HLA-B27 binding of peptide from its own sequence and similar peptides from bacteria: implications for spondyloarthropathies

The spondyloarthropathies are associated by an unknown mechanism with HLA-B27 and certain bacteria. HLA-B27 shares sequence with proteins from enteric bacteria. The B*2705 sequence contains a nonapeptide, LRRYLENGK, predicted to bind in the binding cleft of B27. Some nonapeptides from enteric organisms that share sequence with this nonapeptide of B27 also bind B27. These observations suggest an unappreciated mechanism for autoimmunity that may operate in the B27-associated spondyloarthropathies involving peptides bound to and derived from histocompatibility alleles.

Second-line treatment in seronegative spondylarthropathies

The literature concerning second-line treatment of seronegative spondylarethropathies from 1940 to August 1993 was reviewed. Sulfasalazine appeared to be effective in the treatment of ankylosing spondylitis (AS) and promising in reactive arthritis (ReA) and Reiters' syndrome (RS). Methotrexate and azathioprine were associated with a remarkable improvement in some cases of AS and RS. Methylprednisolone and levamisole were both efficacious in AS, but levamisole was associated with occasional severe side effects. Radiation therapy led to short-term improvement in AS, but was abandoned because of severe long-term side effects. Only sulfasalazine has been studied in sufficient detail to allow definitive conclusions, but methotrexate and azathioprine may be promising drugs.

[The concept of the adaptive functional dominant of the CNS in clinical neurotraumatology]

A conception of the adaptive functional dominant of the CNS is proposed for the description of general regularities of the course of patho- and sanogenesis in neurotramatologic patients. It was shown that the forming adaptive dominant is responsible for the development of adaptive processes in the posttraumatic period. The interaction of the functional dominant and adaptive potential of sanogenesis leads to the course of the disease with the natural outcome as recovery, complication or lethal outcome.

Is HLA B27 a true marker of axial involvement in psoriatic arthropathy?

Sixty-six patients with psoriatic arthropathy were subdivided into nine groups on the basis of the presence of peripheral arthritis, axial disease whether or not fulfilling the New York criteria for ankylosing spondylitis both associated and not associated with peripheral arthropathy and bilateral or monolateral lateral sacro-iliitis. Only the group with axial disease sacroiliitis+spondylitis) without peripheral arthritis and not fulfilling the NY criteria showed a truly increased B27 prevalence. However, in this atypical group, only 2 patients had a true ankylosing pattern-like spondylitis. On the other hand, in the group with axial disease fulfilling the NY criteria, only one of 9 patients was B27+. We conclude that B27 is not a true marker of axial involvement in psoriatic arthropathy.

[Leukocyte expression of the LFA-1 adhesion molecule in spondylarthropathies]

The expression of adhesion molecule Leukocyte Function Antigen-1 (LFA-1) on peripheral blood leukocytes was evaluated (using a monoclonal antibody anti CD11a/LFA-1) in 52 spondylarthropathies (SA) (35 HLA B27 positive), 12 healthy patients, 24 active rheumatoid arthritis (RA) and 12 systemic lupus (SLE) patients. LFA-1 expression on lymphocytes was similar in the different groups of patients, but LFA-1 expression on granulocytes was higher in SA than in controls (p < 0.05) or in RA or SLE. Fluorescence intensity of anti LFA-1 staining on SA granulocytes correlated with serum IgA levels. There was no difference between HLA B27 positive/negative, biologically inflammatory (CRP > 21 mg/l)/non inflammatory SA patients. This study seems to confirm the granulocyte and IgA involvement in immunopathogenesis of spondylarthropathies.

Spondyloarthropathies and psoriatic arthritis in children

Data that are relevant to the general understanding of the juvenile-onset spondyloarthropathies are reviewed here. Seronegative enthesopathy and arthropathy syndrome is considered the earliest recognizable form of juvenile-onset spondyloarthropathy, from which other syndromes and diseases emerge. The group also includes juvenile-onset ankylosing spondylitis, a disease defined in adult-based terms when definite changes have occurred in the axial joints; ankylosing tarsitis, a complex disorder in which foot problems resemble those of the spine in ankylosing spondylitis; Crohn's disease and ulcerative colitis-related peripheral and, especially, HLA-B27 axial disease; reactive arthritis and Reiter's syndrome, which might be further classified according to its cause; and juvenile psoriatic arthritis, a disease that resembles juvenile rheumatoid arthritis more than does juvenile-onset spondyloarthropathy.

[The balneotherapy importance of the silicon compounds in siliciferous waters when used externally]

Bath therapy was assigned to 300 patients with primary hypothyroidism, chronic venous insufficiency of the legs, neurologic symptoms of lumbar osteochondrosis. Fresh, siliceous, siliceous carbon-dioxide and carbon-dioxide waters were tested comparatively. It is reported that siliceous baths with threshold silicon compounds concentration 50 mg/l had the effect similar to that of fresh-water baths. Indications have been specified for introduction of carbon dioxide and siliceous carbon dioxide baths in the diseases studied.

Psoriatic spondyloarthropathy in men and women: a clinical, radiographic, and HLA study

Psoriatic spondyloarthropathy as defined by the presence of inflammatory back pain and stiffness, sacroiliitis on physical examination, radiographic evidence of grade greater than or equal to 2 sacroiliitis, and classical or paramarginal syndesmophytes on spinal radiographs was identified in 82 women and 112 men followed at the Psoriatic Arthritis Clinic according to a standard protocol. A logistic regression analysis was performed to look for variables which discriminate between men and women with this condition. No differences in type of peripheral arthritis, degree of damage, or medication were noted between the two groups. However, there was some evidence for more advanced spondyloarthropathy in men. There were no differences in the frequency of HLA B27 or any of the psoriatic arthritis-related HLA antigens. Thus, there may be gender-related differences in the expression of psoriatic spondyloarthropathy, which are unrelated to HLA antigens.

Influence of antibiotics on IgA and IgG response and persistence of Yersinia enterocolitica in patients with Yersinia-associated spondylarthropathy

The IgA and IgG antibody response to plasmid-encoded outer membrane proteins was studied in 59 patients with yersinia-associated spondylarthropathy during 15 months of follow-up. Initially, all patients had specific IgA and IgG antibodies to the 36 and 46 kDa and 30% also to the 26 and 58 kDa released proteins, which correlated with the finding of virulent Yersinia bacilli in intestinal biopsies. IgA disappeared in 69% of untreated patients after nine months and persisted in 31% after one year. IgA disappeared within three to six months in 81% of the patients treated with antibiotics for four to six weeks and persisted in 6% after one year (p less than 0.002). IgG antibodies to the 36 and 46 kDa outer membrane proteins persisted in 80% of all patients. Disappearance of IgA was coupled with disappearance of yersinia from intestinal biopsies.

Immunoglobulin isotype composition of circulating and intra-articular immune complexes in patients with inflammatory joint disease

The immunoglobulin (Ig) heavy chain isotype composition of intra-articular and circulating immune complexes (ICs) were determined by a Raji cell flow cytometric assay in paired serum and synovial fluid samples from 15 patients with rheumatoid arthritis (RA) and 15 patients with other articular diseases (osteoarthritis, ankylosing spondylitis, gout, psoriatic arthritis, Reiter's disease). ICs were most prevalent in synovial fluid samples of patients with RA but were infrequently detected in serum and synovial fluid samples from the non-RA patients. ICs in patients with RA were heterogeneous both in the prevalence of Ig subclasses identified and in the distribution of the respective Ig isotypes within the complexes. Furthermore, differences were observed in the Ig isotype composition of ICs in paired serum and synovial fluid samples indicating that circulating ICs may not always arise simply by spill-over from articular sites. The possible mechanisms for IC formation in RA are discussed with reference to four patients who displayed features of extra-articular disease.

Heart conduction disturbance: an HLA-B27 associated disease

In recent studies from Sweden an increased prevalence of HLA-B27 associated diseases and of HLA-B27 was found in an unselected group of men with permanently implanted pacemakers and with a heart block. Furthermore, a significantly increased prevalence of HLA-B27 was found in men with a pacemaker who had no clinical or radiological signs of HLA-B27 associated disease. To obtain more insight into the association between HLA-B27 and heart block, and the possible role of HLA-B27 in causing this block, a study was made of 35 patients with a pacemaker and heart block of unknown cause, selected from a total group of 350 men with pacemakers who were still alive at the time of the study. One of these 35 men had ankylosing spondylitis and two patients had an asymptomatic sacroiliitis, but all three were HLA-B27 negative. HLA-B27 was present in five (14%) patients, which is a significantly higher prevalence than in healthy controls (17/292, 6%). This percentage is equal to the percentage of HLA-B27 positivity found in the Swedish study on unselected men with an implanted pacemaker, in whom the presence of an HLA-B27 associated disease had been excluded. It suggests that factors other than HLA-B27 are important in the pathogenesis of heart block in most patients.

Platelet aggregating activity in serum from patients with HLA-B27 associated rheumatic and cardiac disorders: a possible link to the proliferative vascular changes

OBJECTIVE

To search for possible serum factors (immunochemical abnormalities) that reflect HLA-B27 associated inflammatory process with the proliferative endarteritis, which is an important cause of severe bradycardia and aortic valve regurgitation.

PATIENTS AND METHODS

Seventy four men with pacemakers were studied: 24 were HLA-B27 positive and had associated rheumatic and cardiac disorders, 13 were B27 positive but had no clinical or radiographic signs of a related rheumatic condition, and 37 were B27 negative controls. Randomly obtained serum samples were examined for a series of serum factors.

RESULTS

Thirteen (57%) of the 23 patients with HLA-B27 and associated rheumatic and cardiac conditions had platelet aggregating activity in their serum. No such activity was found in sera from patients in the other groups. None the less, immunochemical abnormalities were common among patients of all groups; 30 (41%) had antinuclear antibodies or rheumatoid factor or both.

CONCLUSION

The platelet aggregating activity found in patients with HLA-B27 and associated rheumatic and cardiac conditions may reflect serum factors that increase the stickiness of platelets and increase their adhesion to the vessel wall. This suggests a link via release of platelet derived growth factor(s) with the characteristic histopathological feature of proliferative endarteritis. Immunochemical abnormalities were common in serum from all men with pacemakers.

Prevalence of HLA-B27 in patients with back pain attending a pain clinic

101 patients presenting to a pain clinic with low back pain were tested for HLA-B27 status. Eight (7.9%) of the patients were positive for HLA-B27. This prevalence is similar to that recorded in the general population and suggests that few patients referred to our clinic with back pain have undiagnosed spondyloarthropathies.

Soluble HLA-DR molecules in patients with HLA class II versus class I associated disorders

HLA genes have been identified as key genetic factors contributing to many chronic diseases characterized by autoimmune features. The role of HLA encoded molecules in the pathogenesis of these diseases is unresolved. We have now analysed soluble HLA-DR molecules circulating in the serum of patients with different autoimmune diseases and have defined parameters controlling serum levels. Patients with HLA-DR associated diseases were characterized by elevated serum concentrations of HLA-DR molecules and were clearly distinct from patients with HLA-B27 associated disorders. We did not find evidence for a correlation between disease activity, laboratory abnormalities and elevated serum concentrations of soluble HLA-DR molecules. Studies in normal individuals indicated that soluble HLA-DR molecules are at least partially regulated by the HLA haplotype. Highest serum concentrations were found in individuals carrying the HLA-DR3 or HLA-DR4 haplotype raising the possibility that the phenomenon of HLA-disease association reflects differences in the genetic control of soluble HLA-DR molecules. Interferon-gamma treatment caused an increase in serum concentrations of soluble HLA-DR molecules, whereas a decrease of circulating HLA-DR molecules was associated with an immunosuppressive with cyclosporine A. These data suggest that the patient's immunoresponsiveness represents a second important mechanism controlling circulating HLA-DR molecules.

Proteoglycan-induced polyarthritis and spondylitis adoptively transferred to naive (nonimmunized) BALB/c mice

Mononuclear cells from BALB/c mice with progressive polyarthritis and spondylitis induced by injection of fetal human articular cartilage proteoglycan (PG) were used to transfer arthritis by intravenous injection into irradiated, nonimmunized syngeneic mice. Successful transfer of arthritis to BALB/c mice required the injection of lymphocytes from mice with arthritis, along with 50 micrograms of human fetal PG, or lymphocytes stimulated in vitro with either fetal human PG or with mouse cartilage PG. In addition, interleukin-2 or immune sera from animals with arthritis significantly reduced the time to onset of transferred disease. The onset of adoptively transferred arthritis, using cells and antigen, from the time of the first injection (38.2 +/- 18.2 days, mean +/- SD) was shortened if lymphocytes from mice with transferred arthritis were reinjected (retransferred) into other, irradiated syngeneic mice (6.1 +/- 2.6 days). The appearance of autoreactive antibodies to mouse cartilage PG in the sera of mice with adoptively transferred arthritis (secondary or tertiary) preceded the appearance of the first clinical symptoms by a few days. The transfer of arthritis was blocked by pretreatment of donor (arthritic) lymphocytes with either anti-T cell or anti-B cell antibodies and complement. Exposure of mononuclear cells from mice with arthritis to PG, and its removal prior to transfer, also resulted in transfer of the arthritis. PG-induced arthritis was not transferred to nonirradiated mice, nor to irradiated mice injected with lymphocytes from animals with primary arthritis without chondroitinase ABC-digested fetal human PG. Arthritis never developed after injection of immune sera from mice with arthritis (without cells), nor when cells of nonarthritic animals were used with chondroitinase ABC-digested fetal human PG, with or without interleukin-2.

Major histocompatibility complex class II antigen (HLA-DR) expression by ileal epithelial cells in patients with seronegative spondylarthropathy

Major histocompatibility complex molecules act as non-specific receptors for antigenic proteins and present them to T-cells. Presented antigen together with class II molecules activates antigen specific T-helper cells and may trigger a cellular immune response. The expression of HLA-DR antigens by epithelial cells was examined with an indirect peroxidase technique in ileal biopsies from 38 patients with seronegative spondylarthropathy and features of acute or chronic gut inflammation on biopsy, 14 patients with chronic inflammatory bowel disease, 10 rheumatic and 10 non-rheumatic controls. In acute ileitis, there was more HLA-DR expression in villous and crypt epithelial cells than in non-inflamed controls (p less than 0.01). In chronic inflammation and in chronic inflammatory bowel disease, class II antigens were more expressed in villus (p less than 0.02) and crypt epithelium (p less than 0.01). Strong HLA-DR expression in crypt epithelial cells was connected with active inflammation (p less than 0.02). These findings suggest binding of unknown enterobacterial or nutritional luminal antigens to HLA-DR antigens normally present in enterocytes. The enterocytes act as antigen presenting cells causing a local increase of targets for activated T-cells and trigger the gut inflammation responsible for the clinical symptoms of the seronegative spondylarthropathy.

Destructive lesions of small joints in seronegative spondylarthropathies: relation to gut inflammation

Destructive lesions of small joints were found in 40 out of 211 patients suffering from seronegative spondylarthropathies (SpA) on whom ileocolonoscopy with biopsies of the ileum and colon were performed. The destructive lesions of small joints, radiologically only distinguishable from rheumatoid arthritis lesions by the pauciarticular and asymmetrical involvement, the rare tendency to fusion and the rare occurrence of periosteal hypertrophy, were observed more frequently in patients presenting subclinical inflammatory gut lesions, predominantly of the chronic type, than in patients without gut inflammation.

Traditional and new types of spondarthritis with special consideration of spondylodiscitis

In rheumatology the so-called "seronegative spondarthritis" is a group of diseases characterized by the presence of HLA-B 27. This group includes the typical ankylosing spondylitis as well as atypical spondylopathies such as those occurring in psoriasis, Reiter's disease and chronic inflammatory enteropathies, which attack mainly the spine and secondarily the peripheral joints. In some severe cases, non-infectious, sterile spondylodiscitis was observed. These can lead to instability and fracture, followed by pseudarthrosis of the involved segment of the spine. In contrast to these traditional spondarthritides three new types are marked by the lack of HLA-B 27. 1) "Spondarthritis hyperostotica pustulo-psoriatica" (F. Schilling), a very rare variation of psoriatic spondylopathy, sometimes accompanied by spondylodiscitis. 2) Arthritis and spondarthritis in acne fulminans. 3) Destructive arthropathy and spondylopathy in long-term hemodialysis, occasionally occurring with spondylodiscitis, a very new type of spondarthritis. The amyloid B (beta-2-micro-globulin), discovered only four years ago, plays a dominant role in the pathogenetic chain of this disease. Details of the etiology of these very impressive diseases are presented. Destructive spondylodiscitis will no doubt be a challenge to neurosurgeons.