Isolation of Chlamydia trachomatis or Ureaplasma urealyticum from the synovial fluid of patients with Reiter's syndrome

BACKGROUND

The aim of this study was to contribute to the insight of the role of the infectious agent in ethiopathogenesis of the Reiter's syndrome development, which could directly influence the choice of treatment of these patients.

METHODS

Eighteen patients with urogenital form of the Reiter's syndrome and 16 controls (6 with rheumatoid arthritis and 10 with pigmented villonodular synovitis) were included in the study. In all patients standard laboratory analyses of the blood, urine and stool were made; antibody titer to Chlamydia trachomatis and Ureaplasma urealyticum was determined in synovial fluid and serum; isolation of Chlamydia trachomatis and Ureaplasma urealyticum in urethral, cervical and conjunctival swabs, as well as in prostatic and synovial fluid, was also made. HLA typing was done, too. Chlamydia was isolated in the McCoy cell culture treated with cycloheximide, while Ureaplasma was identified according to its biochemical properties grown on cell-free liquid medium.

RESULTS

Chlamydia trachomatis was isolated from the synovial fluid of 4 patients with Reiter's syndrome (22.2%), while Ureaplasma urealyticum was isolated in 7 of them (38.9%). These microorganisms were not found in any synovial fluid of the control group patients.

CONCLUSION

Presence of these bacteria in the inflamed joint might be an important factor in etiopathogenesis of this disease, and it supports the hypothesis that arthritis in Reiter's syndrome is probably of the infectious origin.

Sporadic enteric reactive arthritis and undifferentiated spondyloarthropathy: evidence for involvement of Salmonella typhimurium

OBJECTIVE

To define the candidate bacterial trigger and cytokine profile of synovial fluid mononuclear cells (SFMC) in patients with sporadic enteric reactive arthritis (ReA) and undifferentiated spondyloarthropathy (uSpA).

METHODS

The study group comprised 10 patients with ReA and 23 with uSpA who fulfilled European Spondylarthropathy Study Group criteria. Ten patients with rheumatoid arthritis (RA) served as disease controls. IgG, IgA, and IgM antibodies to Shigella flexneri, Salmonella typhimurium, and Yersinia enterocolitica were measured in sera and SF by ELISA. Peripheral blood mononuclear cell (PBMC) and SFMC proliferation assays were done in the presence or absence of crude bacterial lysates. Bacterial antigens and DNA in synovial cells were detected by indirect immunofluorescence and polymerase chain reaction, respectively. Interferon-g (IFN-g), interleukin 10 (IL-10), and IL-4 were measured in 18 h SFMC culture supernatants in presence of bacterial lysate.

RESULTS

Antibodies to S. typhimurium were significantly elevated in the sera of 8 of 25 patients compared to controls (0/22; p < 0.05). The ratio of SF:serum anti-salmonella IgA was significantly higher in patients compared to controls (p < 0.0002). The ratio of SF:serum IgA antibodies to S. typhimurium was higher than that for S. flexneri (p < 0.007) and Y. enterocolitica (p < 0.05). Out of 25 patients, 8, 2, and none had elevated antigen-specific SFMC proliferation response to S. typhimurium, S. flexneri, and Y. enterocolitica, respectively, whereas no control had elevated response. Salmonella antigens were detected in the synovial cells of 4 out of 14 patients. There was significantly higher IFN-g production from SFMC of patients who had increased proliferative response to Salmonella (LTT+) in the presence of Salmonella antigens compared to antigen control. The mean +/- SD of the ratio of IFN-g:IL-10 in the LTT+ patients was significantly lower compared to controls. Conclusion. S. typhimurium is probably one of the triggers for enteric ReA and uSpA in our cohort of patients, and the immune response is characterized by increased production of both IL-10 and IFN-g.

Cutaneous vasculitis and reactive arthritis following respiratory infection due to Chlamydia pneumoniae: report of a case

Unlike Chlamydia trachomatis and C. psittaci, the association of C. pneumoniae infection with immunological complications, such as reactive arthritis (ReA) or erythema nodosum (EN) has been rarely reported. Here we present the case history of a patient with C. pneumoniae community acquired pneumonia (CAP) who subsequently developed a ReA and a cutaneous vasculitis. A 45-year-old HLA B27 negative male developed an asymmetric and additive arthritis and a cutaneous leukocytoclastic vasculitis with IgM and complement papillary deposition along hypodermic vessel walls about three weeks after the onset of respiratory symptoms. The diagnosis of chronic Chlamydia pneumoniae infection was based on serology and PCR. Cultural and serological investigations for other infectious agents commonly involved in ReA were negative. This is the first report on the occurrence of two immune-based complications, associated to Chlamydia pneumoniae infection. Therefore, since this infection is very common in our population, although often asymptomatic, should be systematically considered as a common causative agent of ReA and of vasculitis.

Reactive arthritis and other sequelae following sporadic Salmonella typhimurium infection in British Columbia, Canada: a case control study

OBJECTIVE

To describe sequelae occurring in the 3 months after sporadic Salmonella typhimurium (ST) infection in British Columbia (BC), Canada.

METHODS

We compared the incidence of sequelae to similar symptoms in controls; identified risk factors for developing sequelae; identified the incidence of reactive arthritis (ReA) as diagnosed by a rheumatologist, and assessed primary care physician diagnosis of ReA. A questionnaire was administered by telephone to cases of ST occurring in BC between December 1, 1999, and November 30, 2000; and to controls obtained from the BC provincial client registry. Cases reporting symptoms were followed up by a rheumatologist.

RESULTS

Thirty-five of 66 (53%) cases reported any symptom, 17 (26%) reported joint symptoms. The Mantel-Haenszel odds ratio (weighted by sex and pediatric/adult) of a salmonella case reporting "any symptom" compared to controls was 5.42; 95% confidence interval (CI) 2.18-16.27; and reporting joint symptoms was 4.40; 95% CI: 1.25-19.53. The sex distribution of cases reporting joint symptoms was not significantly different. No medication taken during the salmonella infection was significantly different between the cases who had joint symptoms and those who did not. Four cases (2 adults, 2 children) were considered by the rheumatologist to have symptoms consistent with ReA, 2 of these had been told by a physician that their symptoms were related to their ST infection.

CONCLUSION

Cases were more than 4 times more likely to report joint symptoms than controls; and despite the loss of many cases to followup, 6% of all cases were considered to have ReA.

Poststreptococcal reactive arthritis

Poststreptococcal reactive arthritis (PSRA) refers to a poststreptococcal arthritic condition that does not fulfill the Jones Criteria for diagnosis of acute rheumatic fever. Clinical features include additive rather than migratory arthritis that responds relatively poorly to salicylates and nonsteroidals; persistence for mean of 2 months; elevated acute phase reactants; and laboratory (usually serologic) evidence of recent group A streptococcal infection. PSRA is not associated with HLA-B27 but rather with HLA-DRB1*01. Because up to 6% of PSRA patients develop mitral valve disease, it is recommended that antistreptococcal prophylaxis be administered for 1 year and then discontinued if there is no evidence of cardiac involvement.

Ureaplasma urealyticum as a possible cause of reflex sympathetic dystrophy syndrome

We describe the cases of two patients with clinical and radiological findings of the reflex sympathetic dystrophy syndrome (RSDS) in whom the history of a previous genito-urinary inflammation and high levels of ESR lead us to suspect a hidden reactive arthritis. However, instrumental examinations showed a characteristic picture of RSDS without evident signs of arthritis. In both patients we decided a treatment with quinolones because of detection of an ureaplasma urealyticum genito-urinary infection. This brought to complete remission of the joint symptoms in a few days. Our findings suggest that ureaplasma urealyticum can cause and sustain a RSDS picture, maybe with a reactive arthritis-like mechanism, and that an antibiogram-driven antimicrobial treatment can be rapidly effective against this disorder.

Detection of bacterial DNA in Latin American patients with reactive arthritis by polymerase chain reaction and sequencing analysis

OBJECTIVE

Bacteria and/or their antigens are thought to play a role in the pathogenesis of reactive arthritis (ReA). Polymerase chain reaction (PCR) using the 16S ribosomal RNA-PCR method was used to identify bacterial DNA in synovial fluid (SF) and tissue (ST) in a well defined group of patients with chronic ReA. In addition, species found were identified by means of sequence analysis.

METHODS

We examined 15 ST and 5 SF samples of 15 patients with ReA, 5 ST samples of 5 patients with osteoarthritis (OA), and 8 SF from 8 patients with closed traumatic knee injuries using a nested PCR with universal 16S rRNA primers. In addition, a nested PCR was developed to detect DNA sequences of Salmonella sp. and Mycoplasma sp. Automated sequencing and comparative data analysis (GenBank) were also performed to identify the species.

RESULTS

Bacterial DNA was identified in 8 cases, 5 ST and 3 SF; Chlamydia trachomatis (n = 2), Pseudomonas sp. (n = 3), and Bacillus cereus (n = 2) were the most common microorganisms identified. A variety of microorganisms including Clostridium sp., Lactobacillus sp., Pseudomonas migulae, P. fluorescens, and P. putida, and Neisseria meningitidis serogroup B were also identified. In half of the cases (4/8) 2 to 3 bacterial antigens were identified simultaneously.

CONCLUSION

Bacterial DNA is present in the joints in patients with chronic ReA. A wide spectrum of bacteria including some not previously associated with ReA were identified. Further studies are needed to establish their exact role in the pathogenesis of ReA and related arthritides.

Reactive arthritis or chronic infectious arthritis?

Microbes reach the synovial cavity either directly during bacteraemia or by transport within lymphoid cells or monocytes. This may stimulate the immune system excessively, triggering arthritis. Some forms of ReA correspond to slow infectious arthritis due to the persistence of microbes and some to an infection triggered arthritis linked to an extra-articular site of infection.

[Reactive arthritis: current characteristics and the role of Chlamydia infections in development of a clinical picture]

AIM

To examine present-day peculiarities of reactive arthritis (ReA) and effects of chlamydial infection on ReA clinical manifestations.

MATERIAL AND METHODS

120 ReA patients entered the trial. Urogenital variant was in 85%, enterocolitic in 15% of the patients. Etiology of ReA was defined with special methods diagnosing chlamydial and ureaplasma infection in scrapes from urethral or cervical epithelium (a cytological test, an enzyme immunoassay, polymerase chain reaction, cultural technique of ureaplasma detection). Antichlamydial antibodies were identified with enzyme immunoassay and reaction of indirect immunofluorescence. Factor analysis and indirect consecutive image recognition were applied.

RESULTS

In all the cases, enterocolitic ReA was preceded by acute intestinal infection. In urogenic ReA the disease started with urethritis (62.7%), conjunctivitis (2.0%), arthritis (31.4%) or talalgia (3.9%). Initially, the occurrence of a full Reiter's triad was 15%, incomplete (two signs of the three)--46.7%. The debute was characterized by predominant oligoarticular lesion (65%), in the advanced stage polyarthritis was frequently diagnosed (49.6%). Pain most frequently located in the low spine (60.5%). X-ray evidence on degenerative-dystrophic alterations of the peripheral joints and spine was obtained in 54.2% ReA cases. 60 patients were examined for chlamydial and ureaplasma infection. The etiology of ReA was chlamydial, ureaplasmic and chlamydo-ureaplasma in 43.3, and 35%, respectively. The etiology was not identified in 16.7% cases. Such extraarticular symptoms as urogenital, ocular, skin and mucosal, cardiovascular, lymph nodes were observed in 61.7, 22.5, 13.3, 76.7 and 13.3%, respectively.

CONCLUSION

At present, ReA is characterized by the following most typical features: polymorphism of clinical symptoms at the disease onset, predominance of polyarticular variant of articular involvement at the advanced stage of ReA, high incidence of extraarticular manifestations. The factor analysis shows that clinical picture of ReA is established by "activity" and "unfavourable course" factors.

Comparison of rheumatological and gastrointestinal symptoms after infection with Campylobacter jejuni/coli and enterotoxigenic Escherichia coli

OBJECTIVES

To estimate the incidence of postinfectious joint complaints after Campylobacter jejuni/coli enteritis compared with enteritis caused by enterotoxigenic E coli (ETEC). To compare gastrointestinal symptoms, antibiotic treatment, and antibody levels among patients with and without joint symptoms.

METHOD

Questionnaires were sent to 210 consecutive patients with Campylobacter infection and an equal number of patients with E coli (ETEC). Blood samples for anti-Campylobacter antibodies were collected after two weeks, three months, six months, and two years.

RESULTS

Twenty seven of 173 (16%) patients with Campylobacter and 10/177 (6%) with E coli (ETEC) reported joint symptoms (p=0.004). In the Campylobacter group duration of diarrhoea was a median of 13 days for patients with arthralgia and seven days for those without joint pain (p=0.0058). Patients with E coli had diarrhoea of longer duration than patients infected with Campylobacter (14 days v seven days; p=0.0005). E coli patients had fewer gastrointestinal symptoms than Campylobacter patients (p=0.0001). Fifty nine per cent of Campylobacter patients with joint pain had received antibiotic treatment because of enteritis compared with 26% with enteritis only (p=0.03). Campylobacter species and serotypes were equally distributed in both groups and there was no difference in anti-Campylobacter antibody levels between the groups.

CONCLUSION

There was a significantly increased risk of developing joint symptoms after contracting Campylobacter infection compared with E coli. Campylobacter patients with joint pain had more severe gastrointestinal symptoms and longer duration of diarrhoea. Antibiotic treatment does not seem to prevent reactive joint symptoms. Levels of anti-Campylobacter antibodies were the same in both groups.

[Reactive arthritis: advances in diagnosis and treatment]

Reactive Arthritis (ReA) is an aseptic synovitis developing after a primary infection distant from the joint, mainly localized in the gastrointestinal (Enteroarthritis) or genitourinary tract (Uroarthritis). Because of either the asymmetric joint involvement, the possibility of involvement of the spine and enthesis, and the HLA-B27 association ReA is considered one of the spondylarthropathies. Recently, bacterial components or viable bacteria were found in joints during ReA. For this reason, the limits between ReA itself and infectious arthritis are now less definite. Generally accepted diagnostic and classification criteria are still lacking but the improvement in techniques for detection of bacteria increase the possibility to identify the triggering agents. Several studies have examined the role of antimicrobial drugs in ameliorating the natural course of ReA, with some positive results for Uroarthritis only. However, more conventional treatments based on NSAIDs, sulfasalazine and steroids are effective in many cases.

[Chlamydia pneumoniae: an cause of reactive arthritis?]

Chlamydia pneumoniae is a common cause of acute infections within the upper respiratory tract. It is less well known that chlamydia pneumoniae, just like chlamydia trachomatis, may also trigger reactive arthritis. We describe three patients with arthritis possibly triggered by chlamydia pneumoniae. The patients showed the typical symptoms of reactive arthritis like asymmetric oligo- or polyarthritis, dactylitis, enthesiopathies and tendovaginitis. The course of the disease was quite different. The first patient developed persistent polyarthritis which required longterm treatment with a rheumatic disease modifying drug; the second patient improved after several weeks and the third patient experienced a full remission within a few days.

Use of a peptide based enzyme immunoassay in diagnosis of Chlamydia trachomatis triggered reactive arthritis

OBJECTIVE

To assess the presence of circulating IgA and IgG antibodies to Chlamydia trachomatis in sera of patients with reactive arthritis (ReA) and other arthritides.

METHODS

A peptide based enzyme immunoassay (EIA) was used to study 132 patients divided into 5 groups: C. trachomatis triggered ReA, uroarthritis, enteroarthritis, oligoarthritis, and rheumatoid arthritis (RA). Followup sera were available from 19 patients.

RESULTS

An increased prevalence of C. trachomatis antibodies was observed in patients with ReA triggered by C. trachomatis; 18/23 (78%) had IgA and 19/23 (83%) had IgG antibodies. In patient groups with uroarthritis (n = 12), enteroarthritis (n = 56), oligoarthritis (n = 16), and RA (n = 25), C. trachomatis IgA/IgG antibodies were detected in 58%/75%, 27%/21%, 25%/31%, and 20%/32% of patients, respectively. Both the IgA and IgG antibodies were positive in 74%, 50%, 16%, 25%, and 12% of the patients with C. trachomatis triggered ReA, uroarthritis, enteroarthritis, oligoarthritis, and RA, respectively. Based on positivity of both isotypes the sensitivity of the assay was 74% and specificity 84%. In the followup sera, an association between circulating C. trachomatis-specific antibody concentrations and clinical disease outcome of the arthritis was seen in patients with culture-positive C. trachomatis triggered ReA.

CONCLUSION

C. trachomatis species-specific peptide EIA correlates well with conventional diagnosis of primary C. trachomatis infection in patients with ReA. This assay may be a valuable contribution to the diagnosis of C. trachomatis triggered ReA.

Reactive arthritis and Reiter's syndrome following an outbreak of gastroenteritis caused by Salmonella enteritidis

Reactive arthritis and Reiter's syndrome have been reported following gastroenteritis. Prevalence studies for these conditions are uncommon, and the prevalence of Reiter's syndrome after Salmonella enteritidis infection has not been previously reported. After a large outbreak of S. enteritidis gastroenteritis, a survey of persons exposed to the implicated food source was conducted, and those with reactive arthritis were evaluated for possible risk factors. Among 481 persons responding to the questionnaire, 217 cases of S. enteritidis gastroenteritis were identified (31 confirmed and 186 clinical cases; attack rate, 45%). Twenty-nine percent of the cases had symptoms of reactive arthritis, 3% had symptoms of Reiter's syndrome, and 10% had reactive arthritis with oral ulcers. Markers for severe illness (diarrhea > or =7 days, emergency room visit or hospitalization, and antibiotic treatment) were statistically significant but colinear factors associated with reactive arthritis. Increased awareness of postdysenteric reactive arthritis and Reiter's syndrome is recommended.

Defective Fas ligand-mediated apoptosis predisposes to development of a chronic erosive arthritis subsequent to Mycoplasma pulmonis infection

OBJECTIVE

To determine whether defective T cell apoptosis is associated with the development of a chronic arthritis subsequent to mycoplasma infection, and to determine whether deletion of T cells can prevent the development of this arthritis.

METHODS

B6 wild-type (B6-+/+), B6-lpr/lpr, and B6-gld/gld mice were infected with Mycoplasma pulmonis. The severity of lymphocytic infiltration and joint damage was evaluated, and the degree of recovery of viable mycoplasma from the spleen and joints was determined. Antigen-presenting cells derived from Fas mutant lpr mice (lpr-APC) were transfected ex vivo with an adenovirus (Ad) vector to yield lpr-APC expressing high levels of Fas ligand (lpr-APC-AdFasL), which in turn were transferred intraperitoneally into M pulmonis-infected B6-gld/gld mice. The development of arthritis subsequent to M pulmonis infection and the induction of apoptosis of cells within the synovial tissue and lymph nodes of lpr-APC-AdFasL-treated B6-gld/gld mice were determined.

RESULTS

Infection of B6-lpr/lpr and B6-gld/gld mice with M pulmonis resulted in an acute-phase inflammation of the synovium that later developed into a chronic erosive arthritis. Similar infection of B6-+/+ mice resulted only in an acute joint inflammatory response that resolved. Chronic arthritis in B6-gld/gld mice and B6-lpr/lpr was not due to persistent infection, since there were no differences in the rates of clearance of M pulmonis from the joints of B6-gld/gld or B6-lpr/lpr mice compared with B6-+/+ mice. Treatment of infected B6-gld/gld mice with lpr-APC-AdFasL resulted in a significantly decreased incidence of chronic arthritis that was associated with a decrease in lymph node T cells, but not with apoptosis of synovial T cells or fibroblasts.

CONCLUSION

Defective Fas/FasL-mediated apoptosis of T cells is an important factor that rendered arthritis-resistant B6 mice susceptible to the development of a chronic erosive arthritis subsequent to mycoplasma infection. In vivo lpr-APC-AdFasL cell-gene therapy is a safe and effective method for inhibiting the development of this arthritis.

Reactive arthritis

Reactive arthritis is a disease affecting mostly young adults. Owing to a greater general awareness the diagnosis has become more common during recent years. It is well established that ReA is caused by an infection, mostly in genetically susceptible individuals. The pathogenetic mechanisms are still poorly understood, and the treatment rests mainly on anti-inflammatory drugs or steroids. Vigorous and early treatment of the triggering infection may prevent the development of ReA but this is rarely possible in everyday clinical practice. Despite its name, the disease should be considered as a general disorder that affects not only the joints. The prognosis is not as good as earlier believed, and relapses or chronic development are not unusual.

Bacterial DNA in synovial fluid cells of patients with juvenile onset spondyloarthropathies

OBJECTIVE

To identify bacterial DNA in synovial fluid cells of patients with active juvenile onset spondyloarthropathy (SpA).

METHODS

The main group of study constituted 22 patients with juvenile onset SpA. In addition, five patients with adult onset SpA and nine with rheumatoid arthritis (RA) were studied. Polymerase chain reaction (PCR) with either genus- or species-specific primers was performed on synovial fluid cells to detect DNA sequences of Chlamydia trachomatis, Yersinia enterocolitica, Salmonella sp., Shigella sp., Campylobacter sp. and Mycobacterium tuberculosis. The presence of antibacterial antibodies in sera and synovial fluid was also determined by enzyme-linked immunoassay.

RESULTS

The synovial fluid of nine patients with juvenile onset SpA, three with adult onset SpA and one with RA contained bacterial DNA. Five juvenile onset SpA samples had DNA of one single bacterium; two juvenile onset SpA and three adult onset SpA had DNA of two bacteria and two juvenile onset SpA had DNA of three bacteria. Overall, Salmonella sp. DNA was detected in seven synovial fluid samples, Shigella sp., Campylobacter sp. and M. tuberculosis were found in four samples each, and C. trachomatis was found in two. The bacterial DNA findings correlated with neither diagnosis nor disease duration. One RA synovial fluid had DNA of Campylobacter sp. Neither serum nor synovial fluid antibacterial antibodies correlated with DNA findings or clinical diagnosis.

CONCLUSION

In this study, single and several combinations of bacterial DNA were identified in the synovial fluid of patients with long-term undifferentiated and definite juvenile onset SpA and adult onset SpA. Of relevance is that bacterial DNA corresponds to bacteria producing endemic disease in our population.

Bacteria-Triggered reactive arthritis: implications for antibacterial treatment

Reactive arthritis (ReA) is definitely caused by an infection. Several observations suggest that the triggering microbe may persist in the tissues of the patient for a prolonged time. The obvious conclusion is to consider antibacterial treatment. In two instances antibacterial agents are of definite value: in the primary and secondary prevention of rheumatic fever and for early eradication of Borrelia burgdorferi in order to prevent development of the arthritis associated with Lyme disease. Altogether, clinical and experimental data exist to indicate that if antibacterial treatment of ReA can be started very early during the pathogenetic process, the disease can be prevented or the prognosis improved. In fully developed ReA, the value of antibacterial agents is less certain. All available evidence indicates that short term antibacterial treatment has no effect on the prognosis and final outcome of ReA, and the results with long term administration of antibacterials are also overall poor. In some instances sulfasalazine appears useful, rather as a result of its antirheumatic effect or influence on an underlying inflammatory bowel disease than its action as an antibacterial agent. Tetracyclines have also been found to have an effect on ReA, but again, this is probably due to their anti-inflammatory action rather than any antibacterial effect.

Chromosomal DNA from a variety of bacterial species is present in synovial tissue from patients with various forms of arthritis

OBJECTIVE

We and others have reported the presence of Chlamydia and other bacterial species in joint specimens from patients with reactive arthritis (ReA). The present study was conducted to investigate whether bacteria other than those specified by diagnostic criteria for ReA could be identified in synovial fluid (SF) or tissue from patients with various arthritides, and whether the presence of such organisms corresponds to particular clinical characteristics in any patient set or subset.

METHODS

DNA in synovial biopsy samples and SF obtained from 237 patients with various arthritides, including ReA, rheumatoid arthritis, and undifferentiated oligoarthritis, was assayed by polymerase chain reaction (PCR) using "panbacterial" primers; we chose only samples known to be PCR negative for Chlamydia, Borrelia, and Mycoplasma species. PCR products were cloned, and cloned amplicons from each sample were sequenced; DNA sequences were compared against all others in GenBank for identification of bacterial species involved.

RESULTS

Ten percent of patient samples were PCR positive in panbacterial screening assays. Bacterial species identified belonged to the genera Neisseria, Acinetobacter, Moraxella, Salmonella, Pseudomonas, and others. Thirty-five percent of PCR-positive patients showed the presence of DNA from more than a single bacterial species in synovium; overall, however, we could identify no clear relationship between specific single or multiple bacterial species in the synovium and any general clinical characteristics of any individual or group of patients.

CONCLUSION

This analysis provides the first systematic attempt to relate bacterial nucleic acids in the synovium to clinical characteristics, joint findings, and outcomes. Many patients with arthritis have bacterial DNA in the joint, and, in some cases, DNA from more than a single species is present. However, except for 1 case of a control patient with staphylococcal septic arthritis, it is not clear from the present study whether the synovial presence of such organisms is related to disease pathogenesis or evolution in any or all cases.

Intra-articular co-infection by Borrelia burgdorferi and Chlamydia trachomatis

OBJECTIVE

Chlamydia trachomatis and Borrelia burgdorferi infections are frequently the cause of unexplained oligoarthritis, as shown by identification of bacteria specific DNA in joint material from patients with reactive arthritis, Lyme arthritis, and undifferentiated oligoarthritis. The aim of this study was to determine whether the two organisms occur simultaneously in joint material from patients with arthritis.

METHODS

Seventy six patients with unexplained arthritis were prospectively studied. Synovial fluid was obtained from all patients and examined for DNA from C trachomatis and B burgdorferi using specific polymerase chain reaction (PCR) protocols. Data concerning prior genitourinary infection or a history of tick bite were recorded and serum antibodies to C trachomatis and B burgdorferi were determined.

RESULTS

Six patients (8%) had DNA from both C trachomatis and B burgdorferi in the same synovial fluid specimen (mean leucocyte count 11.925/mm(3), 65% granulocytes). These patients (four men, two women; mean age 33.7 years) all had oligoarthritis of the knee, ankle, or both (mean disease duration 11.3 months). From the history and serological examination, four patients had some evidence of actual or previous infection with one or other of the bacteria, while the other two patients had a positive serological test for Chlamydia only.

CONCLUSIONS

DNA from two different microorganisms which are known to be triggering agents for arthritis may be present simultaneously in joint material from patients with unexplained oligoarthritis. This finding raises the question as to whether, in such cases, one or both bacteria contribute to the pathogenesis of the disease or whether they are only innocent bystanders.

From reactive arthritis to rheumatoid arthritis

Reactive arthritis was initially described as a sterile synovitis, without microbial components present in the joint tissue. It has, however, become evident that bacterial degradation products, and even bacterial DNA, are present in the synovium of patients with this disease. Since intestinal pathogens are important causes of reactive arthritis, and since cellular homing allows transport of bacterial products from the gut to synovium, we have approached the etiology of rheumatoid arthritis from this point of view. A series of observations has led to a hypothesis that patients with rheumatoid arthritis might favour, for genetic reasons, intestinal bacteria which are capable of inducing arthritis. In the long-run, with continuous seeding of bacterial products from the gut, the synovial inflammation is followed by erosion, exposition of cartilage antigens, and autoimmunity.

Frequency of triggering bacteria in patients with reactive arthritis and undifferentiated oligoarthritis and the relative importance of the tests used for diagnosis

OBJECTIVE

Reactive arthritis (ReA) triggered by Chlamydia trachomatis or enteric bacteria such as yersinia, salmonella, Campylobacter jejuni, or shigella is an important differential diagnosis in patients presenting with the clinical picture of an undifferentiated oligoarthritis (UOA). This study was undertaken to evaluate the best diagnostic approach.

PATIENTS AND METHODS

52 patients with ReA, defined by arthritis and a symptomatic preceding infection of the gut or the urogenital tract, and 74 patients with possible ReA, defined by oligoarthritis without a preceding symptomatic infection and after exclusion of other diagnoses (UOA), were studied. The following diagnostic tests were applied for the identification of the triggering bacterium: for yersinia induced ReA-stool culture, enzyme immunoassay (EIA), and Widal's agglutination test for detection of antibodies to yersinia; for salmonella or campylobacter induced ReA-stool culture, EIA for the detection of antibodies to salmonella and Campylobacter jejuni; for infections with shigella-stool culture; for infections with Chlamydia trachomatis-culture of the urogenital tract, microimmunofluorescence and immunoperoxidase assay for the detection of antibodies to Chlamydia trachomatis.

RESULTS

A causative pathogen was identified in 29/52 (56%) of all patients with ReA. In 17 (52%) of the patients with enteric ReA one of the enteric bacteria was identified: salmonella in 11/33 (33%) and yersinia in 6/33 (18%). Chlamydia trachomatis was the causative pathogen in 12/19 (63%) of the patients with urogenic ReA. In patients with the clinical picture of UOA a specific triggering bacterium was also identified in 35/74 (47%) patients: yersinia in 14/74 (19%), salmonella in 9/74 (12%), and Chlamydia trachomatis in 12/74 (16%).

CONCLUSIONS

Chlamydia trachomatis, yersinia, and salmonella can be identified as the causative pathogen in about 50% of patients with probable or possible ReA if the appropriate tests are used.

Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature

Clostridium difficile is most commonly associated with colonic infection. It may, however, also cause disease in a variety of other organ systems. Small bowel involvement is often associated with previous surgical procedures on the small intestine and is associated with a significant mortality rate (4 of 7 patients). When associated with bacteremia, the infection is, as expected, frequently polymicrobial in association with usual colonic flora. The mortality rate among patients with C. difficile bacteremia is 2 of 10 reported patients. Visceral abscess formation involves mainly the spleen, with 1 reported case of pancreatic abscess formation. Frequently these abscesses are only recognized weeks to months after the onset of diarrhea or other colonic symptoms. C. difficile-related reactive arthritis is frequently polyarticular in nature and is not related to the patient's underlying HLA-B27 status. Fever is not universally present. The most commonly involved joints are the knee and wrist (involved in 18 of 36 cases). Reactive arthritis begins an average of 11.3 days after the onset of diarrhea and is a prolonged illness, taking an average of 68 days to resolve. Other entities, such as cellulitis, necrotizing fasciitis, osteomyelitis, and prosthetic device infections, can also occur. Localized skin and bone infections frequently follow traumatic injury, implying the implantation of either environmental or the patient's own C. difficile spores with the subsequent development of clinical infection. It is noteworthy that except for cases involving the small intestine and reactive arthritis, most of the cases of extracolonic C. difficile disease do not appear to be strongly related to previous antibiotic exposure. The reason for this is unclear. We hope that clinicians will become more aware of these extracolonic manifestations of infection, so that they may be recognized and treated promptly and appropriately. Such early diagnosis may also serve to prevent extensive and perhaps unnecessary patient evaluations, thus improving resource utilization and shortening length of hospital stay.

Frequency of chlamydial antibodies in patients with internal derangement of the temporomandibular joint

PURPOSE

This study investigates whether an increased frequency of serum antibodies to Chlamydia trachomatis is found in patients with internal derangement of the temporomandibular joint (TMJ).

PATIENTS AND METHODS

An indirect immunofluorescence antibody assay for the detection of serum immunoglobulin G antibodies for C trachomatis was used for most patients. Forty-one female patients were evaluated.

RESULTS

Three of 41 patients (7%) had serum antibody titers that were considered positive for active C trachomatis infection. Eleven patients (27%) were considered to have had a past infection based on the immunoglobulin G or immunoglobulin A titer results. Using the binomial test, we found that the probability of observing 14 positive results (34%) was significant (P < .0001).

CONCLUSIONS

An increase in the frequency of serum antibodies to C trachomatis was found in patients with internal derangement of the TMJ. Serologic testing for antibodies to bacteria associated with reactive arthritis might be useful in the evaluation of patients with internal derangement of the TMJ.

Recurrent episcleritis associated with brucellosis

PURPOSE

To document the clinical course and the treatment of episcleritis associated with brucellosis.

METHODS

Three consecutive cases of patients with recurrent episcleritis associated with brucellosis were evaluated through clinical and laboratory data including serology (tube agglutination), blood culture, and synovial fluid culture.

RESULTS

All the patients had ingested contaminated milk and/or fresh cheese. The diagnosis of brucellosis was confirmed by high antibody titer, positive blood culture, negative synovial fluid culture and unresponsive condition to the previous nonspecific therapy for episcleritis and reactive arthritis. The patients responded well to the therapy with doxycycline and rifampicin.

CONCLUSION

We proposed that recurrent episcleritis had a co-occurence with reactive arthritis in the course of the brucellosis, and that it responded well to the antibrucellar antibiotics rather than to steroids. This also implies that brucellosis as a rule is an underlying triggering infection associated with reactive arthritis.

Ciprofloxacin v placebo for treatment of Yersinia enterocolitica triggered reactive arthritis

Patients with yersinia triggered reactive arthritis were double blind randomly allocated to receive treatment with ciprofloxacin 500 mg twice daily orally or placebo during three months. The diagnosis was made by serology (specific IgA and IgG antibodies to yersinia outer membrane proteins (yops)), positive culture, and/or demonstration of Yersinia enterocolitica antigen in colon biopsy specimens. Patients were evaluated monthly during and after treatment up to 12 months. Of 18 patients enrolled, all could be evaluated for safety, 16 for efficacy. There was a tendency towards faster remission and relief of pain in those receiving ciprofloxacin. Y enterocolitica was eliminated from the gut associated lymphoid tissue in six of seven patients receiving ciprofloxacin compared with none of nine patients receiving placebo. Patients receiving placebo had more and prolonged circulating IgA antibodies against yops than patients treated with ciprofloxacin.

Reactive arthritis: preliminary microbiologic analysis of the human temporomandibular joint

PURPOSE

The presence of Chlamydia trachomatis has been previously shown in the temporomandibular joint (TMJ). This study investigated whether the presence of other bacteria associated with reactive arthritis (ReA) can be identified in the TMJ.

MATERIALS AND METHODS

Posterior bilaminar tissue removed during TMJ surgery from 26 patients (24 F, 2 M) was evaluated for the presence of C. trachomatis, Mycoplasma fermentans, Mycoplasma genitalium, Campylobacter jejuni, Yersinia enterocolitica, Salmonella spp, and Shigella spp by highly specific polymerase chain reaction (PCR) assays.

RESULTS

Bacterial DNA was identified in the TMJ as follows: C. trachomatis, 11 of 26 (42%); M. fermentans/orale, 6 of 26 (23%); M. genitalium, 9 of 26 (35%). Nine of 26 TMJs (35%) had the presence of a single bacterial species. Eight of 26 TMJs (31%) had more than 1 species, as follows: C. trachomatis with either M. genitalium or M. fermentans/orale in 5 of 26 (19%), M. fermentans/orale with M. genitalium 2 of 26 (8%), and C. trachomatis/M. fermentans/orale/M. genitalium, 1 of 26 (4%). A total of 17 of 26 (65%) of TMJs had the presence of bacteria identified in the TMJ. Campylobacter jejuni, Y. enterocolitica, Salmonella spp, and Shigella spp were not identified in any samples.

CONCLUSIONS

The presence of M. genitalium in the human TMJ has not been previously reported. The presence of bacteria in the TMJ, either singly or concurrently with other bacteria, may serve as the pathogenetic mechanism of TMJ inflammation. The presence of 2 bacteria from the urogenital tract in the TMJ suggests that internal derangement of the TMJ may occur as a result of a sexually acquired infection.

Rheumatic disorders associated with streptococcal infections

The proteins in the cell wall of Streptococcus have many functions, with some proteins being regarded as a marker of their rheumatological potential. High levels of antibodies directed against some proteins are seen in patients with acute rheumatic fever. The theory of molecular mimicry forms the basis of the relationship between the bacteria and the disease acute rheumatic fever. A distinct entity which does not fulfil Jones' criteria, and which is known as post-streptococcal reactive arthritis following infection with beta-haemolytic streptococci, is being encountered more frequently. A pyogenic form of arthritis due to Streptococcus is one of the most common and serious joint infections and requires prompt recognition and treatment.

Helicobacter pylori--a trigger of reactive arthritis?

Four cases of reactive arthritis (ReA) related to Helicobacter pylori (HP) are presented. These were identified by IgG, IgM and IgA ELISA tests performed on sera obtained from a 2-year prospective study on 186 patients with a clinical picture suggesting ReA as a possible diagnosis. If anti-HP IgM and IgA or IgG were positive, the case was considered related to HP. Three out of four HP ReA patients were originally classified as "possible ReA", i.e. having a clinical picture of ReA but without any identified triggering microorganism. IgG antibodies against cagA and vacA were detected in three and two cases respectively. The HP ReA patients did not present with typical clinical or laboratory features differentiating them from ReA induced by Chlamydia trachomatis (N = 25) or enteropathogenic bacteria (N = 27). However, compared to findings in patients with ReA due to enteropathogenic bacteria the number of active joints was higher (six versus two), duration of arthritis longer (3.9 weeks versus 2 weeks) and the CRP (C-reactive protein) lower (43 versus 59). Our findings suggest that HP may be included in the list of possible arthritis triggering microbes.

Reactive arthritis

During the past year, no big advances were reported in understanding the pathogenesis or treatment of reactive arthritis (ReA). The need for generally accepted diagnostic criteria has become a central issue. Regarding pathogenesis, attention has been drawn to a similarity between ReA and the experimental antigen-induced arthritis. Molecular mechanisms of the HLA-B27-associated pathogenesis have remained, in spite of intensive research, so far a mystery. It is apparent that antibiotics have no effect on the fully developed reactive arthritis, with the exception of patients with Chlamydia-triggered ReA, who might benefit from a course of antibiotics.

Modification of disease outcome in Salmonella-infected patients by HLA-B27

OBJECTIVE

To study whether HLA-B27 modifies the outcome of Salmonella infection in vivo.

METHODS

The frequency of HLA-B27 was determined in 198 Salmonella-infected patients and 100 healthy controls by immunofluorescence and polymerase chain reaction. The excretion of Salmonella was monitored at monthly intervals. The symptoms of acute infection and possible joint involvement were evaluated using questionnaires.

RESULTS

Thirty-eight of 198 Salmonella-infected patients (19.2%) and 13 of 100 healthy controls (13.0%) were HLA-B27 positive. The excretion of Salmonella did not differ significantly between HLA-B27-positive and -negative patients, or for patients with versus those without joint symptoms. As many as 35 patients (17.7%) reported Salmonella-triggered joint symptoms. Three of 14 patients (21.4%) with arthralgia, 5 of 13 patients (38.5%) with probable reactive arthritis (ReA), and 6 of 8 patients (75%) with confirmed ReA were HLA-B27 positive. The duration and severity of joint symptoms directly correlated with HLA-B27 positivity. Women reported Salmonella-induced pain and swelling of joints more frequently than men (P = 0.07 and P = 0.03, respectively). Patients with Salmonella-triggered joint symptoms reported abdominal pain and headache more frequently than patients without joint symptoms (P = 0.05 and P = 0.004, respectively).

CONCLUSION

HLA-B27 did not (at least, not strongly) confer susceptibility to Salmonella infection. Salmonella excretion correlated neither with HLA-B27 positivity nor with the occurrence of joint symptoms. Joint symptoms were surprisingly common during or after Salmonella infection. HLA-B27-positive patients had a significantly increased risk of developing joint and tendon symptoms. Moreover, HLA-B27 positivity correlated with the development of more severe and prolonged joint symptoms.

Chlamydia pneumoniae present in the human synovium are viable and metabolically active

We demonstrated that chromosomal DNA from Chlamydia pneumoniae is present in synovial tissue in at least some patients with reactive arthritis/Reiter's syndrome and other arthritides. Here, we provide initial molecular evidence that the bacterium is viable and metabolically active when present in the synovium. We used reverse transcription-polymerase chain reaction (RT-PCR) assays targeting primary transcripts from the chlamydial rRNA operons, and mRNA from several C. pneumoniae genes (hsp60, ompA, KDO transferase, Mr=76000 protein), to analyse RNA preparations from synovial tissue of 10 patients with various forms of arthritis; each patient was known to be PCR-positive for C. pneumoniae DNA in synovium prior to RT-PCR assays. Two PCR-negative patients served as controls for RT-PCR assays. In the 10 patients PCR-positive for C. pneumoniae DNA, RT-PCR assays targeting primary transcripts from the rRNA operons of the organism showed that these molecules were present in each sample, as were transcripts from the bacterial hsp60 gene. Assays targeting mRNAs from the Mr=76000 protein and the KDO transferase genes of C. pneumoniae gave positive results for 6/10 preparations. We were unable to identify mRNA from the chlamydial major outer membrane protein gene (ompA) in any preparation. RNA preparations from the two control patients were negative in all RT-PCR assays targeting C. pneumoniae transcripts. These results indicate that in patients infected with the organism, synovial C. pneumoniae are viable and metabolically active, as are C. trachomatis cells in the same context. Such viability is consistent with a role in long-term contribution to pathogenesis in joint disease.

Poststreptococcal reactive arthritis

The occurrence of an entity designated poststreptococcal reactive arthritis (PSReA) has been highlighted in recent reports. The syndrome was considered part of the spectrum of acute rheumatic fever by some, whereas others stressed the differences between the two diseases. As distinct from acute rheumatic fever, PSReA is characterized by a shorter latency period between the inciting streptococcal infection and the onset of arthritis, a higher frequency of involvement of the small joints and axial skeleton, poor response to aspirin and other nonsteroidal anti-inflammatory drugs, a protracted course of arthritis, a low incidence of carditis, and absence of other major manifestations of acute rheumatic fever. Recent studies have demonstrated an increased frequency of DRB1*01 in patients with PSReA, which contrasts with the increased frequency of DRB1*16 in rheumatic fever. Because 6% of patients with PSReA have been reported to have late onset carditis, it is judicious to recommend that patients with PSReA receive prophylactic antimicrobials for a minimum period of 5 years or until the age of 21 years, whichever is longer.

Reiter's syndrome caused by Streptococcus viridans in a patient with HLA-B27 antigen

A 26-year-old male patient with mitral valve prolapse and HLA-B27 antigen received endodontic treatment for dental caries. Two weeks later fever, dysuria, diarrhea, sterile inflammatory arthritis of lower limbs, enthesitis, dactylitis, conjunctivitis, and uveitis consecutively developed. Blood culture performed at the time of active arthritis yielded Streptococcus viridans. He did not have any history of psoriasis, acute infectious diarrhea, chronic inflammatory bowel diseases, or sexually transmitted diseases. Laboratory studies also excluded the possibility of infections by human immunodeficiency virus, hepatitis B or C virus, chlamydia, and streptococci from the upper airway. This report indicates that Streptococcus viridans can be the triggering microorganisms of Reiter's syndrome in some circumstances.

Report on the Fourth International Workshop on Reactive Arthritis

There are large differences in the antigenicity and biology of the ReA-associated bacteria. For induction of arthritis, the relevance seems to be only that antigenic material reaches the joint, alive or dead. If there is a common antigen, it has to be a highly conserved one. Bacterial hsp60 seems to be an immunodominant T cell antigen in ReA, but there must be other relevant antigens shared by these different bacteria. An ineffective immune response (for example, low production of TNFalpha) seems to contribute to the manifestations and course of ReA. Although arthritis can also occur in its absence, HLA-B27 plays an important role in the pathogenesis of ReA and the other SpA. Current data suggest that B27 probably acts as an antigen-presenting molecule for a still-unknown arthritogenic molecule. Comparison of ReA with IBD-associated arthritis suggests that there might indeed be a common antigen shared by ReA-associated bacteria and bacteria of the gut flora. CD8+ T cells seem to be important in ReA and other SpA. In some parts of the world, such as in Mexico, ReA could be a major predisposing cause of the development of AS. Antibiotic treatment is not effective, probably because the triggering bacteria are already dead or in a partly latent state at the time arthritis occurs. Based on this knowledge and on new technologies, it should be possible in future years to derive answers to the questions about ReA and the other SpA and, as a consequence, to find a cure.

What determines arthritogenicity of bacterial cell wall? A study on Eubacterium cell wall-induced arthritis

OBJECTIVE

To study what determines the arthritogenicity of the bacterial cell wall (CW) using Eubacterium CW-induced arthritis in the rat.

METHODS

Eubacterium aerofaciens, previously reported as arthritogenic, and E. limosum and E. alactolyticum, known as non-arthritogenic, were used. Gas chromatography-mass spectrometry (GC-MS) was applied to analyse the chemical composition of the bacterial cell wall. Cellular immune response was measured by concanavalin A (Con A) stimulation and FACScan analysis. Also, serum antibodies against the injected cell wall were determined.

RESULTS

Unexpectedly, from the two strains of E. aerofaciens used only one proved to be arthritogenic (with a CW inducing chronic arthritis after a single intraperitoneal injection), even though these two strains were 100% identical by 16S rDNA analysis. CW of the other E. aerofaciens strain induced only transient acute arthritis; CW of E. limosum and E. alactolyticum induced weak signs of acute arthritis. Based on the GC-MS analysis and on the results published previously, putative structures of peptidoglycan (PG) in the four CW preparations are presented. It is apparent that the presence of lysine in position 3 of the PG stem peptide contributes to arthritogenicity but is alone not decisive. Both strains of E. aerofaciens were immunosuppressive, when tested by Con A response at 2 weeks after CW injection. Such an immunosuppression was not observed after injection of CW from E. limosum or E. alactolyticum. FACScan analysis for six T cell markers and studies on serum antibody responses did not reveal any differences in the effect of the four bacterial strains used.

CONCLUSIONS

The results obtained suggest that the chemical structure of PG present in the bacterial CW is decisive in determining arthritogenicity/non-arthritogenicity. Therefore, from two bacterial strains belonging to normal human intestinal flora and 100% identical by 16S rDNA analysis, one proved to be arthritogenic and the other non-arthritogenic.