-negative spondyloarthropathy in a 30-year-old female whopresented with persistent low backache and pain in the hipwith signiWcant weight loss. The diagnosis of TB wasconWrmed by CT scan guided aspiration which revealedacid-fast bacilli. She responded very well to antituberculartreatment.

Out of the 220 cases, 32 SSA patients were diagnosedwith uveitis of which 28 (18.54%) were B27-positive, andoccurrence of uveitis with B27-positivity in SSA was sig-niWcant. Gupta et al. [21] reported B27-positivity in 64.30cases of acute uveitis. They also reported that 10 cases ofuveitis, associated with ankylosing spondylitis, were alsoB27-positive. Contrary to our study, Linssen et al. [24]reported that 119 out of 154 patients of AAU were HLAB27-positive in which 79 cases were of AS, while Monnetet al. [25] reported that only 46.30% of B27-positive caseswith uveitis were diagnosed with AS.

Selvaraj [19] found cross-reactivity between HLA B27antigen and bacterial strain of Klebsiella and Shigella. Bothorganisms can cause gastrointestinal manifestation andarthritis. Some workers [26] reported on the role of gastro-intestinal infection in AS patients. In our study, about36.36% of patients had gastrointestinal disturbances andXatulence, which was more in B27-positive patients (39 vs.30%). Contrarily, they reported that out of 1,089 patients,only 2.5% patients had urinary tract infection and 4.6% hadgastrointestinal infection. Valtonen et al. [15] reported highStreptolysin O titre in 6 out of 50 patients of reactive arthri-tis. A study from Finland reported that out of 32 cases ofReA patients, 6.9% had a high titre of ASO [13]. In ourstudy, comparatively more patients (20.40%) had elevatedASO test.

Table 2 Association of various infections with HLA B7

TB tuberculosis, AAU acute anterior uveitis, UT urinary tract infection,G gastrointestinal infection, S streptococcal infection, S statisticallysigniWcant, NS statistically nonsigniWcant

Infection B7-positive (n = 33)

B7-negative (n = 187)

�2

No. Percentage No. Percentage

TB 6 18.18 38 20.52 0.27 (NS)

AAU 4 12.12 28 14.97 0.18 (NS)

UTI 9 27.27 33 17.64 1.68 (NS)

GI 12 36.36 68 36.36 0.00 (NS)

SI 8 24.24 37 19.79 0.34 (NS)

Table 3 Association of various infections with HLA Bw4

TB tuberculosis, AAU acute anterior uveitis, UT urinary tract infection,G gastrointestinal Infection, S streptococcal Infection, S statisticallysigniWcant, NS statistically nonsigniWcant

Infection Bw4-positive (n = 166)

Bw4-negative (n = 54)

�2

No. % No. %

TB 38 22.89 6 11.11 6.40 (S)

AAU 27 16.26 5 09.25 1.60 (NS)

UTI 31 18.67 11 20.37 0.08 (NS)

GI 63 37.95 17 31.48 0.73 (NS)

SI 35 21.08 10 18.51 0.16 (NS)

Table 4 Association of various infections with HLA Bw6

TB tuberculosis, AAU acute anterior uveitis, UT urinary tract Infection,G gastrointestinal Infection, S streptococcal Infection, S statisticallysigniWcant, NS statistically nonsigniWcant

Infection Bw6-positive (n = 120)

Bw6-negative (n = 100)

�2

No. % No. %

TB 23 19.17 21 21.00 0.93 (NS)

AAU 17 14.17 15 15.00 0.03 (NS)

UTI 27 22.50 15 15.00 1.98 (NS)

GI 44 36.67 36 36.00 0.01 (NS)

SI 24 20.00 21 21.00 0.03 (NS)

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Conclusion

Thus, our study concludes that GI is a common infection inour area, and TB and AAU infections are common predis-posing factors in SSA patients, as it was found to be statisti-cally signiWcant. Probably both B27 and Bw4 havemolecular mimicry with microbial antigen of tuberculousbacilli and streptococci and other pathogens causing GI andUTI.

Acknowledgment We are thankful to the University Grant Commis-sion for the Wnancial support.

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