We report a 25-year-old woman presenting with sarcoidosis and bilateral sacroiliitis. Her sarcoidosis related symptoms (malaise, cough and dyspnoea) improved dramatically under treatment with steroids but severe back pain persisted. Only seven similar cases have been described over the last 40 years and the question of a possible association between the two diseases has been raised. However, prevalence data from the literature and the apparent lack of genetic links are better arguments for coincidence than for association

Felten, A. von

Michel, B. A.

Speich, R.

Stucki, Gerold

English

Universität München: Elektronischen Publikationen

436-439 Clinical rheurnatology, 1992, 11, N ~ 3 
Case report 
Ankylosing Spondylitis and Sarcoidosis 
Coincidence or Association ? Case Report 
Review of the Literature 
and 
G. S T U C K I ,  A.  V O N  F E L T E N * ,  R.  S P E I C H * ,  B . A .  M I C H E L  
Summary We report a 25-year-old woman presenting with sarcoidosis and bi- 
lateral sacroiliitis. Her sarcoidosis related symptoms (malaise, cough and dysp- 
noea) improved dramatically under treatment with steroids but severe back pain 
persisted. Only seven similar cases have been described over the last 40 years and 
the question of a possible association between the two diseases has been raised. 
However, prevalence data from the literature and the apparent lack of genetic links 
are better arguments for coincidence than for association. 
Key words Ankyiosing Spondylitis, Sacroiliitis, Sarcoidosis, HLA-B27, HLA-B8, 
HLA-DR3. 
INTRODUCTION 
Since 1951, when Verstraeten (1) reported a first case 
with both sacroiliitis and sarcoidosis, six similar cases 
have been described in the literature, including only one 
female patient. Already Verstraeten and later Martin 
(2), Deshayes (3), Cabanel (4), Blanchon (5) and Ger- 
ster (6) raised the question about a possible association 
between the two diseases. We report another case of a 
25-year-old woman presenting typical findings of sarcoi- 
dosis and a six-month history of bilateral iliosacral pain. 
The probability of an association between the two dis- 
eases is discussed. 
CASE REPORT 
The personal history of the 25-year-old female patient 
revealed a single episode of lumbar pain on motion ir- 
radiating to both legs in 1985; X-rays showed a 
spondylolisthesis of L5 on S1. Being in good health until 
February 1990, the patient then noted pain in her mid- 
back and in the area of the right sacroiliac joint irradi- 
ating to the right buttock. Maximum pain regularly in- 
terrupted her sleep between one and three o'clock in the 
Department of Rheumatology and Physical Therapy, *Department of 
Internal Medicine, University Hospital, Zurich, Switzerland. 
morning. And low back stiffness was present for about 
two hours after rising. Further symptoms included recur- 
rent fever up to 38~ poor appetite, and weight loss of 
10 kilos within a six-month period. In March 1990 anky- 
losing spondylitis was diagnosed by a practicing rheuma- 
tologist based on symptoms, clinical findings and inflam- 
matory erosive X-ray changes of both sacroiliac joints 
(Fig. 1). HLA-B27 was positive, an ileocolonoscopy in- 
cluding biopsy and histology examinations of both the il- 
eum and colon were normal, the erythrocyte sediment- 
ation rate (ESR) was 16 mm after 1 hour (Westergren). 
There was no evidence of presence of another form 
among the seronegative spondyloarthropathies. In June 
1990 the patient was referred to our inpatient clinic for 
evaluation because of severe general malaise and in- 
creasing pain resistent to NSAID's (indomethacin, di- 
clofenac, ibuprofen, phenylbutazone). Upon admission 
the patient reported severe low back pain irradiating to 
the buttocks, dyspnoea and palpitation when climbing 
two flights of stairs, and a nonproductive cough. The 
clinical examination revealed limited painful motion of 
both lumbar (Schober Index 10/11 cm) and thoracic 
spine in all directions. The thoracic excursion was lim- 
ited to 80/83 cm. The sacroiliac provocation tests were 
strongly positive on both sides. No other significant find- 
ings were present. Laboratory screening showed an ESR 
of 34 mm after 1 hour, a C-reactive protein of 36.1 mg/1 
(upper limit 10 mg/1), a slight thrombocytosis of 443 x 
Ankylosing spondylitis and sarcoidosis 437 
Fig. 1 : Bilateral sacroiliitis on ap view. 
Table I : Case reports with both ankylosing spondylitis and sarcoidosis 
Author Sex Age Musculoskeletal symptoms Manifestations of sarcoidosis Time Therapy Course 
(year of pub- (age at onset) (age at onset) interval 
lication) (months) 
Verstraeten m 36 ankylosing spondylitis bihilar lymphadenopathy 72 none 
(1951) (30) (36) 
Martin m 58 ankylosing spondylitis bihilar lyrnphadenopathy 84(?) none 
(1953) (45 ?) (38) 
Deshayes m 48 ankylosing spondyfitis bihilar lymphadenopathy, ? prednisolone 
(1%5) (40) pulmonary fibrosis 
(4O) 
Brun f 34 left sacroiliitis bihilar lymphadenopathy, 8 steroids, chemotherapy 
(1966) (34) pulmonary fibrosis 
(33) 
Cabanel m 40 bilateral sacroiliitis bihilar iymphadenopathy, 0 (?) chemotherapy, phenylbuta- 
(1973) (24) pulmonary fibrosis zone 
(24) 
Blanchon m 24 left pulmonary fibrosis, parotitis, 12 prednisone 
(1976) sacroiliitis peripheral iymphadenopathy 
(21) (18) 
Gerster m 27 bilateral sacroiliitis, relapsing bihilar lymphadenopathy, 6 phenylbutazone 
(1981) " uveitis erythema nodosum, arthritis 
(24) left ankle (25) 
? 
subsequent pulmonary fibro- 
sis 
less back pain under steroids 
subsequent oligoarthritis 
(knee, hip) and ankylosing 
spondylitis 
subsequent bony cysts (hand, 
feet), skin ulceration, epid- 
idymitis 
subsequent bihilar lymphade- 
nopathy; left ankle arthritis 
and erythema nodosum dis- 
appear; low back pain per- 
SlSts. 
103/~tl and normocalcaemia (the reported incidence of 
hypercalcaemia in sarcoidosis varies from 2 to 63%, (7)). 
The angiotensin converting enzyme level was also within 
normal limits (44% of patients with bihilar lymphade- 
nopathy but normal lung parenchyma have angiotensin 
converting enzyme levels within normal limits, (8)). On 
chest X-ray (Fig. 2) a bihilar lymphadenopathy and a 
normal lung parenchyma were found and confirmed by 
computerized tomography. Pulmonary function tests re- 
vealed a moderate restrictive lung disease with a mild 
obstructive component, and a slightly decreased carbon 
monoxide diffusing capacity. Transbronchial biopsy 
438 G. Stucki, A. von Felten, R. Speich, B.A. Michel 
showed multiple noncaseating granulomas with epithe- 
loid and multinucleated giant cells (Fig. 3), and bron- 
chioalveolar lavage yielded an increased helper T-cell to 
supressor T-cell ratio of 4.5:1 (a ratio of over 3.5:1 yield- 
ed a sensitivity of 53.2% and a specificity of 92.8% in 
accord with reference 9). The ratio in the blood was 
2.1:1. All acid-fast and fungal stains and cultures were 
negative. Electrocardiogram, echocardiography, and 
ophthalmologic examination were normal. Under treat- 
ment with prednisone starting at 50 mg per day, general 
malaise, dyspnoea and cough disappeared, and ESR 
(6 mm/1 hour), C-reactive protein (16 rag/l), pulmonary 
function tests and bihilar lymphadenopathy returned to 
normal. After a follow-up of one year, however, the pa- 
tient still suffers from severe low back pain exacerbating 
at night despite high doses of indomethacin. A tissue 
typing for the HLA antigens revealed the following re- 
suits: A1, - ;  B8, 27; DR3, 4 (DRw52, 53; DQw2, 3). 
DISCUSSION 
Fig. 2: Chest roentgenogram showing bilateral hilar 
lymphadenopathy. 
This is a report of a 25-year-old woman with ankylos- 
ing spondylitis who developed symptomatic pulmonary 
sarcoidosis. Despite prompt improvement of the sarcoi- 
dosis related malaise, dyspnoea and cough as well as the 
ESR under treatment with prednisone, persistent in- 
Fig. 3: Transbronchial biopsy showing noncaseating granuloma with epitheloid cells including a multinuclear giant cell. 
Ankylosing spondylitis and sarcoidosis 439 
f l ammato ry  back  pa in  was n o t e d  desp i t e  add i t i ona l  
N S A I D  therapy.  This  d i f f e rence  b e t w e e n  the  t h e r a p e u -  
tic responses  of  p u l m o n a r y  and  muscu loske le t a l  symp- 
toms suggests  the  p r e s e n c e  of  d i f fe ren t  p a t h o g e n e t i c  
mechan i sms  involved in the  two d isorders .  Based  on ep-  
idemiologica l  da t a  t he re  is no  r eason  to a s sume  an  as- 
socia t ion  of  the  two en t i t i es  each  having a re la t ive ly  high 
preva lence .  T h e  p reva lence  o f  ankylos ing spondyl i t i s  is 
r e p o r t e d  as 1 p e r  1000 p o p u l a t i o n  (10), and  the  prev-  
a lence  of  sarcoidos is  var ies  f rom 0.04 in Spa in  to 64 p e r  
1000 popu la t i on  in Sweden  (11). The re fo r e ,  b a s e d  on 
pu re  co inc idence ,  p reva lence  d a t a  for  the  two d i so rde r s  
a re  to be  expec ted  in the  o r d e r  of  0.00004 to 0.064 p e r  
1000, the  number s  be ing  even h igher  if assoc ia t ion  of  the  
two d iseases  is assumed.  In the  l i t e ra tu re ,  however ,  only  
seven similar  cases  were  r e p o r t e d  over  a p e r i o d  of  39 
years  indica t ing  the  lack  of  an assoc ia t ion  b e t w e e n  sar-  
coidosis  and  ankylosing spondyl i t i s  ((1-6,12), T a b l e  I) .  
A gene t i ca l l y -de t e rmined  p red i spos i t i on  to deve lop  ei- 
t he r  sa rco idos i s  or  ankylos ing  spondyl i t i s  has  b e e n  no ted  
in ce r t a in  g roups  of  pa t ien ts .  H L A - D R 5  was s ignif icant-  
ly i nc reased  in an  e n d e m i c  c lus te r  of  p a t i e n t s  wi th  sar- 
coidosis  in G e r m a n y  (13,14), and  H L A - B 8  has  been  as- 
soc ia ted  with  acu te  sa rco idos i s  - r e l a t e d  a r thr i t i s  (15) 
and  with  s p o n t a n e o u s  r e so lu t ion  (16). H L A - B 8  and  
H L A - D R 3  have b e e n  as soc ia t ed  with  acu te  onse t  of  sar-  
co idos i s  with a r thr i t i s  (17,18). O n  the  o t h e r  hand ,  t h e r e  
is a c lea r  assoc ia t ion  of  ankylos ing  spondyl i t i s  wi th  H L A -  
B27 (19). However ,  no  c o m m o n  gene t ic  l inks have been  
iden t i f i ed  for  the  two d i sorders .  In te res t ing ly ,  in our  pa -  
t i en t  we found  H L A - B 2 7  as well  as H L A - B 8  and  H L A -  
D R 3  to be  posi t ive.  T h e  p r e s e n c e  of  the  typical  H L A  
specif ic i t ies  for  bo th  d i seases  may  ind ica te  the  coexist-  
ence  of  two i n d e p e n d e n t  d i sease  processes .  
In  conclus ion,  r e sponse  to the rapy ,  p r e va l e n ce  da t a  
f rom the  l i t e r a tu r e  and  the  a p p a r e n t  lack of  gene t i c  l inks 
a re  b e t t e r  a rgumen t s  for  co inc idence  than  for  associa-  
t ion.  
REFERENCES 
1. Verstraeten, J.M., Bekaert, J. Association de spondylite anky- 
losante et de sarcoidose. Acta Tuberc Belg 1951, 42, 149-151. 
2. Martin, E., Fallet, G.H. Pneumopathies chroniques et rhumatis- 
me. Schweiz Med Wochenschr 1953, 83, 776-782. 
3. Deshayes, P., Desseauve, J., Hubert, J., Lemercier, J.P., Geoffroy, 
Y. Un cas de polyarthrite au cours d'une sarcoidose. Un cas de 
spondylarthrite ankylosante au cours d'une sarcoidose. Rev 
Rhum 1965, 32, 671-674. 
4. Cabanel, G., Jacquot, F., Phelip, X., Gras, J.P., Mouries, D. Les 
formes articulaires de la sarcoidose. Sem H6p Paris 1973, 49, 
3051-3060. 
5. Blanchon, P., Paillas, J., Lauriat, H., Tominez, G. Localisations 
pelvi-rachidiennes et rachidiennes de la sarcoidose de B.B.S.. 
Ann Med Interne 1976, 127, 843-848. 
6. Gerster, J.C., Chappuis, P. Association d'une sarcoidose agu~ et 
d'une spondylarthrite ankylosante. Schweiz Rundschau Med 
1981, 70, 2356-2359. 
7. Goldstein, R.A., Israel, H.L., Becker, K.L., Moore, C.F. The in- 
frequency of hypercaleemia in sarcoidosis. Am J Med 1971, 51, 
21-30. 
8. Studdy, P.R., Lapworth, R., Bird, R. Angiotensin converting en- 
zyme and its clinical significance-a review. J Clin Pathol 1983, 36, 
938-947. 
9. Costabel, U., Teschler, H., Guzman, J., Kroegel, C. Bronchoal- 
veol~ire Lavage : Zwischenbilanz nach zehn Jahren ldinischer An- 
wendung. Med Klin 1990, 85, 367-387. 
10. Carter, E.T. Epidemiology of ankylosing spondylitis in Rochester, 
Minnesota, 1935-1973. Arthritis Rheum 1979, 22, 365-370. 
11. Teirstein, A.S., Lesser, M. Worldwide distribution and epidemi- 
ology of sarcoidosis. In : Sarcoidosis and Other Granulomatous 
Diseases of the Lung Vol 20. Ed.: Fanburg, B.L., Marcel Dekker, 
Inc 1983, 101-134. 
12. Brun, J., Pozzetto, H., Buffat, J.J., Soustelle, J., Vauzelle, J.L., 
Patin, R. Sarcoidose vertebrale et sacro-iliaque avec image de 
pseudo-absc6s pottique. Presse Med 1966, 74, 511-515. 
13. Nowack, D., Goebel, K.M. Genetische und diagnostische Bedeu- 
tung der HLA-Merkmale bei der Sarkoidose. Schweiz Med Wschr 
1986, 116, 1479-1480. 
14. Nowack, D., Goebel, K.M. Genetic aspects of sarcoidosis. Arch 
Intern Med 1987, 147, 481. 
15. Brewerton, D.A., Cockburn, C., James, D.C., James, D.G., Nev- 
ille, E. HLA antigens in sarcoidosis. Clin Exp Immunol 1977, 27, 
227-229. 
16. Smith, M.J., Turton, C.W.G., Turner-Warwick, M., Morris, L.M., 
Lawler, S.D. Association of HLA B8 with spontaneus resolution 
in sarcoidosis. Thorax 1981, 36, 296-298. 
17. Hedfors, E., Lindstr6m, F. HLA-B8/DR3 in sarcoidosis. Corre- 
lation to acute onset disease with arthritis. Tissue Antigens 1983, 
22, 200-203. 
18. Kremer, J.M. Histologic findings in siblingswith acute sarcoid arth- 
ritis: Association with the B8, DR3 phenotype. J Rheumatol 
1986, 13, 593-597. 
19. Khan, M.A. HLA and ankylosing spondylitis. In: Ankylosing 
Spondylitis - New Clinical Applications Vol. I. Editor : Calabro, 
J.J., Dick C, Lancaster (England) MTP Press Limited 1987, 23. 
Received : 2 December 1991 ; Revision-accepted : 24 March 1992 
Correspondence to: G. STUCKI, M.D., 
Department of Rheumatology, University Hospital, Gloriastr. 25, 
CH-8091 Zurich. 


Ankylosing spondylitis and sarcoidosis — Coincidence or association?

Open Access LMU ( Ludwig-Maximilians-Univ. München)

436-439 Clinical rheurnatology, 1992, 11, N ~ 3 Case report Ankylosing Spondylitis and Sarcoidosis Coincidence or Association ? Case Report Review of the Literature and G. STUCKI ,  A. VON FELTEN* ,  R. SPE ICH* ,  B .A .  M ICHEL  Summary We report a 25-year-old woman presenting with sarcoidosis and bi- lateral sacroiliitis. Her sarcoidosis related symptoms (malaise, cough and dysp- noea) improved dramatically under treatment with steroids but severe back pain persisted. Only seven similar cases have been described over the last 40 years and the question of a possible association between the two diseases has been raised. However, prevalence data from the literature and the apparent lack of genetic links are better arguments for coincidence than for association. Key words Ankyiosing Spondylitis, Sacroiliitis, Sarcoidosis, HLA-B27, HLA-B8, HLA-DR3. INTRODUCTION Since 1951, when Verstraeten (1) reported a first case with both sacroiliitis and sarcoidosis, six similar cases have been described in the literature, including only one female patient. Already Verstraeten and later Martin (2), Deshayes (3), Cabanel (4), Blanchon (5) and Ger- ster (6) raised the question about a possible association between the two diseases. We report another case of a 25-year-old woman presenting typical findings of sarcoi- dosis and a six-month istory of bilateral iliosacral pain. The probability of an association between the two dis- eases is discussed. CASE REPORT The personal history of the 25-year-old female patient revealed a single episode of lumbar pain on motion ir- radiating to both legs in 1985; X-rays showed a spondylolisthesis of L5 on S1. Being in good health until February 1990, the patient hen noted pain in her mid- back and in the area of the right sacroiliac joint irradi- ating to the right buttock. Maximum pain regularly in- terrupted her sleep between one and three o'clock in the Department of Rheumatology and Physical Therapy, *Department of Internal Medicine, University Hospital, Zurich, Switzerland. morning. And low back stiffness was present for about two hours after rising. Further symptoms included recur- rent fever up to 38~ poor appetite, and weight loss of 10 kilos within a six-month period. In March 1990 anky- losing spondylitis was diagnosed by a practicing rheuma- tologist based on symptoms, clinical findings and inflam- matory erosive X-ray changes of both sacroiliac joints (Fig. 1). HLA-B27 was positive, an ileocolonoscopy in- cluding biopsy and histology examinations ofboth the il- eum and colon were normal, the erythrocyte sediment- ation rate (ESR) was 16 mm after 1 hour (Westergren). There was no evidence of presence of another form among the seronegative spondyloarthropathies. In June 1990 the patient was referred to our inpatient clinic for evaluation because of severe general malaise and in- creasing pain resistent o NSAID's (indomethacin, di- clofenac, ibuprofen, phenylbutazone). Upon admission the patient reported severe low back pain irradiating to the buttocks, dyspnoea and palpitation when climbing two flights of stairs, and a nonproductive cough. The clinical examination revealed limited painful motion of both lumbar (Schober Index 10/11 cm) and thoracic spine in all directions. The thoracic excursion was lim- ited to 80/83 cm. The sacroiliac provocation tests were strongly positive on both sides. No other significant find- ings were present. Laboratory screening showed an ESR of 34 mm after 1 hour, a C-reactive protein of 36.1 mg/1 (upper limit 10 mg/1), a slight thrombocytosis of 443 x Ankylosing spondylitis and sarcoidosis 437 Fig. 1 : Bilateral sacroiliitis on ap view. Table I : Case reports with both ankylosing spondylitis and sarcoidosis Author Sex Age Musculoskeletal symptoms Manifestations of sarcoidosis Time Therapy Course (year of pub- (age at onset) (age at onset) interval lication) (months) Verstraeten m 36 ankylosing spondylitis bihilar lymphadenopathy 72 none (1951) (30) (36) Martin m 58 ankylosing spondylitis bihilar lyrnphadenopathy 84(?) none (1953) (45 ?) (38) Deshayes m 48 ankylosing spondyfitis bihilar lymphadenopathy, ? prednisolone (1%5) (40) pulmonary fibrosis (4O) Brun f 34 left sacroiliitis bihilar lymphadenopathy, 8 steroids, chemotherapy (1966) (34) pulmonary fibrosis (33) Cabanel m 40 bilateral sacroiliitis bihilar iymphadenopathy, 0 (?) chemotherapy, phenylbuta- (1973) (24) pulmonary fibrosis zone (24) Blanchon m 24 left pulmonary fibrosis, parotitis, 12 prednisone (1976) sacroiliitis peripheral iymphadenopathy (21) (18) Gerster m 27 bilateral sacroiliitis, relapsing bihilar lymphadenopathy, 6 phenylbutazone (1981) " uveitis erythema nodosum, arthritis (24) left ankle (25) ? subsequent pulmonary fibro- sis less back pain under steroids subsequent oligoarthritis (knee, hip) and ankylosing spondylitis subsequent bony cysts (hand, feet), skin ulceration, epid- idymitis subsequent bihilar lymphade- nopathy; left ankle arthritis and erythema nodosum dis- appear; low back pain per- SlSts. 103/~tl and normocalcaemia (the reported incidence of hypercalcaemia n sarcoidosis varies from 2 to 63%, (7)). The angiotensin converting enzyme level was also within normal limits (44% of patients with bihilar lymphade- nopathy but normal lung parenchyma have angiotensin converting enzyme levels within ormal limits, (8)). On chest X-ray (Fig. 2) a bihilar lymphadenopathy and a normal lung parenchyma were found and confirmed by computerized tomography. Pulmonary function tests re- vealed a moderate restrictive lung disease with a mild obstructive component, and a slightly decreased carbon monoxide diffusing capacity. Transbronchial biopsy 438 G. Stucki, A. von Felten, R. Speich, B.A. Michel showed multiple noncaseating granulomas with epithe- loid and multinucleated giant cells (Fig. 3), and bron- chioalveolar lavage yielded an increased helper T-cell to supressor T-cell ratio of 4.5:1 (a ratio of over 3.5:1 yield- ed a sensitivity of 53.2% and a specificity of 92.8% in accord with reference 9). The ratio in the blood was 2.1:1. All acid-fast and fungal stains and cultures were negative. Electrocardiogram, echocardiography, and ophthalmologic examination were normal. Under treat- ment with prednisone starting at 50 mg per day, general malaise, dyspnoea and cough disappeared, and ESR (6 mm/1 hour), C-reactive protein (16 rag/l), pulmonary function tests and bihilar lymphadenopathy returned to normal. After a follow-up of one year, however, the pa- tient still suffers from severe low back pain exacerbating at night despite high doses of indomethacin. A tissue typing for the HLA antigens revealed thefollowing re- suits: A1, - ;  B8, 27; DR3, 4 (DRw52, 53; DQw2, 3). DISCUSSION Fig. 2: Chest roentgenogram showing bilateral hilar lymphadenopathy. This is a report of a 25-year-old woman with ankylos- ing spondylitis who developed symptomatic pulmonary sarcoidosis. Despite prompt improvement of the sarcoi- dosis related malaise, dyspnoea nd cough as well as the ESR under treatment with prednisone, persistent in- Fig. 3: Transbronchial biopsy showing noncaseating granuloma with epitheloid cells including amultinuclear giant cell. Ankylosing spondylitis and sarcoidosis 439 f lammatory back pain was noted despite addit ional  NSAID therapy. This di f ference between the therapeu-  tic responses of pu lmonary and musculoskeletal  symp- toms suggests the presence of di f ferent pathogenet ic  mechanisms involved in the two disorders.  Based on ep- idemiological  data there is no reason to assume an as- sociation of the two entit ies each having a relatively high prevalence. The prevalence of  ankylosing spondyl it is is reported as 1 per  1000 populat ion (10), and the prev- alence of sarcoidosis varies from 0.04 in Spain to 64 per  1000 populat ion in Sweden (11). Therefore,  based on pure coincidence, prevalence data for the two disorders are to be expected in the order  of 0.00004 to 0.064 per  1000, the numbers being even higher if associat ion of the two diseases is assumed. In the l i terature,  however, only seven similar cases were repor ted over a per iod of 39 years indicating the lack of an associat ion between sar- coidosis and ankylosing spondylit is ((1-6,12), Table I). A genet ica l ly-determined predisposi t ion to develop ei- ther sarcoidosis or ankylosing spondylit is has been noted in certain groups of patients.  HLA-DR5 was signif icant- ly increased in an endemic  cluster of pat ients  with sar- coidosis in Germany (13,14), and HLA-B8 has been as- sociated with acute sarcoidosis - re lated arthrit is (15) and with spontaneous resolut ion (16). HLA-B8  and HLA-DR3 have been associated with acute onset of sar- coidosis with arthrit is (17,18). On the other  hand, there is a clear associat ion f  ankylosing spondyl it is with HLA-  B27 (19). However,  no common genetic l inks have been ident i f ied for the two disorders.  Interest ingly,  in our pa- t ient we found HLA-B27 as well as HLA-B8  and HLA-  DR3 to be positive. The presence of the typical HLA specif icit ies for both diseases may indicate the coexist- ence of two independent  disease processes. In conclusion, response to therapy,  prevalence data from the l i terature and the apparent  lack of genet ic  l inks are bet ter  arguments for coincidence than for associa- tion. REFERENCES 1. Verstraeten, J.M., Bekaert, J. Association de spondylite anky- losante et de sarcoidose. Acta Tuberc Belg 1951, 42, 149-151. 2. Martin, E., Fallet, G.H. Pneumopathies chroniques et rhumatis- me. Schweiz Med Wochenschr 1953, 8 776-782. 3. Deshayes, P., Desseauve, J., Hubert, J., Lemercier, J.P., Geoffroy, Y. Un cas de polyarthrite au cours d'une sarcoidose. Un cas de spondylarthrite ankylosante au cours d'une sarcoidose. Rev Rhum 1965, 32, 671-674. 4. Cabanel, G., Jacquot, F., Phelip, X., Gras, J.P., Mouries, D. Les formes articulaires de la sarcoidose. Sem H6p Paris 1973, 49, 3051-3060. 5. Blanchon, P., Paillas, J., Lauriat, H., Tominez, G. Localisations pelvi-rachidiennes t rachidiennes de la sarcoidose de B.B.S.. Ann Med Interne 1976, 127, 843-848. 6. Gerster, J.C., Chappuis, P. Association d'une sarcoidose agu~ et d'une spondylarthrite ankylosante. Schweiz Rundschau Med 1981, 70, 2356-2359. 7. Goldstein, R.A., Israel, H.L., Becker, K.L., Moore, C.F. The in- frequency of hypercaleemia in sarcoidosis. Am J Med 1971, 51, 21-30. 8. Studdy, P.R., Lapworth, R., Bird, R. Angiotensin converting en- zyme and its clinical significance-a review. J Clin Pathol1983, 36, 938-947. 9. Costabel, U., Teschler, H., Guzman, J., Kroegel, C. Bronchoal- veol~ire Lavage : Zwischenbilanz nach zehnJahren ldinischer An- wendung. Med Klin 1990, 85, 367-387. 10. Carter, E.T. Epidemiology ofankylosing spondylitis in Rochester, Minnesota, 1935-1973. Arthritis Rheum 1979, 22, 365-370. 11. Teirstein, A.S., Lesser, M. Worldwide distribution and epidemi- ology of sarcoidosis. In : Sarcoidosis and Other Granulomatous Diseases of the Lung Vol 20. Ed.: Fanburg, B.L., Marcel Dekker, Inc 1983, 101-134. 12. Brun, J., Pozzetto, H., Buffat, J.J., Soustelle, J., Vauzelle, J.L., Patin, R. Sarcoidose vertebrale t sacro-iliaque avec image de pseudo-absc6s pottique. Presse Med 1966, 74, 511-515. 13. Nowack, D., Goebel, K.M. Genetische und diagnostische Bedeu- tung der HLA-Merkmale bei der Sarkoidose. Schweiz Med Wschr 1986, 116, 1479-1480. 14. Nowack, D., Goebel, K.M. Genetic aspects of sarcoidosis. Arch Intern Med 1987, 147, 481. 15. Brewerton, D.A., Cockburn, C., James, D.C., James, D.G., Nev- ille, E. HLA antigens in sarcoidosis. Clin Exp Immunol 1977, 27, 227-229. 16. Smith, M.J., Turton, C.W.G., Turner-Warwick, M., orris, L.M., Lawler, S.D. Association of HLA B8 with spontaneus resolution in sarcoidosis. Thorax 1981, 36, 296-298. 17. Hedfors, E., Lindstr6m, F. HLA-B8/DR3 in sarcoidosis. Corre- lation to acute onset disease with arthritis. Tissue Antigens 1983, 22, 200-203. 18. Kremer, J.M. Histologic findings in siblingswith acute sarcoid arth- ritis: Association with the B8, DR3 phenotype. J Rheumatol 1986, 13, 593-597. 19. Khan, M.A. HLA and ankylosing spondylitis. In: Ankylosing Spondylitis - New Clinical Applications Vol. I. Editor : Calabro, J.J., Dick C, Lancaster (England) MTP Press Limited 1987, 23. Received : 2 December 1991 ; Revision-accepted : 24 March 1992 Correspondence to: G. STUCKI, M.D., Department of Rheumatology, University Hospital, Gloriastr. 25, CH-8091 Zurich. 

Angiotensin converting enzyme and its clinical significance-a review.

Association d'une sarcoidose agu~ et d'une spondylarthrite ankylosante. Schweiz Rundschau Med

Association de spondylite ankylosante et de sarcoidose. Acta Tuberc Belg

Association of HLA B8 with spontaneus resolution in sarcoidosis. Thorax

Epidemiology of ankylosing spondylitis in

Genetic aspects of sarcoidosis.

Genetische und diagnostische Bedeutung der HLA-Merkmale bei der Sarkoidose. Schweiz Med Wschr

Histologic findings in siblingswith acute sarcoid arthritis: Association with the B8, DR3 phenotype.

HLA and ankylosing spondylitis. In: Ankylosing Spondylitis -

HLA antigens in sarcoidosis. Clin Exp Immunol

HLA-B8/DR3 in sarcoidosis. Correlation to acute onset disease with arthritis. Tissue Antigens

Les formes articulaires de la sarcoidose.

Localisations pelvi-rachidiennes et rachidiennes de la sarcoidose de B.B.S.. Ann Med Interne

Pneumopathies chroniques et rhumatisme. Schweiz Med Wochenschr

Sarcoidose vertebrale et sacro-iliaque avec image de pseudo-absc6s pottique. Presse Med

The infrequency of hypercaleemia in sarcoidosis.

Un cas de polyarthrite au cours d'une sarcoidose. Un cas de spondylarthrite ankylosante au cours d'une sarcoidose. Rev Rhum

Worldwide distribution and epidemiology of sarcoidosis.

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Ankylosing spondylitis and sarcoidosis — Coincidence or association?

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