Arthro-osteitis--a clinical spectrum

Arthro-osteitis is an uncommon condition which can be associated with palmoplantar pustulosis. It forms part of a group of conditions which include the synovitis, acne, pustulosis, hyperostosis, osteitis syndrome (SAPHO) and sternocostoclavicular hyperostosis. We report four cases illustrating the clinical spectrum of this condition which occurred in the absence of concomitant skin lesions. One patient had extensive aortic calcification a feature not previously reported in this condition, which may represent a low grade inflammatory aortitis.

Autoantibodies in malaria, tuberculosis and hepatitis B in a west African population

Following reports of associations between autoantibodies and living in the tropics, we have studied the seroprevalence and nature of anti-nuclear antibodies, anti-cardiolipin antibodies, antibodies to extractable nuclear antigens and anti-neutrophilic cytoplasmic antibodies in 351 West Africans with malaria, tuberculosis or hepatitis B, or in good health. Amongst healthy West Africans we found a seroprevalence of 7% for anti-nuclear antibodies with several staining patterns, and of 30.3% for anti-cardiolipin antibodies. Among patients with tuberculosis and malaria there was twice that frequency of anti-nuclear antibodies (predominantly speckled in pattern), and anti-neutrophil cytoplasmic antibodies (predominantly IgM) were demonstrated in a few cases. A possible association between IgG anti-cardiolipin antibodies and tuberculosis was observed (P < 0.05), but antibodies to double-stranded DNA were not elevated and no antibodies to extractable nuclear antigens were found in any of the patients or healthy individuals studied. Our findings suggest the need for caution in the interpretation of autoantibody tests in subjects from or living in the tropics, as well as in patients with tropical infections.

Identification of tissue inhibitor of metalloproteinase-2 (TIMP-2)-progelatinase complex as the third metalloproteinase inhibitor peak in rheumatoid synovial fluid

The metalloproteinases are a family of enzymes that can degrade all the components of the extracellular matrix. These potent enzymes are often found in proenzyme forms and require activation before the substrate can be digested. To prevent unlimited connective tissue destruction a number of inhibitors exist to limit their activity. In a previous study it was found that metalloproteinases in proenzyme form and metalloproteinase inhibitors were often present in rheumatoid synovial fluids. Two of these inhibitors were identified in rheumatoid synovial fluid as alpha 2 macroglobulin and tissue inhibitor of metalloproteinase (TIMP), the specific metalloproteinase inhibitor. A third inhibitory peak was unidentified. In the study reported here it was shown that this third inhibitor can be purified using gelatin-Sepharose chromatography and consists of TIMP-2 bound to progelatinase (relative molecular weight 72,000) in a similar way to that found in concentrated connective tissue culture medium. The importance of these proteinase inhibitors in synovial fluid is discussed.

CAMPATH-1H in inflammatory arthritis

CAMPATH-1H is a humanised mAb directed against lymphocytes. This mAb has been used to treat patients with rheumatoid arthritis. Clinical improvement with reduction in the Ritchie index and joint score has lasted for up to 8 months in some patients. A profound and prolonged lymphopaenia is induced by the mAb, with CD4+ numbers remaining suppressed for up to one year.

The measurement of collagenase, tissue inhibitor of metalloproteinases (TIMP), and collagenase-TIMP complex in synovial fluids from patients with osteoarthritis and rheumatoid arthritis

OBJECTIVE

To compare the levels of collagenase, tissue inhibitor of metalloproteinases (TIMP), and collagenase-TIMP complex in synovial fluid (SF) from patients with rheumatoid arthritis (RA) and patients with osteoarthritis (OA). This study aims to clarify existing data from previously used enzyme or inhibitor activity assays performed following separation by gel filtration, by using a 1-step enzyme-linked immunosorbent assay (ELISA) for each component.

METHODS

Total collagenase, free TIMP, and collagenase-TIMP complex were measured using a newly developed, specific double-antibody sandwich ELISA:

RESULTS

Levels of both collagenase and TIMP were significantly higher in RA patients (collagenase 1,560 +/- 150 ng/ml [mean +/- SEM], TIMP 1,610 +/- 130 ng/ml; n = 80) than OA patients (collagenase 420 +/- 90 ng/ml, TIMP 1,050 +/- 60 ng/ml; n = 80), with the difference being especially striking for collagenase. Sixteen RA fluids had detectable levels of collagenase-TIMP complex, compared with only 3 OA fluids.

CONCLUSION

The level of total collagenase in SF is greater in RA than OA, while levels of free TIMP show more overlap between the 2 diseases; this may simply reflect the increased inflammation seen in RA, or it may reflect a different disease mechanism.

Suprascapular nerve block for persistent rotator cuff lesions

The suprascapular nerve supplies sensory nerves to the posterosuperior aspect of the shoulder, including major portions of the rotator cuff. Suprascapular nerve block using steroid/bupivacaine is temporarily effective in reducing pain in rotator cuff tendinitis and tears, improving movement range in tendinitis and is possible in an outpatient setting with little or no complication risk.

The pattern of rheumatic disorders seen amongst patients attending urban and rural clinics in west Africa

There is a growing interest in the study of the pattern of rheumatic disorders in Africa. This has led to our studying the pattern of rheumatic disorders seen among patients attending both urban and rural clinics in West Africa. A wide spectrum of rheumatic diseases was observed among those attending both clinics. Osteoarthritis and soft tissue lesions were most commonly seen while inflammatory joint disease and connective tissue disorders were less commonly observed. We consider that these observations have significant rheumatological health care implications for West Africa and may provide useful aetiopathogenic clues.

Monoclonal antibodies against human fibroblast collagenase and the design of an enzyme-linked immunosorbent assay to measure total collagenase

Monoclonal antibodies have been raised against purified human fibroblast collagenase and characterised. One of these antibodies has been used in combination with a polyclonal anticollagenase antibody in a double antibody sandwich ELISA to measure collagenase. The assay range was 2-50 ng/ml collagenase. The assay measures total collagenase, i.e. pro- and active enzyme as well as collagenase in complex with TIMP. The level of collagenase has been measured in sera samples from patients with rheumatoid arthritis and compared with age- and sex-matched controls. The levels measured were: rheumatoid arthritis, 69 +/- 29 ng/ml; normal, 49 +/- 14 ng/ml.

Rheumatoid factor and rheumatoid factor isotypes in loiasis with and without accompanying glomerulonephritis

We have studied the distribution of rheumatoid factor isotypes amongst patients with loiasis with and without accompanying glomerulonephritis to determine the possible role of rheumatoid factor antiglobulins in this disease. Our findings indicate an increase in both immunoglobulin (Ig) G and IgM rheumatoid factor isotypes in patients with filariasis alone as well as in patients with accompanying glomerulonephritis. No association with IgA rheumatoid factor was found. The raised IgG and IgM rheumatoid factor levels did not correlate with corresponding IgG and IgM levels.

Humanised monoclonal antibody therapy for rheumatoid arthritis

Monoclonal antibodies that target T cells have shown some benefit in rheumatoid arthritis although responses have not been long lasting. This is partly due to insufficient therapy consequent upon antibody immunogenicity. Use of humanised antibodies, which are expected to be less foreign to man than conventional rodent antibodies, might overcome this problem. We therefore assessed in a phase 1 open study the potential of a "lymphocyte depleting" regimen of the humanised monoclonal antibody CAMPATH-1H in 8 patients with refractory rheumatoid arthritis. Apart from symptoms associated with first infusions of antibody, adverse effects were negligible. Significant clinical benefit was seen in 7 patients, lasting for eight months in 1. After one course of therapy, there was no measurable antiglobulin response, although 3 out of 4 patients have become sensitised on retreatment. Humanisation reduces the immunogenicity of rodent antibodies but anti-idiotype responses may still be seen on repeated therapy, even in patients sharing immunoglobulin allotype with the humanised antibody.

Placebo controlled study showing therapeutic benefit of iloprost in the treatment of Raynaud's phenomenon

Iloprost is a chemically stable analog of prostaglandin I2 showing the same properties as the naturally occurring substance, but with advantages of ease of handling and administration to patients. A double blind within patient comparison of intravenous iloprost and placebo was undertaken in 13 patients with Raynaud's phenomenon severe enough to warrant short term hospitalization for intravenous dilator therapy; thermography was used as one form of assessment. Our results, while showing improvements in frequency of Raynaud's attacks after iloprost compared with placebo, show no significant effects on other variables.

Thermography of frozen shoulder and rotator cuff tendinitis

The role of thermography in the diagnosis of soft tissue lesions of the shoulder was evaluated by screening 28 patients with unilateral frozen shoulder and 86 patients with unilateral rotator cuff lesions. Index shoulders were then compared with the normal side. Differences in skin temperature distribution were found in 82% of subjects with frozen shoulder, nearly three-quarters of whom had reduced skin temperature. There was no consistent pattern of shoulder skin temperature found in rotator cuff tendinitis patients (49% normal, 28% reduced, 23% increased). Thermography can be helpful in the diagnosis of frozen shoulder but further studies are required to determine whether it is useful in other soft tissue shoulder lesions.

Polyclonal antibodies against human fibroblast collagenase and the design of an enzyme-linked immunosorbent assay to measure TIMP-collagenase complex

A polyclonal antibody has been raised against purified human fibroblast collagenase and characterised. This antibody has been used in combination with a monoclonal anti-TIMP antibody in a double antibody sandwich ELISA to measure TIMP-collagenase complex. The assay range was 5-50 ng/ml complex, quantitated in terms of the TIMP component. The assay can measure complex even in the presence of at least a 40-fold excess of free TIMP. The level of TIMP-collagenase complex has been measured in serial samples of synovial fluid from two patients with septic arthritis; high levels of complex are found in some samples, and the level of complex shows an inverse relationship with the level of free TIMP.

Soft tissue shoulder lesions in the African

Soft tissue disorders including shoulder lesions are uncommonly reported in Africans. A combined hospital and community study amongst an African population showed that soft tissue shoulder lesions are not uncommon; however, medical attention is seldom sought for these conditions.

Localized scleroderma and hemiatrophy in association with antibodies to double-stranded DNA

Localized scleroderma involves primarily skin but also muscle, bone and synovium. Further associations and transitional forms have been reported. We report here two cases showing associations between localized scleroderma and vasculitis, mononeuritis multiplex, juvenile chronic arthritis and hemiatrophy. In particular our cases both possess antibodies to double-stranded DNA, a finding not previously reported.

The differential responses of human skin and synovial fibroblasts to stanozolol in vitro: production of prostaglandin E2 and matrix metalloproteinases

The anabolic steroid, stanozolol, is used therapeutically to treat a number of pathological conditions and its clinical effects suggest that it can modulate connective tissue breakdown. The ability of this compound to stimulate prostaglandin E2 (PGE2), collagenase, gelatinase and stromelysin production by human synovial and skin fibroblasts in vitro was examined. The results showed that stanozolol significantly stimulated, in a dose dependent manner, PGE2, collagenase and stromelysin production by skin fibroblasts. However, no stimulation was seen in the synovial cell lines. In contrast, no effect on gelatinase production was seen in either cell type, following exposure to stanozolol. The synovial and skin lines both exhibited a significant stimulation of PGE2 and all three metalloproteinases in response to interleukin-1 beta (IL-1 beta). The anabolic steroids nortestosterone and oxymetholone demonstrated no ability to stimulate PGE2 or collagenase production in either skin or synovial fibroblasts. These results suggest that stanozolol exerts differential effects on skin and synovial fibroblasts in vitro which may enable the elucidation of the mechanism of action of the compound in vivo.

Serological profile of rheumatoid arthritis in west Africa

Rheumatoid arthritis (RA) in West Africa is atypical in a number of respects. In order to investigate this we evaluated the serological profile of a series of West African patients diagnosed as having RA. We found the presence of a wide range of autoantibodies including antinuclear antibodies (ANA), anticardiolipin antibodies and antineutrophil cytoplasmic antibodies but the pattern of these autoantibodies was similar to that reported in other studies. Our serological studies support the hypothesis that these patients do have RA and the presence of these autoantibodies is of interest with regards to implications for diagnosis.

The secretion of the tissue inhibitor of metalloproteinases (TIMP) by human synovial fibroblasts is modulated by all-trans-retinoic acid

The matrix metalloproteinases are a family of enzymes involved in the turnover of the connective tissues. The regulation of these enzymes is complex, involving the control of synthesis, the activation of proenzyme forms and the presence of specific inhibitors. Retinoids have been reported to inhibit the production of metalloproteinases by human and rabbit synovial fibroblasts and by human skin fibroblasts. The production of the highly specific tissue inhibitor of metalloproteinases (TIMP) by connective tissue cells may be crucial in the regulation of connective tissue breakdown and this present study was undertaken to determine if retinoic acid (RA) could modulate TIMP and collagenase production by synovial fibroblasts. The results show that RA at concentrations from 10(-7) to 10(-5) M significantly stimulated the secretion of TIMP by two of three human synovial cell lines. The effect of mononuclear cell factor (MCF) on TIMP and collagenase levels was also investigated. The apparent reduction of collagenase levels in the presence of RA, could result from a failure to accurately measure this enzyme in the presence of increased levels of TIMP.

Humanized monoclonal antibody treatment in rheumatoid arthritis

A 41-year-old woman with active, seropositive erosive rheumatoid arthritis was treated with the humanized monoclonal antibody Campath 1H. She had not responded or developed side effects to myocrisin, sulfasalazine and penicillamine, and had not responded to inpatient bedrest and physiotherapy. There was a rapid clinical improvement within 24 hours of infusion, which was maintained for about 12-14 weeks after the infusion. The lymphocyte count was suppressed for 7 months after treatment. There were no significant side effects during or after treatment. No anti-Campath 1H response was detected. This preliminary study suggests humanized monoclonal antibody therapy may be of value in the treatment of rheumatoid arthritis.

Transforming growth factor beta stimulates the production of the tissue inhibitor of metalloproteinases (TIMP) by human synovial and skin fibroblasts

IL-1 stimulates the secretion of metalloproteinases by a variety of connective tissue cells and is thought to be the primary inducing agent of connective tissue breakdown in rheumatoid arthritis. Transforming growth factor-beta (TGF-beta) is known to be capable of inhibiting the synthesis of metalloproteinases and to be able to partially inhibit interleukin-1 (IL-1) induced cartilage degradation. The present paper examines the ability of TGF-beta to modulate the action of IL-1 on fibroblasts of synovial and skin origin and investigates the secretion of the tissue inhibitor of metalloproteinases (TIMP) by these cells after exposure to TGF-beta and IL-1. The principal findings are that when four out of five fibroblast lines were exposed to TGF-beta and IL-1 in combination they displayed a significant increase in TIMP secretion; furthermore, in two of these cell lines a significant stimulation of TIMP secretion was induced by TGF-beta alone.

Liver scan abnormalities in polymyalgia rheumatica/giant cell arteritis

Liver involvement in polymyalgia rheumatica/giant cell arteritis (PMR/GCA) before treatment and during follow-up of up to 3 1/2 years was assessed in 74 patients clinically, with liver function tests, isotope scans and blood flow studies. Twenty-seven patients had elevated alkaline phosphatase levels which fell to normal after 2.6 weeks treatment. Both PMR and GCA patients were affected, the latter more commonly. Isotope scans were abnormal in 7 of 29 patients and remained abnormal on follow-up. The arterial fraction of hepatic flow was significantly reduced in GCA patients in comparison with those having PMR only; values became normal after treatment. These abnormalities may be due to hepatic arteritis.

Shoulder disorders in the elderly: a community survey

A community survey of identifiable symptomatic shoulder disorders in a sample of 644 elderly people over age 70 (318 male and 326 female) revealed a prevalence of 21%. Shoulder disorders were more common in women (25%, versus 17% in men). Approximately 70% of the cases of shoulder pain involved the rotator cuff. Fewer than 40% of the subjects sought medical attention for these symptoms. Increased medical awareness is needed, since the elderly often do not volunteer information about such symptoms.

Rheumatoid factor quantitation: a comparison of ELISA and nephelometric methods

Quantitation of rheumatoid factors (RF) by nephelometry, and more recently by enzyme linked immunosorbent assay (ELISA), are achieving increasingly common usage. Sera from 101 rheumatoid patients were compared by both methods and screened by a latex fixation method. Good correlation was found between the two assay techniques, the ELISA showing greater sensitivity and measuring IgG RF and IgA RF in addition to IgM RF. Both assay methods were reliable, accurate, rapid and sensitive for routine clinical purposes.