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The unifying concept of spondyloarthritis (SpA) was introduced by the group of Wright et al. in 1974 [1, 2] following a series of studies in a group of inflammatory disorders until then considered to be variants of rheumatoid arthritis (RA). It was, however, their own clinical work on psoriatic arthritis (PsA) that led them to formulate their concept of SpA [2]. The basic characteristics that bound the group were the following: (a) absence of rheumatoid factor; (b) absence of subcutaneous nodules; (c) peripheral arthritis; (d) radiologic evidence of sacroiliitis, with or without ankylosing spondylitis (AS); (e) tendency to manifest clinical interrelationships between individual members of the group, particularly psoriasiform skin or nail lesions, ocular, buccal, genitourinary inflammation, or bowel ulceration, erythema nodosum, pyoderma gangrenosum, and thrombophlebitis; and f) familial aggregation. Initial considerations for inclusion in this group were the following: PsA, reactive arthritis (ReA) (formerly Reiter’s disease), ulcerative colitis, Crohn’s disease, Whipple’s disease, Behcet’s syndrome, and AS. At present, further advances in the field have led to removing from the group Whipple’s disease and Behcet’s syndrome, and studies led by the group ASAS have proposed newer classification criteria that are being used for clinical research studies [3]. Other inflammatory disorders, including gout, Still’s disease, and hemochromatosis, were initially considered for inclusion but not considered further due to their lack of clinical, familial aggregation. Gouty arthritis, including axial gout, may merit further investigation [4, 5]. In this issue of Clinical Rheumatology, Dagan et al. described acute onset of psoriatic spondyloarthritis (PSpA) in three patients following a recent streptococcal infection and concluded that acute psoriatic SpA (PSpA) should be considered in the differential diagnosis of new-onset inflammatory back pain followed by psoriasis in young adults who had a recent throat infection [6]. All patients exhibited inflammatory back pain with evidence of acute axial SpA on MRI and psoriatic SpA occurred within 7–10 days of a confirmed streptococcal infection. One patient had guttate psoriasis, another developed pustular psoriasis, while the third had an exacerbation of pustular palmoplantar psoriasis. Due to the severity of the clinical picture and lack of clinical response to conventional anti-inflammatory therapy, two patients required treatment with TNF-α inhibitors. Authors further comment that axial involvement in post-streptococcal reactive arthritis (PSRA) is a rare event and that acute psoriatic SpA as a manifestation of PSRA has yet to be described. Streptococcus pyogenes, the group A Streptococcus (GAS), is the most common cause of bacterial pharyngitis in children and adults, and a number of inflammatory manifestations are described with GAS pharyngitis, which can lead to chronic diseases in patients. Other groups including B, C, and G can also be associated with disease in humans. Group A Streptococci are best known for their association with rheumatic fever, but other clinical well-established associations are guttate psoriasis, post-streptococcal glomerulonephritis, scarlet fever, cutaneous vasculitis, and poststreptococcal reactive arthritis (PSRA) [7, 8]. Of particular relevance to this discussion is the distinction between acute rheumatic fever (ARF) and post-streptococcal reactive arthritis (PSRA). There are no gender differences between ARF and PSRA. There is a bimodal age distribution in PSRA, with a peak incidence at 8–14 years and a secondary peak at 21–37. In ARF, there is a single peak at 12 years. Genetics may also * Luis R. Espinoza lespin1@lsuhsc.edu

Expanding the spectrum of spondyloarthritis (SpA): post-streptococcal reactive arthritis (PSRA)-related psoriatic spondyloarthritis (PSpA)