Paget's disease in a patient with ankylosing spondylitis--a diagnostic dilemma

A patient is described in whom the diagnosis of Paget's disease was complicated by the presence of ankylosing spondylitis. The mechanism for the unusual distribution of pagetic bone is discussed.

Relationship between genotype for the cytochrome P450 CYP2D6 and susceptibility to ankylosing spondylitis and rheumatoid arthritis

OBJECTIVES

To determine whether particular genotypes for the cytochrome P450 enzyme CYP2D6, a polymorphic enzyme, are associated with susceptibility to ankylosing spondylitis (AS) and rheumatoid arthritis (RA), or linked with any specific clinical or familial features of the two conditions.

METHODS

CYP2D6 genotypes were determined in 54 patients with AS, 53 patients with RA, and 662 healthy controls. Leucocyte DNA was analysed for the presence of mutations by restriction fragment length polymorphism analysis with the restriction enzyme Xbal and by two separate polymerase chain reaction assays.

RESULTS

On the basis of odds ratio (OR), individuals with two inactive CYP2D6 alleles were more susceptible to AS than controls (OR 2.71, 95% confidence interval (CI) 1.04 to 7.08), with a stronger effect for the CYP2D6B allele (OR 4.11, 95% CI 1.54 to 11.0). No significant differences in the distribution of overall genotypes and allele frequencies were observed between RA and controls. No significant relationships were found between the skeletal, extraskeletal or familial features of AS or RA (iritis, psoriasis, inflammatory enteropathy and rheumatoid nodules, kerato-conjunctivitis sicca, pleuritis, rheumatoid and antinuclear factors) and the overall genotype.

CONCLUSIONS

Our findings suggest a modest association between homozygosity for inactive CYP2D6 alleles, particularly CYP2D6B alleles, and susceptibility to AS. However, our results fail to demonstrate a genetic link between CYP2D6 genotype and RA.

Bone alkaline phosphatase in rheumatic diseases

A double monoclonal immunoradiometric assay specific for bone alkaline phosphatase (BAP) was used to determine whether the raised total alkaline phosphatase (TAP) often found in patients with active rheumatoid arthritis (RA) and ankylosing spondylitis (AS) is derived from bone or liver. Fifty-eight patients with RA were compared to 14 with AS and 14 with non-inflammatory rheumatic diseases (NI). None had clinical liver disease and only one had a slightly elevated aspartate transaminase activity. Elevated BAP concentrations were found in seven patients (5 RA, 1 AS, 1 NI), only two of whom also had abnormal TAP. Abnormal TAP activities were found in only three patients (all RA). BAP did not correlate with disease activity in RA or AS. In contrast, TAP correlated with disease activity (assessed by plasma viscosity) in RA (P < 0.002) and gamma-glutamyl transferase (GGT) also correlated with plasma viscosity in RA (P < 0.01). Both TAP and BAP were significantly correlated with GGT in RA (P < 0.001 and P < 0.02, respectively). These findings are discussed, together with possible reasons for the conflicting nature of some of the observations.

Polymorphism in an HLA linked proteasome gene influences phenotypic expression of disease in HLA-B27 positive individuals

OBJECTIVE

To investigate the potential influence of the HLA-linked LMP (low molecular weight polypeptide) genes on disease susceptibility in HLA-B27 individuals with ankylosing spondylitis (AS).

METHODS

A polymorphic CfoI restriction enzyme site in the coding region of one proteasome gene was evaluated in 125 genomic DNA samples from B27 individuals with well documented AS, 55 of whom had had acute iritis, and 42 samples from normal, ethnically matched B27 blood donors where AS was excluded.

RESULTS

Analysis of individuals with B27 AS with iritis revealed significant differences in allelic distribution of this biallelic locus compared to patients with B27 AS without iritis. Furthermore, homozygosity for the disease associated allele was significantly more prevalent in patients with AS with iritis (72.7%) than in patients without iritis (38.6%) (p(uncorrected) = 0.0003) or B27 controls (45.2%) (p(uncorrected) = 0.01).

CONCLUSION

Our findings support the involvement of additional HLA linked genes in the phenotypic expression of disease in B27 individuals and suggest a role for the non-B27 HLA haplotype in susceptibility to iritis.

[Physical factors in the treatment of patients with ankylosing spondylarthritis]

The effect of decimeter electromagnetic waves, ultrasound, induction therapy, crysanol phonophoresis was compared in relevant treatment of 180 AS patients. The response to the above factors was almost similar in AS activity of the I degree. Central AS of the II degree of activity was more sensitive to decimeter waves while for peripheral and rhizomelic forms the results of crysonal phonophoresis were more positive. Dominating immunocorrective effect of the waves and partial immunodepressive action were referred to decimeter waves and crysanol phonophoresis, respectively.

[Acetylator phenotype in spondylarthritis ankylopoietica]

The authors studied the distribution of acetylator phenotypes among 136 AS patients (100 male, 36 female). 67 per cent of all patients were slow acetylators, 72 per cent of the males. Both rates are higher than that of the healthy Hungarian population. The authors draw attention to the clinical importance of investigating the acetylator type before sulphasalazine treatment because it may help in prescribing the effective dose and avoiding side effects.

Studies of humoral and cell-mediated immunity to peptides shared by HLA-27.1 and Klebsiella pneumoniae nitrogenase in ankylosing spondylitis

One-hundred and twenty-four patients with spondylarthropathies were studied for antibodies to the peptides from HLA-B27.1 and Klebsiella pneumoniae nitrogenase which share a QTDRED hexamer sequence. Of 60 male Norwegian ankylosing spondylitis (AS) patients 23.3% showed positive ELISA reactivity for B27.1 peptide compared with 4% of Norwegian male controls (P less than 0.10). This difference was not observed among patients and controls from New Mexico. All patients with anti-B27.1 antibody were HLA-B27+. Antibody to B27.1 peptide was present in 20% of normal female controls with at least one previous pregnancy. No female control without previous pregnancy showed positive anti-B27.1 peptide reactivity. Anti-Klebsiella peptide antibody was neither significantly elevated in AS nor correlated with anti-B27.1 peptide antibody. Significant migration inhibition by these peptides was not observed in AS or normal controls. The possible influence of epitope conformation, rather than sequence homology, in potentially cross-reacting determinants shared by bacterial antigens and human Class I molecules requires further study.

Alkaline phosphatase isoenzymes in rheumatic diseases

Serum alkaline phosphatase isoenzymes were determined quantitatively by electrophoresis on cellulose acetate in 168 patients with rheumatic diseases subgrouped for disease activity. Median values of total alkaline phosphatase and bone isoenzyme activity, as well as frequency of patients showing pathological values, increased gradually and significantly corresponding to disease activity in rheumatoid arthritis and ankylosing spondylitis, from 0% in inactive to 90% in very active forms. Bone isoenzyme was much more sensitive than total alkaline phosphatase in moderate disease activity and was also correlated to the number of involved extravertebral joints and pain in ankylosing spondylitis. No correlation was found with stage or duration of disease, age, sex, and erythrocyte sedimentation rate. Additional to bone isoenzyme, liver isoenzymes were elevated in some patients, but with only a weak correlation with disease activity. The intestinal isoenzymes were always normal. We conclude that quantitative determination of serum alkaline phosphatase bone isoenzyme activity is a major indicator for the assessment of disease activity and therapeutic monitoring in rheumatoid arthritis and ankylosing spondylitis.

Alpha 1-antitrypsin phenotypes in acute anterior uveitis

The alpha 1-antitrypsin phenotype PiMZ has been reported to have a higher than normal incidence in patients with acute anterior uveitis, indicating an important role in the immunogenetics of this condition. We have determined the incidence of this phenotype in 72 patients with acute anterior uveitis. It was found to occur in four patients (5.6% of the total), with the highest incidence (3/34 or 8.8%, p less than 0.001) in patients negative for HLA B27 and without sacroiliac joint disease. The incidence in HLA B27 positive patients was normal. No correlation was found with the severity, bilaterality, or recurrence of uveitis. Although this increased incidence is statistically significant in comparison with the normal population incidence of 2.6%, its direct clinical significance is questionable; the most likely explanation for it includes possible linkage with other immunoregulatory genes. We also found a lower than expected incidence of the phenotype PiMS, and discuss the relevance of this finding.

Circulating inhibitor bound elastase in patients with ankylosing spondylitis and rheumatoid arthritis and the influence of sulphasalazine treatment

The plasma concentration of granulocyte elastase in complex with alpha 1 proteinase inhibitor was determined in 42 patients with ankylosing spondylitis (AS) and 33 patients with rheumatoid arthritis (RA). Significantly raised levels of plasma elastase were found in patients with RA, whereas patients with AS had normal values. No correlation was seen between the elastase values and erythrocyte sedimentation rate (ESR), serum haptoglobin, immunoglobulins, or polymorphonuclear cell (PMN) count in either of the patient groups. A correlation was found between the Ritchie index and plasma elastase in patients with RA. After three months' treatment with sulphasalazine a clinical improvement was seen and this paralleled a reduction of the acute phase reaction in both patient groups. A reduction of the circulating elastase values was seen in the patients with RA, whereas no change was seen in patients with AS.

Granulocyte elastase as a new biochemical marker in the diagnosis of chronic joint diseases

Human granulocyte elastase (EC 3.4.21.37) is released from granulocytes in large amounts in chronic inflammatory joint diseases and is therefore of special pathogenic and diagnostic importance. In order to examine the diagnostic significance of this enzyme as a clinico-chemical parameter, we determined the concentration of granulocyte elastase in complex with alpha 1-proteinase inhibitor by an enzyme immunoassay in synovial fluids and plasma of patients with chronic joint diseases. In inflammatory synovial fluids the concentration of complexed elastase correlates well with the granulocyte number and may increase to an extremely high level. In 90% of patients with manifest rheumatoid arthritis increased elastase levels are also observed in the plasma, probably due to the large gradient between the synovial fluid and plasma concentration, whereas in osteoarthrosis normal plasma concentrations were observed. Thus, these results indicate that normal plasma concentrations in patients with chronic joint diseases exclude the diagnosis of rheumatoid arthritis with high probability. The simultaneous determination of complexed elastase in plasma and synovial fluid improves the nosological differentiation of chronic joint diseases. Elastase activity on a specific chromogenic substrate, which was found in many inflammatory synovial fluids, is mainly attributed to elastase alpha 2-macroglobulin complexes. In some purulent synovial fluids, however, we were able to detect free elastase, which has been shown to play an important role in the destruction of articular cartilage.

Superoxide dismutases in polymorphonuclear leukocytes from patients with ankylosing spondylitis or rheumatoid arthritis

The activity of cyanide-sensitive and cyanide-insensitive superoxide dismutase (CNs- and CNi-SOD) was measured in polymorphonuclear neutrophils isolated from the blood of patients with ankylosing spondylitis (A.S.) or adults with rheumatoid arthritis (R.A.). Our purpose was to detect alterations in the protecting activity of these enzymes that might cause rheumatic lesions secondary to superoxide anion generation in the inflammatory loci. There was no difference in total SOD activity (CNs + CNi) in either A.S. or R.A. when compared to the control group. In contrast, CNi-SOD activity decreased in R.A. and A.S. and CNs-SOD activity rose significantly in A.S. only. None of the changes observed in SOD activity correlated with patient's age, erythrocyte sedimentation rate, clinical evolution of the disease or the drug doses administered. It is concluded that the reduced activity of CNi-SOD might be partly responsible for the reduced protection of the joints against oxygen-free radicals in patients with A.S. or R.A. Other factors however appear to have greater effects on the clinical evolution of these diseases.

[Non-lymphoid mononucleated cells in the synovial fluid in arthrosis and various inflammatory arthropathies. Morphologic, quantitative and cytoenzymologic study]

This paper describes a morphologic, quantitative, cytochemical study of mononuclear non lymphoid cells in knee synovial fluid in osteoarthritis and various arthritides. Morphologic criteria allow to identify among these cells various synoviocytic and monocytic subtypes with in both types, phagocytic subtypes. Quantitative study shows in arthritides an important afflux of monocytes and a hyperexfoliation of synoviocytes. In fluids with intermediate cellularity, Monocytes/Synoviocytes ratio allows the differential cytodiagnosis between osteoarthrosis and arthritis. All monocytic subtypes and especially the phagocytic one are highly significantly increased in arthritides. Synoviocytic subtypes show a lower increase, except the phagocytic one, which is not changed. Giant multinuclear synoviocytes are found in every type of disease and cannot constitute a cytodiagnosis marker. Alcian Blue and hyaluronidase treatment show hyaluronate in a few percentage of Synoviocytes. Cytoenzymologic study shows that synoviocytes and monocytes are positive in all tested hydrolases: beta Glucuronidase, Acid Phosphatase, alpha Naphthyl Acetate Esterase, these activities being always higher in synoviocytes. With peroxidase, synoviocytes are always negative, so this reaction although it marks only a minority of monocytic population can be used as an extra cytologic criterion for discrimination of mononuclear cells in synovial fluid. In these four enzymes there is no significant quantitative difference at cellular level between osteoarthrosis and arthritides. Lysosomal enzymatic activity in both monocytic and synoviocytic cells confirms their heterophagic properties. However synoviocytic heterophagy seems to be a physiological process not or few affected by inflammatory events. On the opposite, monocytic heterophagy and then macrophagic transformation of monocytes appears as a major aspect of intrasynovial inflammatory reaction. If a large majority of exfoliated synoviocytes comes from A type synovial lining cells and if they belong to Mononuclear Phagocyte System, why do they so weakly, or not, participate as phagocytes to inflammatory reaction.

[Poly-(ADP ribose) synthesis and regulation disorders in disease]

Poly(ADP-ribose) is a polyanion involved in the regulation of the DNA metabolism of cells. DNA repair, semiconservative DNA-synthesis, differentiation- and trans-formation functions are connected to changes in the activity of the poly(ADP-ribose)-polymerase. The incidence of most cancers shows a steady increase with age while the PAR-synthesis decreases linear in certain cells with age. In some diseases abnormalities could be detected in PAR-synthesis and binding to nuclear proteins.

Increased serum alkaline phosphatase activity in ankylosing spondylitis

Raised serum alkaline phosphatase (AP) levels were found in 13 of 76 patients (17%) with ankylosing spondylitis (AS), and 11 of these 13 underwent further investigation to determine the origin of the increased enzyme activity. Three had levels within the normal reference range on re-estimation, and, of the remaining 8, AP isoenzyme studies indicated an increased liver fraction in 6. Serum gamma-glutamyl transpeptidase (GGT) was raised in only 3 patients. Increased AP activity did not appear to be directly related to disease activity or to drug therapy. These findings confirm the occurrence of increased serum AP activity in AS but challenge a previously reported suggestion that bone is the source of the increased enzyme.

Muscle changes in ankylosing spondylitis

Muscle biopsy of the quadriceps femoris was carried out in 20 patients with classical ankylosing spondylitis (AS). Histological and histochemical studies revealed changes in all biopsies to a varying degree. Central migration of nuclei was present in 80%, reduced fibre size with some atrophy in 40%, localized reaction to acid phosphatase in 75% and a peripheral condensation of reaction product to NADH-TR stain in 55% of biopsies. Furthermore 14 out of 16 patients, whose quadriceps strength was measured, were found to be below the predicted values, when compared to healthy controls of similar weight, and quantitative surface electromyography in 10 showed lower mean power frequency than in controls. A raised plasma creatine kinase was found in only two patients. It is concluded that muscle changes occur in AS and these may account for some of the clinical features of the disease.

Serum immunoreactive prolyl hydroxylase in inflammatory rheumatic diseases

Serum immunoreactive prolyl hydroxylase protein (S-IRPH) was measured in 56 patients with inflammatory rheumatic diseases, and the values were compared with those in 32 control subjects. S-IRPH was above the 95% confidence limit of the controls in about 70% of the patients with active systemic lupus erythematosus, rheumatoid arthritis, scleroderma, Reiter's syndrome, Sjögren's syndrome, polyarteritis nodosa, or polymyositis. Raised values were observed in about half of the patients with an erythrocyte sedimentation rate (ESR) of 21-50 and in about 90% of those with ESR of over 50, whereas only about 10% of the patients with an inactive disease had an S-IRPH concentration exceeding this limit. Only 1 out of 8 patients with active ankylosing spondylitis had a raised S-IRPH value. The results support previous data indicating that significant changes in collagen metabolism occur in active connective tissue diseases. Assays of S-IRPH might be of some value in assessing the activity of these diseases and in monitoring the treatment provided.

Liver function in some common rheumatic disorders

Liver function was studied primarily by determination of serum gamma glutamyl transferase and alkaline phosphatase. In subsamples of patients the investigation was extended by determination of serum amino-transferases, isoenzyme analysis of alkaline phosphatase, 99mtechnetium scintigraphy, and liver biopsy. In 183 in-patients with rheumatoid arthritis, the serum gamma glutamyl transferase level was elevated in 47% and serum alkaline phosphatase (of liver origin) in 24%. A concomitant increase in serum aminotransferases was found in 15% of patients with elevated gamma glutamyl transferase level. A closely similar pattern was found in 45 patients with non-rheumatoid arthritis (ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and undefined arthritis), and in 5 patients with polymyalgia rheumatica. In 23 patients with non-rheumatic inflammation (pneumonia), liver dysfunction was common, though the pattern of serum enzyme changes was different. In rheumatoid arthritis, liver scanning showed irregular or low uptake, but biopsy only indicated reactive hepatitis. Hepatotoxicity could not be traced to any single drug or combination of drugs given. On the contrary, chloroquine appeared to reduce serum gamma glutamyl transferase, and corticosteroids had a similar effect on serum alkaline phosphatase. In patients not treated with corticosteroids, both serum gamma glutamyl transferase and alkaline phosphatase were weakly to moderately correlated with laboratory indices of disease activity (ESR and serum orosomucoid). The frequently occurring isolated increase of serum gamma glutamyl transferase and/or serum alkaline phosphatase in arthritis may be an unspecific reaction to inflammation.

The clinical significance of serum alkaline phosphatase isoenzymes in locomotor diseases

AP isoenzymes were estimated in 292 patients with locomotor diseases and in 124 healthy controls. The diagnostic usefulness of AP determination is increased by estimation of isoenzymes. Investigations were made to study the biological profile of organ specific AP activities: 1. Rheumatoid arthritis and Reiter's syndrome - the total AP and L-AP activities were increased. 2. Ankylosing spondylitis treated by physiotherapy - the total AP, B-AP and I-AP activities were increased. After drug therapy an increase occurred also in L-AP activity while I-AP activity showed no significant change. 3. Progressive OA of hip and knee showed increased levels of total AP and B-AP activities. 4. Degenerative diseases of the spine, chiefly cases of discopathy, showed significantly reduced levels of AP and B-AP activities. 5. In osteoporosis there was an increase in total AP, L-AP, B-AP and I-AP activities. 6. In the active generalised form of Paget's disease, increased levels were found of total AP, B-AP, I-AP and L-AP activities. 7. In neoplastic diseases the isoenzymes can help to reveal metastatic dissemination and thus aid preoperative evaluation. 8. In gout and hyperuricemic syndromes there was a relative increase of B-AP activity and non-significant fall of L-AP activity. Increased levels of L-AP occured in patients with gallbladder disease, after immunosuppressive therapy or after infectious hepatitis. A fall of L-AP levels was found after Corticotrophin and after intraarticular administration of Kenalog. Increased B-AP activities occurred after total hip replacement, in acute or chronic pyelonephritis and in active osteonecrosis and osteoporosis. Anabolic therapy caused a significant fale of B-AP activity to fall significantly. Reduced B-AP levels were also found after antibiotic therapy. Increased I-AP activity was found in cases of osteoporosis, and in secondary amyloidosis; reduced I-AP activity was seen in mucous colitis. The activity of I-AP is assumed to increase as a result of the changed intestinal calcium and phosphorus regulation occurring in association with the enhanced bone tissue metabolism. From this point of view an order of significance is given for the activity of bone pathology in the separate diagnostic groups of locomotor diseases.

Raised serum creatine phosphokinase activity in ankylosing spondylitis

Serum enzyme studies were made on 43 (37 male, 6 female) consecutive patients with ankylosing spondylitis. Serum creatine phosphokinase (CPK) activity was raised above 55 IU/l in 24 (65%) of 37 male patients (range 29-165 IU/l, mean 68) as compared with 2 (4%) out of 47 male controls (range 14-85 IU/l, mean 33: P less than 0-001); levels were greater than 35 IU/l in six (100%) out of six female patients (range 39-100 IU/l, mean 56) as against one (3%) of 35 female controls (range 3-106 IU/l, mean 16; P less than 0-001). The recognized pitfalls in interpreting CPK activity were avoided. In all of sixteen randomly selected patients isoenzyme studies confirmed that muscle is the source of the enzyme. There was a significant correlation between CPK activity and both spinal flexion and the reciprocal of finger-to-floor distance (P less than 0-5 in each case).

[Importance of enzymes in the synovial fluid. Progress report]

The significance and importance of investigation of the synovial fluid enzymes in the main arthropathies are explanined. Tables are given for the main enzymes studied, the cell compartments of origin, and data for their values in rheumatic diseases (as reported in the literature). Stress is laid on the importance of enzymes belonging to the lysosomial compartment, both in the pathogenesis of the underlying inflammation and in the relation to anatomopathological lesions in the joints. Attention is directed to the most widely accepted hypotheses. These ten to see enzymes increases in breakdown of condrocytes, as inflammatory arthritis attributable to synoviocytes and leukocytes. A personal opinion based on prior research is also presented. Further work in this sector is urged a mean of learning more about the pathology of rheumatic diseases.

Haematology and biochemistry of ankylosing spondylitis

Forty men with ankylosing spondylitis have been reviewed clinically, radiologically, haematologically, and biochemically, and the results of the last two compared with a male group of rheumatoid patients and a control group. In the patients with ankylosing spondylitis the haemoglobin levels were much higher and the E.S.R. significantly lower than in the rheumatoid group, and the E.S.R. in the patients with ankylosing spondylitis was unrelated to disease activity as evidenced by pain. The alkaline phosphatase level was raised in 19 cases and in most was derived from bone. Though 10 patients had abnormal globulin levels, the albumin levels were normal, as was renal function in all cases.