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The bone marrow side of axial spondyloarthritis

Nature Reviews Rheumatology volume 19, pages 519–532 (2023)Cite this article

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Abstract

Spondyloarthritis (SpA) is characterized by the infiltration of innate and adaptive immune cells into entheses and bone marrow. Molecular, cellular and imaging evidence demonstrates the presence of bone marrow inflammation, a hallmark of SpA. In the spine and the peripheral joints, bone marrow is critically involved in the pathogenesis of SpA. Evidence suggests that bone marrow inflammation is associated with enthesitis and that there are roles for mechano-inflammation and intestinal inflammation in bone marrow involvement in SpA. Specific cell types (including mesenchymal stem cells, innate lymphoid cells and γδ T cells) and mediators (Toll-like receptors and cytokines such as TNF, IL-17A, IL-22, IL-23, GM-CSF and TGFβ) are involved in these processes. Using this evidence to demonstrate a bone marrow rather than an entheseal origin for SpA could change our understanding of the disease pathogenesis and the relevant therapeutic approach.

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Fig. 1: Bone marrow oedema in axial spondyloarthritis.
Fig. 2: Bone marrow involvement in early spondyloarthritis.
Fig. 3: Bone marrow–enthesis crosstalk.
Fig. 4: Bone marrow niche dysfunction in axSpA.

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Authors and Affiliations

  1. Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy

    Daniele Mauro & Francesco Ciccia

  2. Unit of Rheumatology, San Giovanni Bosco Hospital, Naples, Italy

    Saviana Gandolfo & Enrico Tirri

  3. Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany

    Georg Schett

  4. Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany

    Georg Schett

  5. Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

    Walter P. Maksymowych

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D.M., S.G., G.S., W.P.M. and F.C. researched data and wrote the article. All authors made a substantial contribution to discussion of the content and reviewed and/or edited the manuscript before submission.

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Mauro, D., Gandolfo, S., Tirri, E. et al. The bone marrow side of axial spondyloarthritis. Nat Rev Rheumatol 19, 519–532 (2023). https://doi.org/10.1038/s41584-023-00986-6

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