Proteus IgG antibodies and C-reactive protein in English, Norwegian and Spanish patients with rheumatoid arthritis

The distribution of Proteus antibody levels was compared in English, Norwegian and Spanish patients with rheumatoid arthritis (RA). Using an indirect immunofluorescence method, the IgG antibody titre against Proteus mirabilis was measured in the sera of 27 English, 53 Norwegian and 34 Spanish patients with RA and divided into active and inactive disease groups according to the serum C-reactive protein (CRP) level (> or = 10 mg/l). Serum samples were also collected from 25 English, 30 Norwegian and 14 Spanish healthy individuals who served as controls. The levels of Proteus IgG antibodies were significantly higher in the sera of active RA patients (p<0.001) when compared with the corresponding healthy controls, whether these groups belonged to the English, Norwegian or Spanish populations. Furthermore, active RA patients from each country showed significantly higher levels of Proteus antibodies when compared with inactive English (p<0.01), Norwegian (p<0.001) or Spanish (p<0.001) RA patients. Finally, a significant correlation was observed between Proteus IgG antibody levels and the CRP concentrations in RA patients whether each population was tested individually or all together (p<0.001). The increased levels of Proteus antibodies in RA patients from three different European countries support the concept of a possible aetiopathogenetic role for Proteus microorganisms in the development of RA.

Community-acquired bacterial pneumonia in human immunodeficiency virus-infected patients: validation of severity criteria. The Grupo Andaluz para el Estudio de las Enfermedades Infecciosas

Severity criteria for community-acquired pneumonia (CAP) have always excluded patients with human immunodeficiency virus (HIV) infection. A 1-yr, multicenter, prospective observational study of HIV-infected patients with bacterial CAP was done to validate the criteria used in the American Thoracic Society (ATS) guidelines for CAP, and to determine the prognosis-associated factors in the HIV-infected population with bacterial CAP. Overall, 355 cases were included, with an attributable mortality of 9.3%. Patients who met the ATS criteria had a longer hospital stay (p = 0.01), longer duration of fever (p < 0.001), and higher attributable mortality (13.1% versus 3.5%, p = 0.02) than those who did not. Three factors were independently related to mortality: CD4(+) cell count < 100/microl, radiologic progression of disease, and shock. Pleural effusion, cavities, and/or multilobar infiltrates at admission were independently associated with radiologic progression. A prognostic rule based on the five criteria of shock, CD4(+) cell count < 100/microl, pleural effusion, cavities, and multilobar infiltrates had a high negative predictive value for mortality (97.1%). The attributable mortality for severe pneumonia was 11.3%, as compared with 1.3% for nonsevere disease (p = 0.008). The ATS severity criteria are valid in HIV-infected patients with bacterial CAP. Our study provides the basis for identification of patients who may require hospitalization determined by clinical judgment and the five clinical criteria of shock, a CD4(+) cell count < 100/microl, pleural effusion, cavities, and multilobar involvement. These prognostic factors should be validated in independent cohort studies.

Early complications of endoscopic treatment for superficial bladder tumors

PURPOSE

Bladder tumors are the second most common tumors of the genitourinary system. Approximately 80% of patients initially present with a superficial lesion, which is treated with transurethral resection. Although transurethral resection is a standard procedure, it is not morbidity-free. We assessed the early complications of transurethral resection for superficial bladder cancer and analyzed various factors that may contribute to its occurrence.

MATERIALS AND METHODS

Between January 1979 and December 1996, 2,821 patients with superficial bladder cancer underwent transurethral resection at our center. We assessed intraoperative and immediate postoperative complications of the initial transurethral resection procedure, and correlated them with tumor characteristics.

RESULTS

Of the 2,821 patients in our study 2,461 (87%) were male and 360 (13%) were female. Average age was 65 years (range 16 to 94). Of the 145 complications (5.1%) the most common were bleeding in 78 patients (2.8%) and bladder perforation in 36 (1. 3%). Perforation was extraperitoneal in 30 cases (83%) and intraperitoneal in 6 (17%). Conservative treatment and open surgery were done in 32 (89%) and 4 (11%) patients, respectively. We noted no case of tumor seeding. A repeat procedure was done in 77 patients (2.7%) with bleeding as the leading cause of repeat intervention in 65 (84%). Blood transfusion was required in 96 cases (3.4%). The incidence of complications significantly correlated with the size and number of tumors but there was no association with tumor stage, grade or location.

CONCLUSIONS

The most common complication of transurethral resection for superficial bladder cancer is bleeding. Currently bladder perforation should be managed conservatively with a minimum risk of extravesical tumor seeding. Our results imply that tumor size and multiple tumor resection are associated with a higher complication rate.

Molecular strategies to define HLA haplotype loss in microdissected tumor cells

Loss of heterozygosity (LOH) of chromosome 6p21 is an important mechanism that generates HLA haplotype loss in various human tumors. This mechanism produces non-reversible HLA-deficient tumor cells that can escape T cell immune responses in peptide-vaccinated cancer patients. However, the exact frequency of this mechanism is still unknown, because contaminating stroma in solid tumor tissues masks the tumor DNA obtained from solid samples. A microdissection technique was applied to 4-8 microm sections of cryopreserved tumor tissues from a group of colorectal and laryngeal carcinomas. Fifteen patients were analyzed for the presence of LOH associated with the beta(2)-microglobulin gene in chromosome 15, and five patients for LOH associated with HLA genes in chromosome 6. In two cases, autologous metastasis tissue samples were also available. The patients were selected for showing an altered HLA class I tumor phenotype as determined by immunohistological techniques. DNA was obtained from this microdissected material and amplified in order to detect the presence or absence of nine previously selected microsatellite markers. HLA sequence based typing (SBT) was also applied to these microdissected DNA samples to define the HLA genotype. Microdissection greatly improved the definition of LOH, with nearly 100% signal reduction in one of the alleles. In addition, this procedure allowed us to detect beta(2)-microglobulin LOH in tumors that expressed some HLA molecules. Our data indicate that this procedure can be successfully applied to microdissected samples from solid tumors, thus enhancing the power and sensitivity of LOH detection.

Balloon dilatation in the treatment of ureteral stenosis in kidney transplant recipients

OBJECTIVE

To assess the usefulness of balloon percutaneous dilatation as a starting treatment technique of ureteral stenosis in kidney transplant recipients.

PATIENTS AND METHODS

A total of 472 kidney transplants have been performed at our center between August 1981 and January 1997. The coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function had recovered, antegrade pyelography was performed to confirm ureteral stenosis and to determine its location. The dilatations are performed by means of 5-french balloon-fitted angioplasty catheters.

RESULTS

Thirty patients were diagnosed with ureteral stenosis during follow-up, i.e. an incidence of 6.3%. Transluminal balloon dilatation was made as a first therapeutic option in 18 cases. No immediate complications were observed following dilatation. Disappearance of the stenosis as well as maintenance of the improvement in creatinine levels were verified in 39% of cases (7 patients).

CONCLUSIONS

Ureteral stenosis in kidney transplant recipients should be included as part of the differential diagnosis when there is a deterioration in renal function. Balloon dilatation is the technique chosen as initial treatment of juxtavesical ureteral stenosis because of its good reproducibility and its low morbidity.

Criteria to define HLA haplotype loss in human solid tumors

Short tandem repeat (STR) markers are currently used to define loss of heterozygosity (LOH) of genes and chromosomes in tumors. Chromosome 6 and chromosome 15 STR markers are applied to define loss of HLA and related genes (e.g. TAP and beta2m). The number of STR identified in the HLA region is still increasing. In this study, seven representative STR markers covering the 6p/6q arms of chromosome 6 including the HLA region and two for chromosome 15 flanking the beta2m gene, were selected as minimally required for reliable LOH studies. A multiplex polymerase chain reaction (PCR) strategy is proposed when small number of cells are available in microdissected tumor samples.

Clear cell adenocarcinoma in a female urethral diverticulum

The incidence of a neoplasm within the female urethral diverticulum is rare. Clear cell adenocarcinoma, which is the most common neoplasm, arises from the metaplasia of surface transitional epithelium and the paraurethral ducts. These tumors are usually diagnosed at a late stage, which worsens their prognosis. The treatment of choice is surgery.

Management of superficial transitional cell carcinoma in the intramural ureter: what to do?

PURPOSE

We analyze the evolution of superficial transitional cell carcinoma in the intramural distal ureter treated with transurethral resection.

MATERIALS AND METHODS

A total of 19 patients underwent transurethral resection of the intramural distal ureter with a mean followup of 57 months. All cases were diagnosed as superficial transitional cell carcinoma and all but 2 had a history of bladder tumor. Upper urinary tract followup consisted of excretory urography every 6 months and ureterorenoscopy in cases with a doubtful diagnosis or positive cytology.

RESULTS

Pathological examination revealed stage Ta disease in 42%, T1 in 31.5% and Tx in 26.3% of intramural tumors. Upper urinary tract recurrence was noted in 8 patients (42.1%), including 5 (62.5%) with involvement of the distal ureter. Nontumoral stenosis of the distal ureter in 3 cases was treated endoscopically. An endoscopic procedure resolved 75% of recurrences. A high surgical risk patient who did not undergo open surgery died of recurrence.

CONCLUSIONS

Superficial transitional cell carcinoma of the intramural ureter is uncommon in the setting of multiple bladder tumors and recurrent bladder carcinoma. There was a 42.1% rate of ipsilateral recurrence and endoscopic treatment allowed us to preserve 89.5% of the involved renal units. Closer followup of the urinary tract must be performed since these tumors have a higher incidence of upper urinary tract recurrence.

Haemophilus influenzae pneumonia in human immunodeficiency virus-infected patients. The Grupo Andaluz para el Estudio de las Enfermedades Infecciosas

Although Haemophilus influenzae is a common etiologic agent of pneumonia in patients infected with human immunodeficiency virus (HIV), the characteristics of this pneumonia have not been adequately assessed. We have prospectively studied features of H. influenzae pneumonia in 26 consecutive HIV-infected inpatients. Most of these patients were severely immunosuppressed; 73.1% had a CD4+ cell count <100/microL. A subacute clinical presentation was observed in 27% of the patients and was associated with a higher degree of immunosuppression (P=.04). Bilateral lung infiltrates were noted radiographically in 57.7% of the cases. The mortality attributable to H. influenzae pneumonia was 11.5%. Thus, pneumonia caused by H. influenzae affects mainly patients with advanced HIV disease, and since its clinical and radiological features may be diverse, this etiology should be considered when pneumonia occurs in patients with advanced HIV infection. The mortality rate associated with H. influenzae pneumonia is not higher than that occurring in the general population.

Significant loss of bone mass in patients with early, active ankylosing spondylitis: a followup study

OBJECTIVE

To analyze whether inflammatory disease activity plays a substantial role in the loss of bone mass observed in ankylosing spondylitis (AS) patients who have not yet developed ankylosis.

METHODS

A longitudinal cohort study of 34 patients with early AS (duration <10 years) without ankylosis was conducted. The mean followup was 19 months. Loss of bone mass in defined regions of the lumbar spine and femoral neck was analyzed by dual x-ray absorptiometry. Patients were grouped according to biologic parameters of disease activity (erythrocyte sedimentation rate or C-reactive protein level). Group 1 consisted of 14 patients with active disease; group 2 comprised 20 patients with inactive disease. Serum levels of interleukin-6 (IL-6) and of hormones (sex, thyroid, and calciotropic), vertebral mobility (Schober test), daily physical activity, and treatment administered were recorded every 6 months for all patients.

RESULTS

At the end of the followup period, patients with active AS showed a significant reduction in bone mass in the lumbar spine (mean 1.01 gm/cm2 at study entry versus 0.961 gm/cm2 at followup [P = 0.005]) and femoral neck (0.849 gm/cm2 versus 0.821 gm/cm2 [P = 0.015]), which represented losses of 5% and 3%, respectively. In contrast, no significant reduction in bone mass was observed in patients with inactive AS. As expected, serum IL-6 levels were significantly higher in patients with active AS than in those with inactive disease (mean +/- SD 8.3 +/- 9 pg/ml versus 2.8 +/- 5 pg/ml [P = 0.008]). No significant differences were observed between the 2 groups in any of the other variables analyzed.

CONCLUSION

The observation that loss of bone mass in AS occurred only in patients with persistent active disease strongly suggests that inflammatory activity of the disease itself plays a major role in the pathophysiology of the early bone mineral disorders observed in these patients.

Significant loss of bone mass in patients with early, active ankylosing spondylitis: a followup study

OBJECTIVE

To analyze whether inflammatory disease activity plays a substantial role in the loss of bone mass observed in ankylosing spondylitis (AS) patients who have not yet developed ankylosis.

METHODS

A longitudinal cohort study of 34 patients with early AS (duration <10 years) without ankylosis was conducted. The mean followup was 19 months. Loss of bone mass in defined regions of the lumbar spine and femoral neck was analyzed by dual x-ray absorptiometry. Patients were grouped according to biologic parameters of disease activity (erythrocyte sedimentation rate or C-reactive protein level). Group 1 consisted of 14 patients with active disease; group 2 comprised 20 patients with inactive disease. Serum levels of interleukin-6 (IL-6) and of hormones (sex, thyroid, and calciotropic), vertebral mobility (Schober test), daily physical activity, and treatment administered were recorded every 6 months for all patients.

RESULTS

At the end of the followup period, patients with active AS showed a significant reduction in bone mass in the lumbar spine (mean 1.01 gm/cm2 at study entry versus 0.961 gm/cm2 at followup [P = 0.005]) and femoral neck (0.849 gm/cm2 versus 0.821 gm/cm2 [P = 0.015]), which represented losses of 5% and 3%, respectively. In contrast, no significant reduction in bone mass was observed in patients with inactive AS. As expected, serum IL-6 levels were significantly higher in patients with active AS than in those with inactive disease (mean +/- SD 8.3 +/- 9 pg/ml versus 2.8 +/- 5 pg/ml [P = 0.008]). No significant differences were observed between the 2 groups in any of the other variables analyzed.

CONCLUSION

The observation that loss of bone mass in AS occurred only in patients with persistent active disease strongly suggests that inflammatory activity of the disease itself plays a major role in the pathophysiology of the early bone mineral disorders observed in these patients.

Chromosome loss is the most frequent mechanism contributing to HLA haplotype loss in human tumors

Loss of heterozygosity (LOH) in the short arm of chromosome 6 (6p) was detected in samples obtained from colon (13.8%), larynx (17.6%) and melanoma (15.3%) tumors. The parallel study of HLA-antigen expression in tumor tissues using locus- and polymorphic-specific antibodies in combination with LOH microsatellite analysis on 6p allowed us to establish that LOH in chromosome 6 is a representative phenomenon in most tumor cells present in a given tumor tissue. In most cases, specific HLA alleles had been lost in a predominant population of tumor cells, indicating that LOH is a non-irrelevant mutation that probably confers a selective advantage for survival of the mutant cell. We also demonstrate that LOH frequently occurred through chromosome loss rather than somatic recombination. LOH at all loci studied on the p and q arms of chromosome 6 was observed in at least 56.2% (9/17) cases. This HLA-associated microsatellite analysis was a useful tool for classifying tumors as LOH-positive or -negative, and therefore to consider a patient as a potential non-responder or responder in a vaccination trial.

Expression of HLA G in human tumors is not a frequent event

Expression of HLA G may be a way for tumor cells to escape immuno-surveillance. HLA G is selectively expressed by extravillous trophoblast in the human placenta, a tissue that does not express HLA A or B molecules. It is tempting to propose that tumor cells resemble this unique HLA class I phenotype as they frequently lose classical HLA A, B and C class I expression. Such peculiar HLA class I distribution would in theory allow tumor cells to escape from T- and NK-cell cytotoxicity. To determine whether HLA G is expressed on tumor cells, we studied HLA G mRNA levels using RT-PCR and HLA G cell-surface expression by immunohistological techniques in a panel of 50 human solid tumor tissues, 31 tumor cell lines of different origin, 4 autologous mucosa samples and 3 peripheral white cell samples. We found mRNA transcripts of different HLA G isoforms in most of the samples studied. However, we did not detect cell-surface expression of HLA G using 3 specific monoclonal antibodies (MAbs; 87G, 01G and G223). HLA G was detected only in the U937 myelomonocytic cell line after stimulation with IFN-gamma. We favor the hypothesis that HLA G plays a minor role, if any, in providing an inhibitory signal to NK cells to escape immunosurveillance. We cannot, however, exclude the possibility that some other HLA G isoforms may be expressed in some tumors.

The biological consequences of altered MHC class I expression in tumours

The identification of different mechanisms by which tumours escape from the immune system has helped to evaluate the clinical relevance of a variety of phenotypic changes that occur during tumour development. Among them, changes in HLA class I expression play a leading role in the tumour-host environment since HLA class I molecules interact with T lymphocytes for antigen presentation and with NK cells for inhibition/activation of these immune effector cells. Our laboratory has proposed a classification of the altered HLA class I phenotypes frequently found in human tumours, into five major groups. This review focuses on the tumour phenotypes found in primary and metastatic lesions, the molecular mechanisms that give rise to each phenotype and the clinical implications of these findings.

Differential effect of protein-bound polysaccharide (PSK) on survival of experimental murine tumors

The effect of protein-bound polysaccharide (PSK) on the survival of BALB/c and C57BL/6 mice after intravenous injections of syngeneic murine sarcomas (GR9.B9 and Meth-A), LSTRA lymphoma and B16 melanoma cells was studied. Pretreatment of mice with PSK significantly increased survival after the injection of either type of sarcoma cells, although the effect was attenuated when high numbers of cells were injected. Survival was not modified significantly in LSTRA lymphoma or B16 melanoma. Mice pretreated with anti-asialo GMI serum showed significantly decreased survival from all tumors in comparison with untreated mice injected with tumors, regardless of cell dose used. We observed an inverse correlation between H-2 antigen expression and in vitro NK sensitivity of tumor cells from all lines except B16 melanoma cells. These results clearly suggest that pretreatment of mice with PSK prolongs survival and inhibits metastasis formation in mice injected with sarcoma cells, being this effect highly selective, since survival was not improved in mice injected with LSTRA lymphoma or B16 melanoma.

Ultrasound-guided needle aspiration in prostatic abscess

OBJECTIVES

To review the clinical presentation of prostatic abscess and to assess the usefulness of ultrasound-guided needle aspiration as a treatment option for this condition.

METHODS

Between October 1984 and November 1997, prostatic abscess was diagnosed in 31 patients. The average age was 60 years (range 29 to 79). Prostate ultrasound was performed using either a hypogastric or transrectal approach. Initial therapy included ultrasound-guided needle aspiration in 24 (77.4%), transurethral resection of prostate (TURP) in 5 (16.1%), or conservative management with antibiotic therapy. During follow-up, ultrasound examinations and urine cultures were performed on an outpatient basis.

RESULTS

Past medical history most often included previous urinary infection (15 patients, 48%) and bladder outlet obstruction (13 patients, 42%). Sixty-one percent of patients presented with irritative voiding symptoms at the time of diagnosis. Ultrasound-guided needle aspiration resolved 83.3% of cases; 2 patients needed a second procedure. Three patients required TURP for drainage and 2 to remove an obstruction after abscess resolution.

CONCLUSIONS

A high degree of suspicion is needed to diagnose prostatic abscess clinically. Transrectal ultrasound is necessary for the differential diagnosis. Transrectal ultrasound-guided needle aspiration is a technically simple and effective therapeutic procedure with no morbidity and, in case of failure, may be repeated or a drainage TURP may be undertaken.

High frequency of altered HLA class I phenotypes in invasive colorectal carcinomas

We analyzed the expression of HLA class I antigens in 78 tumor tissue samples obtained from patients diagnosed as having colorectal carcinomas. A broad panel of mAbs defining HLA monomorphic, locus-specific and allele-specific determinants was used. In addition, an antibody defining HLA-C locus-specific determinant (L31) was also tested. Previous reports on these tumors indicated HLA class I losses of 30 to 40%. At least 73% of the patients in the present study had a detectable HLA class I alteration. These altered HLA phenotypes were classified as total HLA loss (18%) (phenotype I); HLA-A locus-specific loss (9%) (phenotype IIIa); HLA-B locus-specific loss (8%) (phenotype IIIb); HLA-A and B locus losses (2%) and HLA allelic losses (36%) (phenotype IV). We found no HLA-C locus losses. Autologous peripheral blood lymphocyte HLA class I typing was always necessary to define phenotype IV. We also studied the CD3 zeta chain in tumor tissues to correlate possible changes in the CD3 signal transduction pathway with HLA alterations. The CD3 ratio was frequently altered, but this alteration could not be correlated with tumor HLA phenotypes. The high frequency of HLA class I losses in colorectal carcinomas suggests that this finding is a widespread phenomenon and may be required to escape T-cell recognition. It remains to be determined whether HLA expression is "normal" in the rest of the 27% of our patients.

Protein bound polysaccharide PSK abrogates more efficiently experimental metastases derived from H-2 negative than from H-2 positive fibrosarcoma tumor clones

We studied the effect of protein-bound polysaccharide PSK on metastatic colonization of BALB/c mice after intravenous injections of different syngeneic murine H-2 positive and H-2 negative tumor clones. The tumor lines used were different clones from chemically induced fibrosarcomas (GR9.B9, an H-2 negative clone from GR9 tumor, and B7.1.B4, an H-2 positive clone from B7.1 tumor). These clones were selected because of their different sensitivity to NK cytotoxicity, which was related to MHC class I expression. Pretreatment of mice with PSK inhibited metastatic colonization derived from B9 H-2 negative tumor cells. In contrast, lung colonization of PSK treated mice injected with B7.1.B4 H-2 positive tumor cells was higher, and differences in the number of colonies between untreated and PSK treated mice were small. In several experiments the effect of PSK was attenuated to a greater degree when high numbers of cells were injected. Abrogation of NK cells with anti-asialo GM1 serum significantly increased (in all tumors and at different cell doses) the number of metastatic colonies in comparison with untreated mice injected with tumors, regardless of the cell dose used. These results clearly suggest that NK cell activation in vivo by the protein bound polysaccharide PSK abrogates metastasis formation in mice. Abrogation was dependent on the H-2 phenotype even when pretreatment consisted of a single dose of PSK. This effect, related to the NK sensitivity of the tumor target, can be used to predict the effect of PSK in vivo.

Secondary amyloidosis in ankylosing spondylitis. A systematic survey of 137 patients using abdominal fat aspiration

OBJECTIVE

To assess the frequency and clinical significance of amyloid deposits in abdominal fat in patients with ankylosing spondylitis (AS).

METHODS

Abdominal subcutaneous fat aspiration (ASFA) by fine needle was performed in 137 unselected patients with AS of more than 5 years of disease evolution. A followup study was done of patients with amyloidosis in the abdominal fat (ASFA positive test) to evaluate the development of clinical amyloidosis.

RESULTS

In 10 (9M/1F) patients with AS, the ASFA revealed amyloid deposits (prevalence of 7%). Patients with AS and an ASFA+ test were older and had more active and severe disease than those without AS. Only 2 ASFA positive test patients had clinical amyloidosis at the time of the test. After a followup period of 2-10 yrs (mean 5.4 +/- 3.2 yrs), 3 more patients developed symptomatology due to amyloidosis. All 5 patients with clinical amyloidosis showed nephropathy, and proteinuria was found in each. The remaining patients did not develop clinical amyloidosis during followup.

CONCLUSION

Amyloid deposits in abdominal fat are not a rare finding in AS. A significant proportion of these patients do not develop clinical amyloidosis after a followup of several years. Thus, an ASFA + test in patients with AS is not always associated with a poor prognosis at least in the short term, although longer followup is required.

Comparative cytokine gene expression in synovial tissue of early rheumatoid arthritis and seronegative spondyloarthropathies

Interleukin 1-beta (IL-1 beta), IL-2, IL-4, IL-5, IL-6, IL-8, tumour necrosis factor-alpha (TNF-alpha), transforming growth factor-beta (TGF-beta) and granulocyte-macrophage colony-stimulating factor (GM-CSF) gene expression was determined in knee synovium of 16 patients with rheumatoid arthritis (RA) and 16 patients with seronegative spondyloarthropathies (SSP), by using polymerase chain reaction (PCR) amplification. The pattern of cytokines observed in RA synovium is of the macrophage-fibroblast type, with the highest expression of IL-1 beta and TGF-beta. GM-CSF and IL-2 bands were visualized in a minority of patients. Neither IL-4 nor IL-5 could be detected. No significant differences were observed in the cytokine profile between patients with early (< 12 months) and more advanced disease. No differences were observed according to gender, age, rheumatoid factor status and the duration of knee synovitis. The pattern of cytokines in the synovium of SSP patients is similar to that observed in RA patients and does not change in relation to disease duration. IL-2 was the only T-cell cytokine observed. These data provide evidence that the macrophage-fibroblast cells have an important role in early and more advanced rheumatoid synovitis, and show that this is also true for SSP peripheral synovitis.

Altered MHC class I antigens in tumors

MHC class I antigens are lost or downregulated in invasive tumors compared with autologous normal tissues. This is observed in most of the newly induced experimental tumors analyzed if they are cloned before passaging in vivo. Similarly, this is observed in 40%-90% of human tumors using the available panel of anti-HLA class I monoclonal antibodies. In both systems the tumor populations are heterogeneous for H-2/HLA expression and composed of clones that express different amounts of MHC class I antigens. This heterogeneity may have a profound influence on tumor behavior, considering the role that MHC antigens play in T and natural killer cell-mediated responses. It is possible that the tumor escape mechanisms from T and natural killer cells select variants that express a particular MHC class I altered phenotype. We review the MHC changes detected in different experimental as well as human tumors and demonstrate the relevance of these altered H-2/HLA tumor phenotypes for implementing immunotherapeutic strategies based on T or natural killer cell-mediated responses.

Scintigraphic evaluation of the severity of inflammation of the joints with 99TCm-HIG in rheumatoid arthritis

A prospective study was carried out to determine the usefulness of 99TCm-human immunoglobulin G (HIG) scintigraphy in the assessment of the severity of joint inflammation. Twenty-four patients with rheumatoid arthritis were studied. The presence or absence of pain and/or swelling was evaluated in 34 joints and a clinical index taking into account the surface area of each joint was calculated. We measured the following biological markers of inflammation activity: erythrocyte sedimentation rate, C-reactive protein, haemoglobin, platelet count, serum levels of IL-6, TNF-alpha and soluble receptors of IL-2. Scintigraphic was performed 4 h after the injection of 740 MBq 99Tcm-HIG. The scans were evaluated by visual and quantitative analysis and the scores in each joint were weighted for joint size. Pathological uptake of the radiopharmaceutical was noted in 46% (24/52) of joints evaluated as painful, 89% (146/164) of swollen joints and 94% (78/83) of both painful and swollen joints. Both the visual and the quantitative scintigraphic indices correlated significantly with the clinical index, the number of painful joints, the number of swollen joints and several biological markers of inflammation. A very high correlation was also found between the visual and the quantitative scintigraphic indices (r = 0.91, P < 0.0001). In conclusion, 99Tcm-HIG scintigraphy is an objective test to detect synovitis and to assess the severity of inflammation. A careful visual analysis of scans is good enough for routine evaluations and computer quantitative analysis should be used when more accurate intra-individual variation is required.

Reduced serum creatine kinase activity in inflammatory rheumatic diseases

OBJECTIVE

To determine if serum CK activity is reduced in inflammatory rheumatic diseases and to evaluate whether this phenomenon is linked to disease activity or steroid therapy.

METHODS

Serum CK activity was measured in patients with systemic lupus erythematosus (SLE, n = 52), rheumatoid arthritis (RA, n = 80), ankylosing spondylitis (AS, n = 82), spondyloarthropathies other than AS (SpA, n = 22), and a miscellaneous group (MI, n = 27), and in 103 control patients with noninflammatory arthropathies (NIA). Laboratory variables of inflammatory activity such as ESR, CRP, platelet count, and hemoglobin (and anti-DNA antibodies and complement levels in SLE) were measured at the same time. Daily dose of steroids was also evaluated.

RESULTS

Serum CK activity was significantly reduced in SLE (mean +/- SD: 49 +/- 41 IU/l), RA (68 +/- 41 IU/l), SpA (88 +/- 53 IU/l), and MI (75 +/- 32 IU/l) compared to controls (111 +/- 38 IU/l) (p = 0.002 for SpA and p < 0.001 for the other groups). No differences in CK values were observed between AS and controls, although AS patients with peripheral arthritis had lower serum CK activity than those without (80 +/- 32 vs 121 +/- 62 IU/l, respectively, p < 0.05. ESR, CRP, and platelets correlated inversely with CK values in RA, AS, and MI. In the SpA group only ESR correlated inversely with CK. In SLE, a positive correlation was found between CK values and CH50 and a negative one with anti-DNA levels. Patients taking steroids had significantly lower CK activity than those without corticotherapy. However, multivariate analysis showed that only inflammatory activity and no steroids had an effect in reducing CK activity.

CONCLUSION

Serum CK activity is significantly reduced in several inflammatory rheumatic diseases. Inflammatory activity seems to play the major role in this phenomenon.

Molecular mimicry: the geographical distribution of immune responses to Klebsiella in ankylosing spondylitis and its relevance to therapy

The discovery that HLA-B27 is linked to ankylosing spondylitis (AS) and HLA-DR1/DR4 to rheumatoid arthritis (RA) has provided new approaches to the study of the possible causation of these diseases. Several theories have been proposed to explain these associations but only one, namely "molecular mimicry", has provided a specific aetiological agent for each of these diseases. Molecular mimicry between HLA-B27 and two molecules in Klebsiella microbes: nitrogenase and pullulanase D has been reported whilst in Proteus microbes, the haemolysin molecule shows sterochemical similarity to HLA-DR1/DR4. Elevated immune responses to Klebsiella microbes have been demonstrated in AS patients from 10 different countries and this wide geographical distribution suggests that the same aetiological agent is probably acting in producing this condition. Furthermore RA patients show similar immune responses to Proteus microbes. Whether AS or RA are caused by these bacteria can only be resolved by tissue typing all rheumatological patients early, in the course of their disease and then assessing their response to antibiotic chemotherapy in longitudinal studies involving double-blind crossover trials. It is possible that in the future, the course of AS or even RA could be modified by adequate antibiotic chemotherapy or even diets which affect the substrates on which these bacteria grow.

Occurrence of antineutrophil cytoplasmic and antineutrophil (peri)nuclear antibodies in rheumatoid arthritis

OBJECTIVE

To elucidate whether sera from patients with rheumatoid arthritis (RA) contain antineutrophil cytoplasmic antibodies (ANCA) or granulocyte specific antinuclear antibodies (GS ANA), or both, and to analyze possible correlations with different clinical and laboratory data.

METHODS

Forty-seven consecutive outpatients with RA were included. Control sera were obtained from patients with well defined rheumatic diseases and from healthy individuals. Serum samples were examined by indirect immunofluorescence (IIF) on both ethanol and paraformaldehyde fixed neutrophils and by ELISA using as substrates myeloperoxidase (MPO), proteinase 3, and a purified extract of alpha-granules. ANA were detected by IIF using cultured HEp-2 cells.

RESULTS

Twenty-three patients (49%) had a perinuclear pattern (p-ANCA) by ethanol fixation, of which only 2 became cytoplasmic on paraformaldehyde fixed cells. These 2 patients also had a positive myeloperoxidase ELISA, while none of the remaining 45 had a positive result from the 3 ELISA performed. All 21 patients (45%) with a p-ANCA pattern that was not modified by paraformaldehyde fixation had a specific immunostaining upon examination at high power magnification; we termed this GS ANA specific pattern. The specificity of this pattern was further confirmed by a doubled blind test performed by 2 independent observers. In our study, all GS ANA pattern positive sera fulfilled the previously known definition of these antibodies. We found no relationship between GS ANA and variables such as disease duration and activity, rheumatoid factor, and vasculitis. Notably, 2 RA patients with "true" ANCA (anti-MPO antibodies) had an associated pulmonary-renal syndrome (microscopic polyangiitis).

CONCLUSION

Most p-ANCA in our series of patients with RA did not seem to correspond to "true" ANCA but to antibodies directed against nuclear or perinuclear antigenic constituents of the neutrophils (GS ANA). The observation of their distinctive and specific immunostaining pattern, when screening patients for the presence of ANCA by IIF, may alert us to the possible presence of RA.

When does amyloidosis complicate systemic lupus erythematosus?

Secondary amyloidosis is a well recognised complication of rheumatic diseases, but the association with systemic lupus erythematosus is very unusual. We report the case of a patient with systemic lupus erythematosus who developed proteinuria due to renal amyloidosis. We also review the cases previously reported and the hypothesis on the pathogenic mechanisms.

D-lactic acid in synovial fluid. A rapid diagnostic test for bacterial synovitis

OBJECTIVE

To analyze the usefulness of D-lactic acid levels in synovial fluid (SF) as a rapid test to support the early diagnosis of bacterial arthritis (BA).

METHODS

A simple modification of the enzyme method used for measuring L-lactic acid was used to analyze levels of D-lactic acid in SF from 20 cases of BA. Results were compared with those from 99 noninfectious arthritis, which included 90 inflammatory SF samples. Total white blood cell count (WBC), percentage of polymorphonuclears (% PMN) and gram stains were also determined.

RESULTS

D-lactic acid levels were significantly higher in BA than in noninfectious arthritis. Using a cutoff value of 0.05 mM, 85% of the SF samples from BA had a positive test for D-lactic acid compared with 4% of the control group. The overall sensitivity of the assay was 85% with a specificity of 96%, showing a positive predictive value for BA of 81% and a negative predictive value of 97%.

CONCLUSION

The data presented suggest that D-lactic acid is an accurate, easy test that can be carried out in any laboratory, to support the early diagnosis of BA.

Different patterns of HLA-DR antigen expression in normal epithelium, hyperplastic and neoplastic malignant lesions of the breast

Fifteen samples of non-tumoural breast tissue, 24 cases of benign lesions, four biopsies of inflammatory carcinomas and 94 tumour samples of primitive mammary carcinomas were analysed for HLA class II expression. We found, first, that HLA class II antigens were detectable in all cases of non-neoplastic breast tissue. Secondly, HLA class II antigen expression was notably increased in benign neoplasms and hyperplastic lesions. In contrast, only 32 out of 94 carcinomas showed expression of HLA-DR antigens, 17 tumours had HLA-DP antigens and 11 carcinomas were positive for the presence of DQ molecules. The expression of class II antigen was associated with the degree of histological differentiation (P < 0.05) but was independent of stromal leucocytic infiltration. Thirdly, HLA-DR was very strongly expressed in intravascular tumoural thrombi, especially in the 'inflammatory carcinomas'. The immunophenotype of inflammatory infiltrate was analysed in benign and malignant lesions. In malignant lesions the mean number of inflammatory cells was significantly higher than in benign lesions. Interestingly, we found no differences in the amount and composition of inflammatory infiltrate between HLA-DR positive and negative tumours.

[Arthropathy associated with infection by parvovirus B19. Description of 4 cases]

Four cases of human parvovirus infection in which the main clinical manifestation was a polyarthritis are described. Four females with ages ranging from 30 to 32 years presented with acute symmetrical polyarthralgias involving hands and knees. In addition, evidence of synovitis in the ankles and tenosynovitis of the fingers was found in two and three cases respectively. Half of the patients noticed an erythematous rash in the preceding days. Laboratory studies were normal in all cases. Antinuclear antibodies and rheumatoid factor were not detected in any case. All patients had significant levels of IgG and IgM antibodies to parvovirus B19 at the time of presentation and a rise in IgG and a fall in IgM levels were seen at two months. All cases cleared up within two weeks without treatment.

Serum cytokines (IL-6, TNF-alpha, IL-1 beta and IFN-gamma) in ankylosing spondylitis: a close correlation between serum IL-6 and disease activity and severity

The aim of our study was to analyse the serum interleukin-6 (IL-6), tumour necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta) and interferon-gamma (IFN-gamma) levels in patients with AS and their relationship with disease activity. An ELISA test was used to analyse serum cytokine (IL-6, TNF-alpha, IL-1 beta and IFN-gamma) levels in 69 patients with AS. Results were compared with those from 43 patients with RA and 36 patients with non-inflammatory back pain. The relationship between serum concentrations of the different cytokines and parameters of disease activity and severity in AS patients was also evaluated. IL-6 and TNF-alpha serum levels, but not IL-1 beta and IFN-gamma, were significantly higher in AS than in NIBP. However, patients with RA showed higher serum levels of IL-6, TNF-alpha and IFN-gamma than both AS and NIBP patients. In AS, IL-6 correlated with clinical parameters of disease activity with significant correlation being observed with laboratory parameters of inflammation such as ESR, CRP, platelet count and clinical parameters of severity such as vertebral mobility. TNF-alpha did not correlate with laboratory or clinical parameters of activity. Macrophagic cytokines (TNF-alpha and IL-6), are increased in AS patients and IL-6 closely correlated with the activity of the disease.

[Tendinitis due to fluoroquinolones. Description of 2 cases]

Two patients with tendinitis by ciprofloxacin are described. In both patients isolated involvement of the Aquilles tendon was produced. The symptoms initiated at 2 to 4 weeks of the beginning of treatment. The two patients had undergone chemotherapy and bone marrow transplantation due to chronic myeloid leukemia and acute promyelocytic leukemia, respectively with no data on recurrence of leukemia being obtained at the time of the tendinitis. Suppression of ciprofloxacin achieved disappearance of the symptomatology.

Lower extremity stress fractures during intermittent cyclical etidronate treatment for osteoporosis

During intermittent cyclical etidronate treatment, a lower extremity pain syndrome associated with stress fractures was observed in three osteoporotic patients. This report describes the development of stress fractures during initial cycles of treatment, with recurrence of symptoms in two patients when etidronate therapy was resumed. Further studies are needed to confirm whether stress fractures are associated with cyclic etidronate treatment and if so, the incidence and pathophysiology need to be determined.

Reduced activity of serum creatine kinase in rheumatoid arthritis: a phenomenon linked to the inflammatory response

In a case-controlled study, serum creatinine kinase (CK) activity was significantly lower in 40 patients with RA than in 40 age- and sex-matched patients with non-inflammatory arthropathies [mean 37.6 (S.D. 29.2) vs 77.7 (S.D. 45.3) IU/l respectively P < 0.0001]. In contrast, serum levels of aldolase and myosin were not significantly lower in RA patients. A significant inverse correlation between CK activity and ESR, CRP and platelet count was observed in RA. There was also a positive correlation between haemoglobin levels and CK values. No correlation was found between CK activity and a meager mass index, disease duration and radiological erosion. No inhibitor of CK activity in the sera of RA patients was found. CK serum activity was markedly reduced in RA, and is related to the inflammatory activity of the disease. This finding may stimulate further exploration on the effect of inflammatory response in muscle metabolism.

Serum IgA anti-Klebsiella antibodies in ankylosing spondylitis patients from Catalonia

IgA antibodies against Klebsiella pneumoniae were measured by immunofluorescence in 84 Catalan patients with ankylosing spondylitis (AS), 41 patients with non-inflammatory arthropathies (NIA) and 22 patients with rheumatoid arthritis (RA). Patients with AS showed higher levels of anti-klebsiella IgA antibodies (IgA-Kp) than NIA and RA patients (4.7 +/- 1.6 U vs 3.7 +/- 1.5 U and 3.1 +/- 1.4 U respectively, p = 0.001). In AS patients a significant correlation between IgA-Kp and levels of C-reactive protein was observed. Although no clear correlation was found between IgA anti-klebsiella and total serum IgA levels, a significant correlation between IgA anti-klebsiella and serum levels of secretory IgA was detected (r: 0.43, p = 0.003). In conclusion, some patients with AS disclosed raised levels of Klebsiella antibodies in sera and this is related to an increase of secretory IgA level. Analysis about the relationship between response to klebsiella and the presence of gut inflammation in AS patients could be of interest.

Histopathologic findings in cutaneous lupus erythematosus

BACKGROUND AND DESIGN

The possible distinction between different types of cutaneous lupus erythematosus (CLE) based on histologic features has been largely debated. This study describes the histopathologic features of three distinct subsets of CLE: chronic, annular-subacute, and papulosquamous-subacute. Biopsy specimens from 92 patients with CLE were examined without the clinical diagnosis being known by the examiners. Of them, 36 clinically demonstrated chronic CLE; 32, annular-subacute CLE; and 24, papulosquamous-subacute CLE.

RESULTS

In chronic CLE, the dermal changes (basement membrane thickening, dermal colloid bodies, pilosebaceous atrophy, and periappendageal infiltrate) were more frequent, while in annular-subacute CLE, a more severe vacuolation of the basal layer and a greater number of epidermal colloid bodies were seen. In addition, pilosebaceous atrophy and more severe epidermal damage were almost exclusive to chronic CLE and annular-subacute CLE, respectively.

CONCLUSIONS

Although some histologic differences between chronic and annular-subacute CLE exist, histopathologic diagnosis of the CLE subsets can only be accurately established when pilosebaceous atrophy or necrosis of all epidermal layers is observed.

Coincidental amyloid nephropathy and IgA glomerulonephritis in a patient with ankylosing spondylitis

A 43-year-old man with ankylosing spondylitis (AS) was admitted with proteinuria and renal insufficiency. Coincidental IgA nephropathy and secondary renal amyloidosis were diagnosed on renal biopsy. This is the first case reported of coincidental IgA nephropathy and renal amyloidosis as a cause of renal insufficiency in a patient with AS. Both entities should be considered in the diagnosis in a patient with AS and renal impairment. A careful study of the renal tissue including, Congo red stain and immunofluorescence studies is necessary to establish a correct diagnosis in these patients.

Prevalence of articular chondrocalcinosis in elderly subjects in a rural area of Catalonia

OBJECTIVES

To undertake an epidemiological survey of the prevalence of radiological chondrocalcinosis in the elderly population of Osona, a rural area of Catalonia, north east Spain.

METHODS

Knee and wrist radiographs were performed on 261 subjects (141 women, 120 men) aged at least 60 years, who attended a series of 35 general practitioners for various medical problems.

RESULTS

Twenty seven subjects had articular chondrocalcinosis, which represents a crude prevalence of 10%. Articular chondrocalcinosis was more often observed in women than in men (14 v 6%). Articular chondrocalcinosis increases in occurrence with age, rising from 7% in subjects aged 60-69 years to 43% in subjects older than 80 years. A similar occurrence of articular chondrocalcinosis was noted in the indigenous population, in which several cases of familial chondrocalcinosis have previously been reported, and in subjects born in other areas of Spain. All but one subject with articular chondrocalcinosis had chondrocalcinosis of the knee. The occurrence of rheumatic disorders did not differ significantly between subjects with articular chondrocalcinosis and those without.

CONCLUSIONS

Articular chondrocalcinosis is an age related disorder, which could partly explain the discrepancies in its prevalence reported in previous studies. In most subjects with articular chondrocalcinosis recruited from an unselected population the clinical manifestations are probably mild or even absent.

Anti-granulocyte perinuclear antibodies but not anti-neutrophil cytoplasmic antibodies (ANCA) in rheumatoid arthritis

We studied 45 patients with rheumatoid arthritis for the presence of ANCA. These antibodies were determined by indirect immunofluorescence (IIF) and by enzyme-linked immunosorbent assays (ELISAs) using as a substrate purified myeloperoxidase and purified extract of azurophilic granules. By IIF, we found a characteristic perinuclear immunostaining pattern in 21 cases (47%). However, no patient had a positive result by the two ELISAs performed. Patients with a positive IIF result had significantly higher levels of anti-nuclear and anti-ds DNA antibodies than those with a negative IIF result. Therefore, these antibodies must correspond to the previously reported as granulocyte specific antinuclear antibodies (GS-ANA).

NON-ASSOCIATION BETWEEN 9.2 KB PvuII RFLP AND SERONEGATIVE SPONDYLOARTHROPATHIES IN SPAIN

Several studies of DNA restriction fragment length polymorphism (RFLP) in ankylosing spondylitis (AS) have been carried out. The association between a recently identified class I HLA 9.2 kb PvuII RFLP and AS remain controversial. In order to evaluate this possible association in an Euro-Caucasian population, the genomic DNA of 42 AS patients and 18 patients with Reiter's syndrome (RS) and 42 healthy controls was analysed. Non-association between 9.2 kb PvuII RFLP and AS or RS was observed. As described previously, a strong association between this fragment and HLA-A3 and/or HLA-A9 antigens was demonstrated. A study of two families showed that this RFLP segregates with HLA-A3 and/or HLA-A9 and independently of the HLA-B27. Our findings support the view that the 9.2 kb PvuII fragment is not universally associated with AS.

Characterization of CD44 antigen during lymphoid ontogeny

We studied immunohistological and biochemical aspects of the CD44 molecule with a mAb produced in our lab: GRHL-1. The characteristic expression of this antigen in cells of B lineage was analyzed. This mAb showed identical immunohistological patterns of reactivity to other mAbs included in CD44 cluster, on a variety lymphoid and nonlymphoid human tissues, and demonstrated similar bands on SDS-PAGE of 125I labeled lymphocyte lysates. This antigen is limited to cells of mature phenotype, and disappears in proliferating B cells in the germinal centers of the lymphoid follicles. CD44 is absent in pre-B and Burkitt cell lines. PKC activation mediate in vitro differentiation of pre-B cell lines. However, it is not involved in up-regulation of CD44 antigen expression.

Immunogenetic findings in cutaneous lupus erythematosus

The serologic features and histocompatibility antigen associations of 93 patients with cutaneous lupus erythematosus are reported. Of them, 37 had chronic cutaneous lupus erythematosus and 56 had subacute cutaneous lupus erythematosus. Subacute cutaneous lupus erythematosus with an annular pattern occurred in 32 patients; 24 had a papulosquamous morphology. Sixty percent of patients with annular subacute cutaneous lupus erythematosus had anti-Ro antibodies. The incidence of this antibody in the other two groups was lower. In addition, patients with annular skin lesions had significant antigen association with HLA-B8 (37.5%; relative risk, 4.6) and HLA-DR3 (59.4%; relative risk, 4.3). There were no significant differences among chronic cutaneous lupus erythematosus and subacute cutaneous lupus erythematosus of the papulosquamous type and the control population for any HLA loci. Thus only patients with annular skin lesions represent a homogeneous subgroup in which there is a striking concordance of anti-Ro antibodies and the HLA-B8 and HLA-DR3 phenotypes.

Reflex sympathetic dystrophy syndrome of the lower limbs in renal transplant patients treated with cyclosporin A

In a 36-month period, 240 patients at our institution received kidney transplants from cadaver donors. Cyclosporin A (CsA) was used as the initial immunosuppressive therapy. Seven patients (5 men and 2 women) developed severe pain, periarticular soft tissue swelling with no effusion, and vasomotor changes in affected areas. Although articular mobility was conserved, most of the patients had great difficulty in walking. A patchy osteoporotic pattern was seen radiographically and increased uptake of 99mtechnetium with a periarticular distribution in the clinically affected areas were found. All of these symptoms and radiographic and scintigraphic signs are compatible with definite reflex sympathetic dystrophy syndrome (RSDS). Articular symptoms began within 3 months after kidney transplantation in all patients; all but 1 patient had plasma CsA levels greater than 200 ng/ml at that time. When the dosage of CsA was reduced, there was concomitant improvement in the RSDS, which appeared when the plasma CsA levels declined to less than 200 ng/ml. The mean duration of the clinical symptoms of RSDS was 8 months. We believe RSDS should be added to the list of complications that may appear in kidney transplant patients who receive CsA treatment.