Clinical presentations of chlamydial and non-chlamydial reactive arthritis

The aim of this study was to investigate the triggering micro-organisms and the clinical as well as laboratory differences between Chlamydial and non-chlamydial reactive arthritis (ReA) in a prospective study on 98 patients with acute/subacute arthritis. An inciting organism was found in 42 patients. Eighteen of these were chlamydial. Fifty-seven percent of all ReA patients were carriers for HLA-B27, which increased to 67% in the chlamydial group. Chlamydial ReA patients had more urethritis (P<0.05) with a longer period between arthritis and inciting infection, significantly lower CRP levels, and involved joint counts (P<0.05). Additionally, sacroiliitis was more frequent besides extra-articular manifestations in chlamydial ReA group. This study shows that chlamydial ReA differs in some points from non-chlamydial ReA, which in turn may affect the evaluation of an arthritic patient. ReA due to chlamydia more frequently encompasses a monoarticular or oligoarticular clinical picture with predominant distal extremity involvement. Non-chlamydial ReA presents higher joint counts and may involve upper extremity joints.

Bone and joint disease associated with primary immune deficiencies

Primary immune deficiencies (PIDs) are characterized by functional and/or quantitative abnormalities of one or more immune system components. Several bone and joint abnormalities can occur in patients with PID, with arthritis being the most common. Joint manifestations, of which arthritis is the most common, occur chiefly in humoral PIDs (agammaglobulinemia, common variable immunodeficiency, hyper-IgM syndromes, and IgA deficiency) and occasionally in other PIDs (chronic granulomatous disease and Wiskott-Aldrich syndrome). Monoarthritis or oligoarthritis is the usual pattern, although polyarthritis may occur, occasionally with nodules suggesting rheumatoid arthritis. Arthritis in patients with PID is usually infectious in nature, the most common causative organism being Mycoplasma, followed by Staphylococcus, Streptococcus, and Haemophilus. These bacteria can induce not only synovial infections, but also aseptic arthritogenic inflammatory responses. Arthritis having no demonstrable relation to chronic infection has been reported also and ascribed to dysimmunity-driven mechanisms that exhibit a number of specific features. Bone lesions are far less common and usually due to infections complicating humoral PID. Distinctive bone manifestations occur in a number of rare PIDs (e.g., hyper-IgE syndrome and Di George syndrome) and in syndromes characterized by spondyloepiphyseal dysplasia. Familiarity with PID syndromes both enhances the diagnostic capabilities of physicians and provides insight into the pathophysiology of bone and joint abnormalities associated with immune dysfunction. In children and occasionally in adults, a combination of bone and/or joint manifestations and hypogammaglobulinemia may indicate PID. When there is no evidence of lymphoproliferative disease, infection, or iatrogenic complications, investigations for PID should be obtained. PID-related arthritis is a unique model for studying the pathogenesis of presumably postinfectious arthritis and of inflammatory joint diseases including rheumatoid arthritis.

Reactive arthritis

Reactive arthritis (ReA) was known as Reiter's disease or Fiessinger-Leroy disease for nearly 100 years. However, during the past 30 years the disease has been known as reactive arthritis, a member of the spondyloarthritis family. Despite knowing the initiating event (infection) and genetic constitution (many patients have HLA-B27) of ReA, a model of interplay between environment and genetics, its pathogenesis is still incompletely known. This review covers the epidemiology, clinical features, treatment, and prognosis of ReA.

Subungual erythema in lymph node tuberculosis with erythema nodosum

We encountered a case of tuberculous lymphadenitis with erythema nodosum presenting with an unusual manifestation as subungual erythema in all the digits. Relevant literature and the possible explanation for the subungual erythema have been discussed.

Poststreptococcal reactive arthritis with thoracic spine involvement in an adult

It is controversial whether poststreptococcal reactive arthritis (PSReA) is an entity separate from acute rheumatic fever (ARF) or is a forme fruste of ARF. Although there are many case series of PSReA in children, this entity is not common in adults. We describe an adult patient with polyarthritis and thoracic spine involvement attributed to PSReA.

Successful Treatment of Postvenereal Reactive Arthritis With Synovectomy and 3 Months’ Azithromycin

BACKGROUND

The effects of antibiotic therapy on the course of postvenereal reactive arthritis have not yet been elucidated.

OBJECTIVE

The objective of this study was to observe the clinical course and outcome of synovectomy and 3 months of azithromycin therapy in patients with reactive arthritis and previously diagnosed triggering bacteria.

METHODS

We performed an open, prospective study on 20 (14 male/6 female) patients with postvenereal reactive knee arthritis, aged 36.7 +/- 14.8 years, and with 16.5 +/- 20.4 months' duration of the disease. Detection of bacteria triggers was done by polymerase chain reaction, isolation and identification, and electron microscopy. Synovectomy was performed in all patients at entry into the study. Azithromycin was given at a dose of 500 mg per day for 5 days, and then 500 mg twice a week, during a 3-month period. Patients without remission were treated with combined antibiotic therapy using a macrolide, quinolone, and tetracycline for the next 4 months. Outcome evaluations of therapeutic efficacy and azithromycin safety were done after 1 and 3 months and 2 years of follow up.

RESULTS

Remission, defined by the absence of joint swelling and tenderness, and extraarticular signs, was reached after 3 months in 15 of 20 (75.0%) patients (P = 0.025). Of 5 patients with persistent knee arthritis, remission was achieved with combined antibiotic therapy in 4. Visual analog scale scores (P < 0.01), the number of patients (P = 0.002), and the number of samples (P = 0.01) with a positive finding of bacteria or their DNA were significantly lower after 3 months of therapy. During the azithromycin therapy, there were no significant adverse effects.

CONCLUSIONS

These patients with reactive arthritis did extremely well on the regimen described. In our study group, the number of patients and the number of samples with positive findings of bacteria or their DNA were lower after the antibiotic treatment combined with surgery, although not all bacteria were eradicated. Adverse effects of prolonged azithromycin administration were insignificant. This open treatment approach is recommended but does need a study with controls.

Synovial Chlamydia trachomatis up regulates expression of a panel of genes similar to that transcribed by Mycobacterium tuberculosis during persistent infection

BACKGROUND

Synovial tissues in patients with Chlamydia associated arthritis are persistently infected by C trachomatis, an organism for which genetic manipulation is not possible. M tuberculosis also engages in persistent infection, and because this bacterium is genetically tractable many groups have been able to define transcriptional characteristics of mycobacterial growth and persistence.

OBJECTIVE

To investigate whether the pattern of gene expression underlying chlamydial persistence is similar to that underlying mycobacterial persistence.

METHODS

194 genes in M tuberculosis that are transcriptionally up regulated to support in vivo growth and persistence of that organism have previously been identified. Each of those genes was compared with the C trachomatis genome to identify orthologues. Expression of selected chlamydial orthologues so identified was assessed by real time RT-PCR in an in vitro model of chlamydial persistence and synovial tissues from patients who were PCR positive for C trachomatis at that site.

RESULTS

67 C trachomatis genes were identified as being orthologous to mycobacterial persistence related genes, representing 35% of the genes tested. The chlamydial orthologues fell into similar metabolic and other categories as those in M tuberculosis. Expression of a majority of selected chlamydial orthologues was strongly up regulated in an in vitro model of chlamydial persistence and in synovial tissues of relevant patients, compared with their expression during active infection.

CONCLUSIONS

These observations provide new insight into the molecular genetic basis underlying chlamydial persistence, and indicate that this information can be obtained, in some instances, by extrapolating observations made in other biological systems and/or organisms.

Arthrite réactionnelle a Clostridium difficile

Extracolonic manifestations of Clostridium difficile infections have rarely been reported as a cause of reactive arthritis. We report the case of a monoarticular arthritis following pseudomembranous colitis. A 45 year-old man was admitted for fever and monoarthritis of the left knee, 8 days after the onset of a C. difficile enterocolitis associated with urethritis. Samples obtained from the knee, urine, and blood cultures remained sterile. Bone scintigraphy revealed a left knee and forefoot hyperfixations. The association of arthritis and urethritis led us to the diagnosis of Fiessinger-Leroy-Reiter syndrome. Antibiotics for arthritis were ineffective and stopped, but they were continued for colitis. NSAIDs were prescribed and clinical manifestations disappeared within 24 hours, the patient resumed walking after 48 hours. Four months later there was no relapse and no sequela.

Aetiology and pathogenesis of reactive arthritis: role of non-antigen-presenting effects of HLA-B27

Spondyloarthropathies are inflammatory diseases closely associated with human leukocyte antigen (HLA)-B27 by unknown mechanisms. One of these diseases is reactive arthritis (ReA), which is typically triggered by Gram-negative bacteria, which have lipopolysaccharide as an integral component of their outer membrane. Several findings in vivo and in vitro obtained from patients with ReA and from different model systems suggest that HLA-B27 modulates the interaction between ReA-triggering bacteria and immune cells by a mechanism unrelated to the antigen presentation function of HLA-B27. In this review we piece together a jigsaw puzzle from the new information obtained from the non-antigen-presenting effects of HLA-B27.

[Results of the microbiological, clinical and immunological examination of children with Reiter's disease]

Infectious agents were detected in 100% of examined children with Reiter's disease (RD). Chlamydia trachomatis were detected in 98% of cases. In children with RD lesions of joints and eyes often took acute forms with cases of sacroiliitis, early muscular atrophy and conjunctivitis. In 95% of the patients the prostatitis manifestations were detected. In children with RD a rised number of CD lymphocytes in combination with the fivefold rised IL-4 content, an essential increase in the activity of C2-C5 components of the complement and a multiple rised level of PSA were registered.

Nonspecific urethritis and reactive arthritis

Nongonococcal urethritis (NGU) is a common sexually transmitted infection most often caused by Chlamydiae and Mycoplasmae. A few other organisms, as well as some nonsexual factors, also contribute to its etiology. NGU can result in considerable physical and psychological morbidity. In a few cases, it can lead to complications like reactive arthritis, and pelvic inflammatory disease, with their attendant morbidities. Correct diagnosis and treatment is therefore imperative in proper management of these cases. While earlier diagnostic support for these infections was limited and expensive, the advent of new methods like the nucleic acid amplification assays (NAA tests) has contributed significantly to better diagnosis. Treatment as per suggested guidelines and follow up of cases and contacts are all crucial in management. Counseling, including advice on behavior change, goes a long way in preventive strategies.

Exacerbation of rheumatoid arthritis following Helicobacter pylori eradication: disruption of established oral tolerance against heat shock protein?

A 62-year-old Japanese woman with RA received an eradication therapy against Helicobacter pylori in November 1999. Eight weeks later, successful eradication was confirmed by negative results for rapid urease test, pathologic findings, and a fall in anti-H. pylori IgG antibody titer. During the course, parameters for RA activity were exacerbated: C-reactive protein 1.1-4.2 mg/dL, rheumatoid arthritis precipitation antigen 2560-5120 dils., erythrocyte sedimentation rate 52-123 mm/h, and complements CH50 50 to over 60 U/mL. Lansbury index increased from 70% to 105%. Two more weeks later, the patient noticed right shoulder pain. She also complained of bilateral gonalgia two months later, and physical examination revealed increased fluid in the knee joints. Prednisolone was required to control the disease activity. The results of this case suggested that RA patients might experience a deleterious effect on the disease activity following H. pylori eradication possibly through disruption of the established oral tolerance against stress protein such as mycobacterial heat shock protein 65.

Reactive joint symptoms following an outbreak of Salmonella typhimurium phage type 135a

OBJECTIVE

To quantify the incidence and clinical features of reactive arthritis (ReA) developing in a cohort exposed to an outbreak of Salmonella typhimurium phage type 135a, and factors affecting host susceptibility to ReA.

METHODS

A screening questionnaire was mailed to 493 patients with confirmed Salmonella infection. Musculoskeletal symptoms and extraarticular manifestations of ReA were quantified. Positive responders with joint pain were invited to participate further, with a detailed history, examination, and investigations including HLA-B27 status.

RESULTS

A total of 261/461 (57%) subjects responded to the questionnaire, with 23/54 adults (43%) and 41/207 children (20%) reporting joint symptoms. Although joint pains were less common in children compared with adults, those children affected usually had eye (34%) or mucocutaneous (37%) symptoms. The incidence of ReA was 14.6%, with adults more frequently affected (24%) than children (12%). This may be an underestimate given the large proportion of children involved. Associated clinical features were similar to previous studies, with the distribution of arthritis affecting the lower limbs predominantly in an oligoarticular pattern, as were the extraarticular manifestations and enthesopathy. We found 17% of subjects were HLA-B27 positive, and 55% were still symptomatic after 6 months.

CONCLUSION

In an Australian cohort study of a S. typhimurium phage type 135a outbreak, joint symptoms were common, affecting 25% of subjects. The incidence of ReA of 14.6% and the clinical features were comparable to previous studies. There was a small effect of HLA-B27 status on the development of ReA.

Reactive arthritis attributable to Shigella infection: a clinical and epidemiological nationwide study

OBJECTIVES

To study the incidence and clinical picture of Shigella associated reactive arthritis (ReA) and the arthritogenicity of various Shigella species in the population.

METHODS

A questionnaire on enteric and extraintestinal, especially musculoskeletal, symptoms was sent to 278 consecutive patients with Shigella positive stool culture and to 597 controls. Analysis of self reported musculoskeletal symptoms was supplemented with clinical examination of those subjects with recent symptoms.

RESULTS

Of the patients, 14/211 (7%) had ReA, and a further 4/211 (2%) other reactive musculoskeletal symptoms (tendonitis, enthesopathy, or bursitis). Of the 14 patients with ReA, all adults, 10 had S sonnei, three S flexneri, and one S dysenteriae infection. HLA-B27 was positive in 36% of the patients with ReA. One control subject had ReA. In the patients with Shigella infection, the odds ratio for developing ReA was 16.2 (95% confidence interval 2.1 to 123.9), p = 0.001.

CONCLUSIONS

ReA occurred in 7% of patients after Shigella infection, with an annual incidence of 1.3/1 000 000 in Finland. Besides S flexneri, S sonnei and S dysenteriae can also trigger ReA.

Relationship between disease activity and infection in patients with spondyloarthropathies

OBJECTIVE

To assess the relationship between disease activity and signs and symptoms of infection in Mexican patients with spondyloarthropathies (SpA).

METHODS

A cross sectional study of 95 non-selected patients with SpA (62 men; mean age 26.4 years), who were examined for signs and symptoms of infection and their association with disease activity. 52 had ankylosing spondylitis (AS), 32 undifferentiated SpA (uSpA), 6 chronic reactive arthritis (ReA), and 5 psoriatic arthritis (PsA). Categorical data were analysed by chi(2) or Fisher's tests.

RESULTS

53 (56%) patients had infections: 41 (43%) upper respiratory tract (URT), 34 (36%) enteric, and 20 (21%) genitourinary infections. More infections occurred in HLA-B27 positive patients as a whole (39 v 5; p = 0.003) and in uSpA (12 v 2; p = 0.005). In AS and uSpA, infections occurred in approximately 50%. 30/39 (77%) patients with active disease (group A) and 23/56 (41%) (group B) (p = 0.001) had infection. There were more enteric infections in group A (47%; p<0.001) and more URT infections in group B (52%; p = NS). 22/30 (73%) patients attributed disease activity to infection.

CONCLUSION

Enteric, and less commonly, URT infections in Mexican patients with SpA, particularly those who were HLA-B27 positive, seem to have a role in the active phase of AS and uSpA.

Doxycycline versus doxycycline and rifampin in undifferentiated spondyloarthropathy, with special reference to chlamydia-induced arthritis. A prospective, randomized 9-month comparison

OBJECTIVE

Chlamydia is a known trigger of reactive arthritis (ReA). It may also be common cause of undifferentiated spondyloarthropathy (uSpA). Persistent, metabolically active, Chlamydiae have been observed in the synovial tissue of these patients years after their initial exposure. Trials with lymecycline and rifampin have shown benefit in early/acute Chlamydia-induced arthritis. In vitro data suggest that persistent Chlamydia become resistant to chronic monotherapy of tetracyclines or rifampin, whereas no such resistance is noted when rifampin is added to antimicrobials that are active against Chlamydia. Rifampin and doxycycline also show synergistic effect against Chlamydia. In addition, rifampin inhibits chlamydial production of heat shock proteins (HSP). HSP60 plays a key role in the chronic persistent state of Chlamydia. We conducted a prospective, randomized 9-month trial to evaluate the efficacy of doxycycline versus a combination of doxycycline and rifampin in the treatment of uSpA.

METHODS

The study enrolled 30 patients with chronic inflammatory arthritis (average disease duration 10 yrs) who fulfilled the European Spondylarthropathy Study Group criteria, with no evidence of inflammatory bowel disease, psoriasis, ankylosing spondylitis, or preceding dysentery. Patients received doxycycline 100 mg po twice daily or a combination of doxycycline 100 mg po twice daily and rifampin 600 mg po daily. They received a 4-question self-questionnaire and a blinded joint examination at each visit. The questions include a visual analog scale (VAS) for their current amount of back pain, duration of morning stiffness, back pain at night, and peripheral joint pain. The blinded joint examination consisted of a swollen joint count (SJC) and a tender joint count (TJC). These 6 variables were assessed at baseline and at 1, 3, 6, and 9 months. Responders were defined as those who improved > or = 20% in at least 4 of the 6 variables at 9 months of therapy.

RESULTS

Comparing the doxycycline + rifampin arm (D/R) versus the doxycycline arm (D) at 9 months of therapy, all 6 variables improved more in D/R versus D, 4 of which were statistically significant. The mean VAS (scale of 100) decreased 24.4 points in D/R in contrast to 3 points in D (p < 0.03). Duration of morning stiffness decreased by 1.2 h in D/R, with a slight increase of 0.1 h in D (p < 0.003). The back pain at night and peripheral joint pain both improved in D/R group versus D (not statistically significant). Finally, the SJC and TJC also improved in D/R (-2.1 and -2.5) versus D (-0.4 and -0.6; p = 0.02, p = 0.03, respectively). Eleven of 15 patients in the D/R arm were responders, whereas only 2 of 15 D group patients were considered responders (p < 0.003).

CONCLUSION

The combination of doxycycline and rifampin for 9 months seemed to be effective in treatment of chronic uSpA. This is the first study to demonstrate therapeutic benefit with antimicrobials to a chronic inflammatory arthritis possibly secondary to persistent Chlamydia.

Major histocompatibility complex class I peptide presentation after Salmonella enterica serovar typhimurium infection assessed via stable isotope tagging of the B27-presented peptide repertoire

Reactive arthritis (ReA) induced by infection with several gram-negative bacteria is strongly associated with expression of the major histocompatibility complex class I molecule HLA-B27. It is thought that due to the intracellular lifestyle of ReA-inducing bacteria, bacterial fragments can be presented by HLA-B27. Cytotoxic T cells recognizing such bacterial peptides or other induced host peptides could cross-react with self peptides presented in the joints, giving rise to disease. Studies to analyze the B27 peptide repertoire in relation to infection were severely hampered, as complex peptide profiles obtained from separate infected and noninfected cell preparations had to be compared. For this study, we applied a new approach to examine the effect of Salmonella enterica serovar Typhimurium infection on the B27 peptide repertoire presented by the HLA-B*2704 subtype associated with disease. Firstly, we showed that both host cell and S. enterica serovar Typhimurium proteins can be tagged metabolically with stable-isotope-labeled arginine. We then designed experiments so that either the tagged endogenous or tagged bacterial B*2704-presented peptide repertoires from infected cells could be analyzed by mass spectrometry from single peptide preparations that included uninfected controls. Using this new approach, we found no evidence for significant changes in endogenous B*2704 peptide presentation after infection or for any S. enterica serovar Typhimurium-derived B27-bound peptide. In conclusion, the hypothesis that S. enterica serovar Typhimurium induces changes in B27 peptide presentation could not be supported.

[Reiter's syndrome after Salmonella infection]

Two patients with Reiter's syndrome, after Salmonella infection were treated on the Infections disease ward at Clinical hospital center in Kragujevac. In the first patient, ten days after the onset of Salmonella infection, signs of edema and pain in the right ankle occurred, accompanied by expressed conjunctivitis. Within next two months consecutive metatarsophalanges changes joint of the right foot have appeared. In the second patient, two weeks after the onset of Salmonella infection, edema of the left hand joints and a week later edema of the right hand and right ankle joints appeared. In both patients inflammatory syndrome was expressed (high erythrocyte sedimentation rates, fibrinogen, C-reactive protein) along with negative rheumatoid factors and positive antigen HLA-B27. Outcome of the disease in both cases was favourable upon receiving nonsteroid antirheumatic therapy. Signs of arthritis disappeared after three months. No signs of recurrent arthritis have been seen during the next four years in the first and next two years in the second patient.

Poststreptococcal reactive arthritis: what is it and how do we know?

OBJECTIVE

To find out whether poststreptococcal reactive arthritis (PSRA) is a discrete, homogeneous clinical syndrome.

METHOD

Literature review from case reports and case series.

RESULTS

One hundred and eighty-eight cases were identified. The age distribution was bimodal, with one peak in childhood and one peak in adulthood. Eighty-three percent of streptococcal isolates were group A. The clinical presentation was heterogeneous but appeared different both from that of acute rheumatic fever (ARF) and from that of HLA B27-associated reactive arthritis. Carditis was rare.

CONCLUSIONS

The term PSRA encompasses significant heterogeneity. The link between the arthritis and the streptococcal infection is unproven.

HLA-B27-associated reactive arthritis: pathogenetic and clinical considerations

Current evidence supports the concept that reactive arthritis (ReA) is an immune-mediated synovitis resulting from slow bacterial infections and showing intra-articular persistence of viable, non-culturable bacteria and/or immunogenetic bacterial antigens synthesized by metabolically active bacteria residing in the joint and/or elsewhere in the body. The mechanisms that lead to the development of ReA are complex and basically involve an interaction between an arthritogenic agent and a predisposed host. The way in which a host accommodates to invasive facultative intracellular bacteria is the key to the development of ReA. The details of the molecular pathways that explain the articular and extra-articular manifestations of the disease are still under investigation. Several studies have been done to gain a better understanding of the pathogenesis of ReA; these constitute the basis for a more rational therapeutic approach to this disease.

Disease mechanisms in reactive arthritis

Reactive arthritis (ReA) occurs after a preceding bacterial infection of the urogenital or gastroenteral tract. The bacteria triggering ReA persist in vivo and seem to be responsible for triggering an immune response. A cytokine imbalance with a relative lack of T-helper 1 cytokines may play an important role allowing these bacteria to survive. This seems to be relevant for manifestation and chronicity of the arthritis. For the chronic cases and cases evolving into ankylosing spondylitis, the interaction between bacteria and human leukocyte antigen B27 plays an additional crucial role. Among others, the arthritogenic peptide hypothesis is one way to explain this association. Human leukocyte antigen B27-restricted peptides from Yersinia and Chlamydia, which are stimulatory for CD8+ T cells derived from patients with ReA, have been identified. The exact role of such peptides for the pathogenesis of ReA and other spondyloarthritides still has to be defined.

Differential expression of three Chlamydia trachomatis hsp60-encoding genes in active vs. persistent infections

Real time RT-PCR was used to assess expression of the three Chlamydia trachomatis hsp60-encoding genes (Ct110, Ct604, Ct755) over time in in vitro systems of active vs. persistent infection, and in synovial samples from patients with Chlamydia-induced arthritis. In HEp-2 cells actively infected with C. trachomatis (serovar K), mRNA from Ct110 (groEL) was apparent by 8 h post-infection (p.i.) and increased more than 10-fold through 48 h p.i.; mRNA from Ct604 followed a similar pattern. Transcripts from Ct755 were abundant at 8 h p.i. and remained 2-3-fold higher than those from Ct110 at all times. In persistently infected human monocytes in culture, expression of Ct110 and Ct755 was low from 1 to 7d p.i., while mRNA from Ct604 was abundant at 1d p.i. and increased more than 3-fold from 1 to 3d p.i., as the organism transited to the persistent state. Those mRNA levels remained high through 7d p.i. Real time analyses of RNA/cDNA from synovial tissue of patients with Chlamydia-associated arthritis showed high Ct604 mRNA levels, consistent with results from the in vitro monocyte system of persistence. These data demonstrate that each chlamydial hsp60-encoding gene is expressed independently, and that the three genes are expressed differentially in active vs. persistent infection. The results further suggest that the Ct604 gene product may function importantly during chlamydial persistence.

[The cellular immune reaction in synovial fluid lymphocytes to Ureaplasma antigens in patients with Reiter's syndrome]

INTRODUCTION

Reiter's syndrome (RS) is an seronegative arthritis that occurs after urogenital or enteric infection which in addition with occular and/or mucocutaneous manifestations presents complete form of disease. According to previous understanding arthritis in the RS is the reactive one, which means that it is impossible to isolate its causative agent. However, there are the more and more authors suggesting that arthritis in the urogenital form of disease is caused by the infective agent in the affected joint. This suggestion is based on numerous studies on the presence of Chlamydia trachomatis and Ureaplasma urealyticum in the inflamed joint by using new diagnostic methods in molecular biology published in the recent literature [1-3]. Besides, numerous studies of the humoral and cell-mediated immune response to "triggering" bacteria in the affected joint have supported previous suggestions [4-7]. Aim of the study was to determine whether synovial fluid T-cells specifically recognize the "triggering" bacteria presumably responsible for the Reiter's syndrome.

METHOD

The 3H-thymidine uptake procedure for measuring lymphocyte responses was applied to lymphocytes derived concurrently from synovial fluid (SF) and from peripheral blood (PB) [8]. Ureaplasma antigen and mitogen PHA stimulated lymphocytes in 24 RS patients (24 PB samples, 9 SF samples) and the results were compared with those found in 10 patients with rheumatoid arthritis (RA) (10 PB samples, 5 SF samples). Preparation of ureaplasma antigen. Ureaplasma was cultured on cell-free liquid medium [9]. Sample of 8 ml was heat-inactivated for 15 minutes at 601C and permanently stirred with magnetic mixer. The sample was centrifuged at 2000 x g for 40 minutes and than deposits carefully carried to other sterile glass tubes (Corex) and recentrifuged at 9000 x g for 30 minutes. The deposit was washed 3 times in sterile 0.9% NaCl, and final sediment was resuspended in 1.2 ml sterile 0.9% NaCl. BACTERIOLOGY: Chlamydia trachomatis was isolated by cell culture using cycloheximide-treated McCoy cells [10], while Ureaplasma urealyticum was identified according to its biochemical properties grown on cell-free liquid medium [9].

RESULTS

Proliferative response of the PB lymphocytes to stimulation by mitogen and ureaplasma antigen did not differ between RS and RA patients. Also, there was no difference in proliferative response of SF lymphocytes to mitogen stimulation between RS and RA patients (Figure 1). However, proliferation of SF lymphocytes stimulated by ureaplasma antigen was significantly elevated in RS patients compared with the control group. This difference is statistically significant (p < 0.05) (Figure 2). Difference in proliferative response of the PB and SF lymphocytes stimulated by the ureaplasma antigen was not found in RS patients.

DISCUSSION

It was found that SF lymphocytes of RS patients showed significantly elevated proliferative response to stimulation by the ureaplasma antigen compared with SF lymphocytes of the control group. There was no difference when the lymphocytes were stimulated by the mitogen. Our findings suggest that elevated proliferative response of lymphocytes is the sign of stimulation cell-mediated immunity to antigen present in inflamed joint. Hence, the main immune response to Ureaplasma is on the cell-mediated level in the affected joint. This confirms the earlier finding reported by Ford et al. who concluded that synovial rather than peripheral blood lymphocytes indicate the microbiological cause of arthritis [11, 12]. Horowitz et al. demonstrated the correlation between clinical remission after antibiotic therapy and eradication of Ureaplasma, together with a decrease in cellular immune response synovial fluid lymphocytes to ureaplasma antigen stimulation [13]. In that study Horowitz did not find statistically significant difference of ureaplasma proliferative response between PB and SF lymphocytes in patients with RS. We obtained the same results. Than we concluded that sensibilization of immune system exist in the presence of foreign antigen in RS patients. The other authors demonstrated higher stimulation indices than the ones we found in our patients [11-15]. This difference may be the result of different preparation of antigens, in other words selection of serotype of Ureaplasma for antigen preparation different conditions of lymphocyte cultivation. We concluded that the presence of antigen, antigen-specific T cells and efficient antigen-presenting cells (CD4+ T cells) in the joint of RS patients strongly suggests that a T-cell-mediated response to bacteria has the central role in the pathogenesis of Reiter's syndrome.

Post-streptococcal reactive arthritis and glomerulonephritis in an adult

We report the case of an adult who developed severe post-streptococcal reactive arthritis (PSRA) and poststreptococcal glomerulonephritis (PSGN) after a subclinical streptococcal infection. Antistreptococcal antibody titres, renal biopsy and the clinical course confirmed the diagnosis. Coincidence of PSRA and PSGN is rare in the adult population and the potential for misdiagnosis exists, particularly when prior streptococcal infection is not apparent. The clinical manifestations of poststreptococcal syndromes are highly variable, and the diagnosis of concomitant PSRA and PSGN should be considered when patients present with glomerulonephritis and inflammatory arthritis. Factors from both the host and the pathogen are probably important in determining disease expression in poststreptococcal syndromes.

[Diagnostic and therapeutic problems in SARA syndrome (sexually acquired reactive arthritis) particularly considering the role of Chlamydia trachomatis]

Reactive arthritis triggered by a sexually transmitted infection is referred to as sexually acquired reactive arthritis (SARA). There is no gold standard for the diagnosis of SARA. None of the tests or the clinical symptoms alone are strong enough to make a definite diagnosis of SARA. Tests to identify Chlamydia trachomatis, when respect typical clinical symptoms are helpful to make the diagnosis of ReA.

How does Chlamydia cause arthritis?

Because the bacterial cause of CIA has been identified and proven to persist at the site of inflammation, the understanding of how Chlamydia cause arthritis has made much progress. The site of entry and the route of dissemination have been identified, the molecular state of persistence is increasingly described, some mechanisms of how Chlamydia can persist despite an actively reacting immune system have been identified, and data regarding how persistent Chlamydia induce inflammation have been obtained. What needs to be achieved in the future--in addition to better understanding the molecular basis of persistence--is to reveal how persisting bacteria can be eliminated. If this information is insufficient for a cure of the disease, it must be determined how the inflammation can be treated more specifically and effectively to cure CIA early and prevent the development of chronic forms that develop into spondyloarthritis.

Identification of HLA-B27-restricted peptides in reactive arthritis and other spondyloarthropathies: computer algorithms and fluorescent activated cell sorting analysis as tools for hunting of HLA-B27-restricted chlamydial and autologous crossreactive peptides involved in reactive arthritis and ankylosing spondylitis

The illustrated clinical and experimental results demonstrate the strong relationship between the MHC class I antigen HLA-B27 and synovial CD8+ T cells with specificity for bacterial and possible self-antigen in SpA. These new aspects obtained in recent experimental and clinical studies might also provide clues to the pathomechanisms of joint inflammation in SpA. In particular, the newly developed techniques will be of great relevance in the near future. New and more precise bioalgorithms reflecting new insights in the biology and biochemistry of proteins as recently presented [98, 99] can be helpful (e.g., a program with an improved prediction of the features of immunoproteasomes). Intracellular and secreted cytokine staining by FACScan allows examination of a great number of cells expressing certain antigens in response to certain stimuli. The analysis of T-cell responses with tetramer/peptide complexes can be useful to screen tissue sections for TCR, recognizing foreign or self-derived epitopes on those complexes loaded with selected (e.g., bacterial) peptides. Identification of arthritogenic peptides and a further understanding of the immunology of the pathomechanisms in SpA might open ways to design new peptide vaccines to prevent inflammation, autoimmunity, and other diseases by early intervention [100].

[The role of diagnostic tests in the identification of Chlamydia trachomatis infection in reactive arthritis]

Reactive arthritis (ReA) is a sterile inflammation of the synovial membrane of one or more joints developing after urogenital or gastro-intestinal infection. The syndrome most frequently follows infection with Chlamydia trachomatis. Useful for the diagnosis can be the serological tests. At present there is the possibility to identify the specific antibodies (IgG, IgA, IgM) to Chlamydia trachomatis. The subject of the study was the group of 87 patients in age 19-78; 58 women and 29 men from whom urogenital smear and serum were tested. The control group were 30 people age 25-70 without rheumatological disorders. Chlamydia trachomatis was found in urogenital smear in 42 (48%), in 56 (64%) patients immunoglobulin IgG were positive, and immunoglobulin IgA in 16 (18%). The laboratory tests and clinical symptoms allow to make a diagnosis of ReA in 38 (43%) and possible ReA in 5 (5.7%) of patients.

CONCLUSIONS

1. There is no gold standard for the diagnosis of ReA. 2. None of the tests or the clinical symptoms alone are strong enough to make a definite diagnosis of ReA. 3. Tests to identify Chlamydia trachomatis, with respect of typical clinical symptoms are useful the diagnosis of ReA. 4. The diagnosis of ReA is most probable if we have typical clinical symptoms, clinical evidence of a preceding infection plus a positive result of serology or PCR plus positivity for HLA-B27.

[Spontaneous and Fas-induced apoptosis of mononuclear leukocytes in rheumatoid arthritis]

A study was made into the ability of mononuclear leukocytes recovered from blood of 77 patients with rheumatiod arthritis (RA), 17 patients with osteoarthrosis deformans (OAD), 18 patients with Chlamydia-associated reactive arthritis (ReA), and 20 healthy controls, to precipitate spontaneous and Fas-induced apoptosis. RA patients versus healthy persons and patients with OAD and ReA displayed lower parameters characterizing spontaneous and Fas-induced apoptosis. A correlation was established between the ability of T- and B-lymphocytes to usher in Fas-induced apoptosis during incubation with RhHA and KonA and degree of RA activity.

Prevalence and molecular diversity of pHS-2 plasmids, marker for arthritogenicity, among clinical Escherichia coli Shigella isolates

Reactive arthritis can occur after numerous bacterial infections, including bacillary dysentery caused by Escherichia coli Shigella. A major risk factor for the disease is the HLA B27 phenotype in the human host. By comparison between plasmid profiles of arthritogenic vs. nonarthritogenic Shigella strains, the pHS-2 plasmid has been previously associated with the arthritogenic capacity of Shigella isolates. However, the prevalence of this plasmid in the various Shigella biotypes and serotypes is largely unknown. On this background, 188 clinical isolates from intestinal disease representing all 46 Shigella serogroups were studied for the presence of the pHS-2 plasmid, using PCR, dot blot and Southern blot techniques and by analysis of restriction fragment length polymorphisms. The pHS-2 plasmid was found in nine of 14 E. coli Flexneri serogroups, in E. coli Dysenteriae 1 and in E. coli Boydii 16. In addition, we show marked variability of this plasmid in E. coli Flexneri 3A and 4A strains. Major biological diversity of the pHS-2 plasmid was found to be strictly related to Shigella serogroups. The prevalence pattern of the pHS-2 plasmid matches published data on arthritogenic Shigella isolates, providing additional indirect evidence for the potential validity of this plasmid as a marker for arthritogenicity.

Determinants of synoviocyte clearance of arthritogenic bacteria

OBJECTIVE

Persistence of intracellular organisms may play a critical role in the initiation and perpetuation of synovitis in reactive arthritis (ReA). We investigated factors that may influence local clearance of arthritogenic pathogens in ReA.

METHODS

We studied 11 HLA-B27 positive patients with spondyloarthropathies and contrasted these patients with 6 HLA-B27 negative control patients with rheumatoid arthritis or osteoarthritis. We employed an ex vivo system in which human synoviocytes derived from patients with ReA are cocultured with arthritogenic pathogens, and intracellular clearance is measured by quantitating colony-forming units over time.

RESULTS

The clearance kinetics of the organisms bore no relationship to the HLA-B27 status of the patient. Clearance of S. typhimurium over a 10 day period was accompanied by a progressive rise in nitric oxide (NO) production, but this appeared not to be rate-limiting, since (1) clearance kinetics were comparable between high versus low NO-producing synoviocytes; and (2) L-NMMA inhibition of NO production did not alter clearance kinetics of S. typhimurium. Interferon-g (IFN-g) was observed to have a small but measurable effect on bacterial clearance. In certain patients with ReA there was a paradoxical stimulatory response to IFN-g, in which the addition of IFN-g was accompanied by an increase in intracellular bacteria. This effect was found to be attributable to IFN-g mediated suppression of NO production in these cells. This pattern was not observed in B27 negative synoviocytes.

CONCLUSION

Intracellular persistence of arthritogenic organisms may contribute to the cellular basis of ReA, but the molecular basis of the bacteriocidal pathways in synoviocytes has not been fully resolved. Our findings indicate that a direct effect of HLA-B27 on these events is unlikely, but that alterations in cytokine response profiles may play a contributory role. Characterizing these mechanisms holds the promise of more specific therapeutic interventions in this disease.

Arthritis associated with enteric infection

Reactive arthritis is classically seen following infection with enteric pathogens such as Yersinia, Salmonella, Campylobacter and Shigella. Inflammatory arthritis has also been described following other enteric infection with organisms such as Clostridium difficile, Brucella and Giardia. Furthermore, arthritis is seen in Whipple's disease, caused by the actinomycete Tropheryma whippelii. This chapter reviews the current understanding of these conditions (with the exception of Brucella, which is discussed in a subsequent chapter). The epidemiology is reviewed, and the contribution of both host and organism to the aetiology and pathogenesis is discussed with particular discussion of the role of HLA-B27 in host susceptibility. Recent work exploring evidence for traffic of pathogenic organisms to the joint is highlighted. A practical approach to the diagnosis and management of the condition is then formulated based, where possible, on clinical trial evidence.

Infections preceding early arthritis in southern Sweden: a prospective population-based study

OBJECTIVE

To detect evidence of infections preceding early arthritis in Southern Sweden and to compare the clinical outcome of remission during a 6-month followup for patients with and without signs of prior infection.

METHODS

Adult patients with arthritis of less than 3 months' duration were referred from primary health care centers to rheumatologists. All patients were systematically screened for infections caused by Salmonella typhimurium and Salmonella enteritidis, Yersinia enterocolitica, Campylobacter jejuni, Borrelia burgdorferi, Chlamydia trachomatis, Chlamydia pneumoniae, and parvovirus B19.

RESULTS

Seventy-one patients were included in this study. Twenty-seven (38%) patients had reactive arthritis (ReA), 17 (24%) undifferentiated arthritis, 15 (21%) rheumatoid arthritis (RA), 4 (6%) psoriatic arthritis, and the rest (11%) other diagnoses. Of all the patients, 45% had evidence of a recent infection preceding the arthritis, as indicated by laboratory tests and/or disease history. C. jejuni dominated the ReA group. The occurrence of recent C. trachomatis, B. burgdorferi, C. pneumoniae, and parvovirus B19 infections was low. Overall, 58% of the patients went into remission during the 6-month followup. Of the patients with a preceding infection, 69% went into remission as compared to 38% of the patients without a preceding infection (p = 0.011). Thirty-three percent of the patients with RA were in remission after 6 months.

CONCLUSION

In this population-based cohort, 45% of the patients presenting with a new-onset arthritis had had a prior infection. Campylobacter ReA dominated the ReA group. There were only a few cases preceded by infections by C. trachomatis, B. burgdorferi, C. pneumoniae, and parvovirus B19 infections. Remission during the first 6 months was especially frequent in the group of patients with a prior infection, but the remission rate was relatively high even for arthritis without prior infection.

Role of bacteria and HLA-B27 in the pathogenesis of reactive arthritis

Strictly speaking, "reactive arthritis" is a conventional term with no study-verified definition. This review will focus on the type of arthritis that is induced by the following species: Chlamydia, Shigella, Salmonella, Yersinia, and Campylobacter. The types of arthritis caused by these pathogens share a clinical pattern that is common in the spondyloarthropathies, especially undifferentiated spondyloarthropathy and Reiter's syndrome. All these diseases, including ankylosing spondylitis, must also share major pathogenetic pathways.

Analysis of a viridans group strain reveals a case of bacteremia due to lancefield group G alpha-hemolytic Streptococcus dysgalactiae subsp equisimilis in a patient with pyomyositis and reactive arthritis

Streptococcus dysgalactiae is classified by a combination of phenotypic and genotypic characteristics into Lancefield group C alpha-hemolytic Streptococcus dysgalactiae subsp. dysgalactiae and Lancefield group C, group G, and group L beta-hemolytic Streptococcus dysgalactiae subsp. equisimilis. In this study, we report the isolation of a catalase-negative, alpha-hemolytic, optochin- and bacitracin-resistant viridans group strain, which does not grow in 10 or 40% bile, on MacConkey agar or bile esculin agar, or in 6% NaCl, from the blood culture of a 73-year-old woman with pyomyositis and poststreptococcal reactive arthritis. Lancefield grouping revealed that the strain was a group G streptococcus. The Vitek system (GPI) showed that it was unidentified, and the API system (20 STREP) showed that it was 95.7% S. dysgalactiae subsp. dysgalactiae. 16S rRNA gene sequencing showed that it was a strain of S. dysgalactiae. Based on phylogenetic affiliation with 16S rRNA gene or GroEL amino acid (another bacterial gene, in addition to 16S rRNA gene, that is highly conserved) sequences, the strain is most closely related to Lancefield group C beta-hemolytic S. dysgalactiae subsp. equisimilis. PCR amplification and sequencing of the streptolysin S structural gene (sagA) and M protein gene (emm) hypervariable region showed the presence of these suspected primary virulence factors. Further studies would delineate whether the isolate is just a hemolysin-deficient variant of group G beta-hemolytic S. dysgalactiae subsp. equisimilis or a novel type of S. dysgalactiae. The present case showed that group G alpha-hemolytic S. dysgalactiae subsp. equisimilis can be associated with serious invasive infection and poststreptococcal sequelae.

Reactive arthritis and serum levels of mannose binding lectin -- lack of association

The purpose was to evaluate the possible association of serum mannose binding lectin (s-MBL) levels on type of triggering microbe, duration of diarrhoea, incidence and course of reactive arthritis (ReA) caused by Salmonella, Yersinia and Campylobacter. Sixty patients with ReA of 1-228 months duration, 173 patients with ReA or uncomplicated enterocolitis caused by Campylobacter, 226 sera from patients with elevated antibody levels against Salmonella, Yersinia or Campylobacter, and 114 blood donors were tested for s-MBL using ELISA technique, both direct mannan binding assay and sandwich ELISA. s-MBL was compared with C-reactive protein (CRP) levels and with the ability of activating complement C4. Among the 114 donors 9% had s-MBL <50 microg/l, 16% had from 50-500 microg/l and 75% had >500 microg/l. The distribution of s-MBL levels in the three-patient groups did not differ significantly from the controls. There were no indications that low s-MBL was associated with prolonged duration of arthritis, diarrhoea or individual bacterial infections. The two MBL assays were comparable with respect to serum concentrations, indicating that the actual circulating MBL was also functionally active. s-MBL exhibited acute phase reactant behaviour and correlated to CRP level, but only in patients with s-MBL concentrations exceeding 1000 microg/l. MBL in 10 randomly selected ReA sera were tested for the ability to activate complement C4. The results did not differ from those of donor controls. This study demonstrates that the distributions of s-MBL levels in serum among patients with ReA are not different from donor controls. The course, outcome or triggering bacteria are not associated with a particular level of s-MBL.