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Figure 1 2 Rheumatic diseases and the gut microbiota Rheumatic conditions cover a wide range of conditions that affect the joints, muscles, connective tissues and immune system ( 2.1 Fibromyalgia and the gut microbiota While FM has historically not been associated with autoimmunity, there is growing evidence that patients display subtle signs of systemic inflammation and immune activation, such as mild increases in circulating pro-inflammatory cytokines, and evidence of microglial activation ( Since 2020, several cohort studies have also provided confirmation of gut microbiota dysbiosis in FM ( For example, a 2025 study by Lopez de Coca and colleagues reported a high prevalence of small intestinal bacterial overgrowth (SIBO) in patients with FM, approximately 59%, with methane-dominant overgrowth being particularly common and significantly more frequent than in controls ( 3 Mechanisms by which the gut microbiota influences fibromyalgia: immune, neuroendocrine, and metabolic pathways 3.1 Immune pathways: gut microbiota and low-grade inflammation The gut microbiota serves as a crucial educator of the host immune system through its continuous interaction with the mucosal immune network ( Dysbiosis may also promote excessive activation of T helper 17 (Th17) cells while impairing Treg function, thereby disrupting the balance between pro-inflammatory and anti-inflammatory immune responses ( Figure 2