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The Rarity of Ankylosing Spondylitis in the Black Race.

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The Rarity of Ankylosing Spondylitis in the Black Race
John Baum and Morris Ziff
Ankylosing spondylitis is apparently rare in the black race. Data collected from
Veterans Administration hospitals in different geographic areas of the United
States indicates an overall frequency of the disease in black Afro-Americans to
be about 25% of that seen in whites. A review of the literature from the
Americas and Africa confirms its uncommon occurrence. A postulated inheritance pattern may depend on multigenic factors.
Ankylosing spondylitis is considered to
be a genetically-determined disease. T h e
mode of inheritance is still the subject of
debate with most early studies indicating
a n inheritance pattern due to an autosomal
dominant gene (1-3). A more recent study,
however, has concluded that the disease is
multigenic in causation (4). T h e frequency in white populations is from 1-3/1000
males (5). Although i t has been stated that
the disease affects all races and appears to
be widespread in all countries (6), there is
little data actually reported from black
population areas. Because we have been
From the Department of Internal Medicine,
Rheumatic Diseases Unit, T h e University of Texas
Southwestern Medical School at Dallas, Dallas,
T e x 75235.
Supported by US Public Health Service Grant
AM-09989 and AM-05154.
JOHN BAUM,MD: Director, Arthritis and Clinical
Immunology Unit, Monroe Community Hospital,
Rochester, NY; Associate Professor of Medicine and
of Preventive Medicine and Community Health,
University of Rochester School of Medicine and
Dentistry, 260 Crittenden Blvd, Rochester, NY
14620. Clinical Scholar, T h e Arthritis Foundation,
New York, NY. MORRISZIFF, MD: Director, Rheumatic Diseases Unit, Professor of Internal Medicine,
University of Texas Southwestern Medical School,
Dallas, Tex.
Reprint requests should be addressed to Dr.
Baum at the University of Rochester.
Submitted for publication March 19, 1970; accepted June 8, 1970.
12
impressed by the uncommon occurrence of
ankylosing spondylitis in black patients
seen at the Dallas Veterans Administration
Hospital, we have attempted to compare
the prevalence of this condition in white
and black men.
MATERIALS AND METHODS
The charts of all patients at the Dallas VA
Hospital in whom the diagnosis of ankylosing
spondylitis had been made from 19.59 to 1966 were
reviewed. Virtually all of these patients had been
seen by one of us or by Dr. Evelyn Hess of this
unit. Those patients who fit the accepted clinical
and radiologic criteria for ankylosing spondylitis
were accepted in the series. T h e criteria included
low Rack pain with restriction of motion of the
lumbar spine, restriction of chest expansion, and
peripheral arthritis of large joints. A negative latex
test and radiologic evidence of bilateral sacroiliac
involvement with or without involvement of the
spine with calcification of the intervertebral ligaments were the laboratory criteria.
Patients with psoriasis, ulcerative colitis, regional
arteritis, or a history of Reiter’s syndrome were not
included, although a detailed examination was not
specifically carried out for the presence of enteric
disease. T h e diagnoses of rheumatoid arthritis were
usually based on the ARA criteria. T h c prevalence
of ankylosing spondylitis i n the black and white
racial groups was compared with that of rheumatoid arlhritis in the same 7-year period. Data were
also collected for total admissions to the hospital
and admission rate by race for a 10-month period in
1966 (Table 1 ) . Comparison with population data
Arthritis and Rheumatism, Vol. 14, No. 1 (January-February 1971)
ANKYLOSING SPONDYLITIS
Table 1. Racial Distribution of Ankylosing Spondylitis, VA Hospital Admissions,
and Regional Male Population (1960 census)
~
Location of census (date)
White
(no.)
Black
(no.)
White
Black
(%I
(%)
~~
Ratio
White: Black
Dallas, Tex
Ankylosing spondylitis (1959-
1966)
41
31
93
7
13.7:l
90
263,354
5,182
165
61,911
1,227
85
81
81
15
19
19
5.6:l
4.2:l
4.2:l
20
57,885
5,450
111
43,291
3,044
95
57
64
5
43
36
20.0:l
1.3:l
1.8:l
103
240.041
711
49,227
94
83
85
6
17
15
14.7:l
4.9:l
5.7:l
137
603,924
2111
180,100
-
87
74
73
13
23
24
6.5:l
3.4:l
3.0:l
301
1,165,204
3211
334,609
90
79
10
21
9.4:l
3.5:l
Rheumatoid arthritis (1959-
1966)
Males
VAH admissions (10 mo, 1966)
Richmond, Va
Ankylosing spondylitis (1966)
Males
VAH admissions (1966)
Pittsburgh, Pa.
Ankylosing spondylitis (1956-
1969)
Males
VAH admissions*
-
-
Manhattan, N Y
Ankylosing spondylitis (1967-
1968)
Males
VAH admissionst
Total
Ankylosing spondyl itis
Males
-
* Based on a hospital census May 28,1969, by Dr. Thomas G.
Benedek.
t Based on a hospital census taken 1day in Sept 1969, by Dr. John H. Ayvazian.
2 P < .03.
Not significant.
11 P < .003.
from the 1960 census was used to determine
whether admission rates by race to this and the
other hospitals investigated was an accurate reflection of the population distribution. LatinAmericans in the data from the Dallas VA Hospital
were included as whites. Information on the
Occurrence of ankylosing spondylitis in other VA
hospitals was kindly supplied at our request. Dr.
John H. Kelly, 111, chief of the medical service of
the Richmond VA Hospital, reviewed all diagnoses
of ankylosing spondylitis for the year 1966 (Table
1) and supplied us with the admission data. Dr.
Thomas G. Benedek reviewed the case reports of
ankylosing spondylitis from the Pittsburgh VA
Hospital during the period 1956-1969 (Table 1).
He also provided counts of the black and white
patients in the hospital on May 28, 1969, since
racial data are no longer compiled in VA hospitals.
Dr. Dominick DiTata, chief of the arthritis clinic at
the Veterans Administration outpatient clinics in
New York, provided data on the patients with
ankylosing spondylitis at the hlanhattan VA Hospital. Counts of black and white patients hospitalized
on 1 day in Sept 1969 were made by Dr. John H.
Arthritis and Rheumatism, Val. 14, No. 1 (January-February 1971)
13
BAUM 81 ZlFF
Ay\aiian, associate chief of staff of the Manhattan
VA Hospital (Table 1 ) . In the latter two hospitals,
in which racial distribution was obtainable only on
the basis of a 1 day census, there was a close
correspondence of racial distribution based on the
hospital counts with that obtained from the 1960
census figures in the areas serviced by the hospitalPittsburgh, and the Borough of Manhattan in
Nev York City. Close correspondence between hospital admission rates and census figures was also
found in the other two hospitals. We did not obtain
detailed clinical histories of the patients in the data
supplied from the other VA hospitals.
Tests for significance werc performed by x 2
analysis using the population data. Similar results
were obtained using the percentages of hospital
admissions and disease frequency by the use of
tables (Documents Geigy Scientific Tables, 1962)
for “exact” confidence limits for P .
RESULTS
T h e ratio of the white to black admissions at the Dallas VA Hospital in 1966 was
4.2:l (Table 1). This corresponds exactly
with the ratio of 4.2: 1 recorded for the white
to black male populations in the Dallas
census of 1960. T h e ratio of the prevalence
of rheumatoid arthritis in hospital admissions of the two races was 5.6:1, a figure
comparable to the hospital population
figures. O n the other hand, the white to
black ratio of ankylosing spondylitis was
13.7:l a value over 3 times the hospital
admission ratio and over 2 times the ratio
obtained for rheumatoid arthritis.
T h e greater prevalence of ankylosing
spondylitis in the white population was
even more impressively borne out by the
figures obtained from the Ricliniond
Veterans Administration Hospital (Table
1). Here the white to black ratio of males
i n the city as recorded in the 1960 census
was 1.3:l. T h e ratio of the hospital admissions of the two races was 1.8:l a comparable figure. On the other hand, the relative
prevalence of ankylosing spondylitis in
whites and blacks respectively was 20:1, in14
dicating a markedly greater prevalence in
the white race than expected from the racial
distribution of the hospital admissions. It is
of interest that the actual figures show that
the diagnosis of ankylosing spondylitis was
made only once in a black patient in this
hospital during a 1 year period while i t was
made i n 20 white patients during the same
period.
At the Pittsburgh VA Hospital the white
to black admission ratio was 5.7:l. There
was a good correlation of the racial distribution in the hospital with the federal census
figures for Pittsburgh, which indicated a
white to black ratio of 4.9: 1. T h e diagnosis
of ankylosing spondylitis between 1956 and
1969 was made in 110 patients. Of these,
only 7 were black, yielding a white to black
ratio of 14.7:l. T h e information supplied
from the Manhattan Veterans Administration Hospital (Table 1) showed an admissions ratio of 3.0:l for white to black males.
Federal census figures also showed a ratio
of 3.0:l. T h e white to black ratio of the
patients with ankylosing spondylitis was
6.5: 1, over twice the hospital admissions ratio.
Racial distribution of the hospital admission rates for the four VA hospitals from
different regions of the United States were
pooled for comparison with the racial distribution of ankylosing spondylitis (Table
1 ) . T h e pooled data shows a greater than
fourfold prevalence of this disease among
whites.
By statistical analysis the frequency of
ankylosing spondylitis i n the black AfroAmerican was significantly lower than in
whites. T h e X* technic was used comparing
the expected frequency in the black male
population with the observed frequency.
This is only a n estimate since we are using
a proportion of the probable cases in the
population. Therefore, the data were fur-
Arthritis and Rheumatism, Vol. 14,
No. l (JanuayFebruary 1971)
ANKYLOSING SPONDYLITIS
ther analyzed by using the figures for the
percentage of black and white hospital
admissions and the percentage frequency of
the disease. Again, the frequency of the
disease was significantly different in the two
groups.
DISCUSSION
Although a number of studies from this
country involving close to 2000 patients
with ankylosing spondylitis have made no
mention of racial prevalence (7-1 1) , this
disease has occasionally been reported in
the black Afro-American in the United
States and surrounding areas (12-16).
Among 46 male patients collected from
hospitals throughout the city of Cleveland
by Hers11 et al (12), there were 43 whites
and 3 blacks. Baker et al (13) found only 3
black patients among 100 patients with
ankylosing spondylitis seen on the orthopedic service of the Duke University
College of Medicine in North Carolina in
1950 over a 6-month period. A report on
sacroiliitis by Gofton et al (14) showed
none with sacroiliitis in a survey of 255
native Jamaicans. Weed et a1 (16) reported
that 1 of their patients was a black woman.
T h i s is the only mention available of a
female Afro-American with ankylosing
spondylitis.
Since there is evidence that ankylosing
spondylitis may be a hereditary disease
( 1 4 , 17, 18), and assuming that this genetic condition occurs predominantly in
whites, one would expect to find it even
less frequently in black Africans than i n
Afro-Americans who are descendants of the
black -4frican group. This would appear to
be true since there are only 5 reports of
ankylosing spondylitis in the native African
(19-23). I n Hall’s study of 10,880 admissions to the Riff Valley Hospital (19), only
1 patient with ankylosing spondylitis was
reported. I n another long-term study (20),
4 patients with ankylosing spondylitis were
found among 314 cases of polyarthritis collected over a 10-year period from a total
group of 165,831 patients at Ibedan,
Nigeria. Alele (21) found 2 cases within a
3-year period in Lagos, Nigeria. I n a case
report from Uganda, Davies and Vaizey
(22) reported that they were unable to find
any prior case reports in an indigenous
African, nor did they have any records of a
patient with ankylosing spondylitis in their
hospital over an 8-year period.
Table 2 lists cases of ankylosing spondylitis in the black race reported in the world
literature in addition to the present report.
I t is of interest that reports of individual
patients with ankylosing spondylitis from
Africa are from Uganda, Kenya, and Rhodesia. These areas represent centers of
tribal groups in the eastern part of Africa.
However, most slaves for the United States
were from Nigeria on the west coast.
I t has been estimated that racial intermixture has produced about 25y0 of a
white component (24,25) in the black
Afro-American. This estimation is based on
the distribution of blood group genes in
the two races. It is of interest that southern
blacks have a lower percentage of Caucasian genes than northern blacks (25). This
would be in agreement with the lower
percentage of ankylosing spondylitis found
in the Richmond series when compared to
the other areas. T h e relative distribution of
multiple blood group genes in the two
races together with the fact that fewer cases
occur i n blacks in a n area such as Richmond, in which blacks have fewer white
genes, indicates that the inheritance pattern in ankylosing spondylitis is likely to be
similar-ie, multigenic. Patients with ankylosing spondylitis have a normal blood
group gene distribution, since the inheritance pattern of blood groups in this dis-
Arthritis and Rheumatism, Vol. 14, No. 1 (January-February 1971)
15
BAUM & ZlFF
Table 2.
Author
Ankylosing Spondylitis in the Black Race
Area
Frequency in hospital admissions (HA)
Hall (19)
Davies, Vaizey (22)
Forbes (23)
Greenwood (20)
Alele (21)
Kenya*
Uganda*
Rhodesia*
Ibedan, Nigeria*
Lagos, Nigeria*
Gofton et a/ (14)
Jamaica, West Indiest
Hersh e t a/ (12)
Baker e t a / (13)
Present authors
Cleveland, Ohiof
Durham, NCS
Richmond, Pittsburgh,
Dallas, NYCf
1 i n 10,880 HA in 2-year period
1 i n unstated no. HA over 8 year period
1 case report
4 i n 165,831 HA i n 10 year period
2 case reports in hosp. pop. over 3 year
period
No instances of sacroileitis i n 255 rormal
males
3 cases ia45 HA males with AS
3 cases in 84 HA males with AS
32 cases in 333 HA males with AS
* Indigenous African
population.
Rural black population.
f Mixed population.
t
ease in a pure white population has been
found to be no different from that of a
normal group (26). T h e suggestion that
the disease is inherited through a dominant
autosomal gene with incomplete penetrance (2,9) could not be examined with
the present data since family studies were
not done.
Since the true frequency of a disease in a
population cannot be determined from
hospital figures, but must be obtained by
direct population sampling, the conclusions made from the present data must be
regarded as tentative. A possible source of
bias in the present data is a difference i n
admission rates between black and white
populations presenting with a disease that
is frequently treated on an ambulatory
basis. Although such a bias cannot be ruled
o u t for patients with ankylosing spondylitis, i t would appear that i t was not reflected
in the overall hospital admission rates.
These were remarkably parallel to the census figures for the racial distribution of
populations in the environs of the hospitals.
16
We must also consider the frequency
with which spondylitis accompanies other
diseases such as Reiter’s disease, ulcerative
colitis, and regional arteritis. Environmental factors as well as genetic factors may
play a role in the occurrence of ankylosing
spondylitis. T h e inhospitality of the tropical African environment for diseases such
as rheumatoid arthritis (27) may also be
reflected by the rarity of ankylosing spondylitis. Indeed, the apparently higher frequency of the disease in the black population in Pittsburgh and New York might
cause us to postulate an increased case rate
related to higher and cooler latitudes.
I n general, the strongest evidence from
the literature and from this study appears
to be that based o n genetic factors.
CONCLUSIONS
T h e prevalence of ankylosing spondylitis
in the United States has been surveyed in
Veterans Administration Hospital populations in four areas of the United States.
T h e distribution of the disease was studied
Arthritis and Rheumatism, Vol. 14, No. 1 (January-February 1971)
ANKYLOSING SPONDYLITIS
relative to hospital admissions rates and
local population distribution by race. T h e
cumulative frequency was a b o u t 25y0 of
that f o u n d i n whites showing a good correlation with the 25y0 estimated presence of
white genes in blacks in the United States.
T h e rarity of ankylosing spondylitis i n
blacks in reports from the American a n d
African literature adds support to the hypothesis that the presence of ankylosing
spondylitis in the black Afro-American is a
result of multigenic factors from white
genes.
ACKNOWLEDGMENT
We are indebted to Drs. Elam C. Toone, John H.
Kelly, 111, Dominick DiTata, John H. Ayvazian,
and Thomas G. Benedek for their help in gathering
these data.
REFERENCES
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Docum rheum, Basel, J.R. Geigy, 1957
2. de Blecourt JJ, Polman A, de BlkcourtMeindersma T: Heredity factors in rheumatoid arthritis and ankylosing spondylitis.
Ann Rheum Dis 20:215-220, 1961
3. Karten I, DiTata D, McEwen C, et al: A
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1962
4. Emery AE, Lawrence JS: Genetics of ankylosing spondylitis. J Med Genet 4:239-244,
1967
5. Masi AT: Population studies in rheumatic
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904-921, 1957
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roentgenographic features. Radiology 47:
551-561, 1946
10. Blumberg B, Ragan C: T h e natural history
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11. Dunham CL, Kautz FG: Spondylartliritic
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Aortic insufficiency associated with rheumatoid spondylitis, Progress in Arthritis.
Edited by JH Talbott, LM Lockie. New
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16. Weed CL, Kulander BG, Mazzarella JA,
et al: Heart block in ankylosing spondylitis.
Arch Intern Med (Chicago) 117:800-806,
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17. Gofton JP, Robinson HS, Trueman GE:
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Ann Rheum Dis 25:525-529, 1966
18. de Blkcourt JJ: Hereditary factors in rheumatoid arthritis and ankylosing spondylitis,
T h e Epidemiology of Chronic Rheumatism. Vol. I. Edited by J H Kellgren, MR
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ID. Hall L: Polyarthritis in Kenya. E Afr Med
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20. Greenwood BM: Polyarthritis in Western
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21. .41ele CO: Chronic rheumatism in hospital
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BAUM & ZlFF
patients in Nigeria. W Afr Med J 18:149159, 1969
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23. Forbes JI: From the Harare Hospital Staff
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18
23. Reed T E : Critical tests of hypotheses for
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Genet 21:71-83, 1969
26. Grqinvik Kornstad AM, Kornstad L, Guldberg D: Blood groups in ankylosing spondylitis. Ann Rheum Dis 27:472473, 1968
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980-1182, 1968
Arthritis and Rheumatism, Vol. 14, No. 1 (Januav-Februay 1971)
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