Intracellular persistence of chlamydial major outer-membrane protein, lipopolysaccharide and ribosomal RNA after non-productive infection of human monocytes with Chlamydia trachomatis serovar K

The replication of Chlamydia trachomatis serovar K was studied in human peripheral blood monocytes (PBMo). The intracellular fate of the bacteria was examined by determining the presence of chlamydial major outer-membrane protein (MOMP), lipopolysaccharide (LPS) and ribosomal RNA (rRNA). In-vitro infection of PBMo with C. trachomatis serovar K was not productive. However, chlamydial MOMP antigen, demonstrated by immunofluorescence, was present in PBMo for up to 14 days. Infected monocytes also contained chlamydial rRNA, measured by in-vitro hybridisation, and LPS, measured by enzyme immunoassay, for up to 14 days. These data are compatible with the hypothesis that the infection of PBMo with C. trachomatis may play a role in the systemic distribution of chlamydial antigens, leading to systemic manifestations of urogenital chlamydial infection.

Follow-up of patients with double stranded DNA antibodies induced by sulfasalazine during the treatment of inflammatory rheumatic diseases

Twenty-four patients with chronic inflammatory joint diseases developed double stranded DNA (dsDNA) antibodies during sulfasalazine (SAS) therapy and 20 of these 24 patients could be followed over a mean period of 11 months. Only one of the patients showed clinical symptoms of systemic lupus erythematosus (SLE). DsDNA antibodies were transient in two thirds of the patients discontinuing SAS treatment and in the same proportion of the individuals who did not interrupt this medication.

Undifferentiated spondyloarthropathies

The term undifferentiated spondyloarthropathy (uSpA) refers to patients with clinical and roentgenographic features suggestive of spondyloarthropathies but not fulfilling the diagnostic or classification criteria for any of the currently established disease categories. The frequency and clinical spectrum of uSpA have been ignored in previous epidemiologic and clinical studies. A generally accepted nosologic concept and definition of uSpA may be needed to overcome this issue. So far the recently developed ESSG criteria have the broadest basis of consent, at least for several European centers. With the use of the ESSG classification criteria the real prevalence may be better defined in the future and the early classification of such patients in clinical practice should be advanced. Nevertheless, the diagnosis of uSpA is only a working label with the implicit demand to solve the clinical conundra by follow-up or even better by identifying the causative or triggering infectious agents.

Epidemiology and economics of NSAID-induced gastropathy

Nonsteroidal anti-inflammatory drug (NSAID) use and gastrointestinal (GI) injury and symptoms are associated in clinical practice, but the importance of this injury is debatable. Most rheumatologists and general practitioners view NSAIDs as extremely valuable and generally well-tolerated first-line agents in the treatment of arthritis and musculoskeletal disorders. Generally, gastroenterologists and surgeons, on the other hand, insist that NSAIDs are dangerous and potentially lethal irritants to the GI mucosa. More frequent NSAID-induced gastropathy may be related to general epidemiological trends in NSAID-using populations: longer life expectancy, multiple risk co-factors for peptic ulcer disease (ie, smoking, alcohol, diet, comedication), and the increased availability of endoscopic examinations. Based on endoscopic studies, the prevalence of NSAID-induced adverse GI events has been documented in published reports. The frequency of bleeding is related to dose and duration of NSAID therapy. Overall, the prevalence of ulcer complications is higher in patients who consume NSAIDs. Cost-benefit analyses indicate that preventing potential GI damage with agents such as misoprostol may reduce the expense of treating the GI side effects associated with NSAID therapy.

Chlamydial rRNA in the joints of patients with Chlamydia-induced arthritis and undifferentiated arthritis

Synovial fluid and synovial membrane specimens of 11 patients with Chlamydia-induced arthritis (CIA), 24 patients with undifferentiated arthritis (UndA), 4 patients with post-enteritic reactive arthritis, 3 patients with Lyme arthritis and 9 patients with rheumatoid arthritis were investigated for the presence of Chlamydia trachomatis (C. trachomatis). A single stranded DNA-probe was used for nucleic acid hybridization with ribosomal RNA (rRNA) from C. trachomatis. In 4 patients (CIA = 1, UndA = 3) chlamydial rRNA was found in the synovial fluid. In one additional patient (CIA) the specimen of a synovial membrane biopsy was positive for chlamydial rRNA. The detection of intra-articular chlamydial rRNA is discussed as an indicator for the presence of viable Chlamydiae in inflamed joints.

[Systemic lupus erythematosus (SLE) with panniculitis and rhabdomyolysis]

In systemic lupus erythematosus as a multi-system disease the involvement of skeletal muscle has been described as a rather mild polymyositis, myopathy or inclusion-body myositis. Here we present a patient with a severe lupus presenting with a fulminant myositis with rhabdomyolysis and panniculitis.

Epidemiology and NSAID induced gastropathy

Population based epidemiologic studies of gastropathy associated with the use of non-steroidal antiinflammatory drugs (NSAID) have shown that NSAID users are at increased risk of adverse gastrointestinal (GI) events and ulcer complications, that the risk of NSAID induced gastropathy is increased among older persons, and that such factors as alcohol use, anticoagulant use and prior GI disorders contribute to the risk of adverse GI events. Clinical epidemiologic studies have shown that ulcer and other mucosal damage is present in a large proportion of NSAID users and that such damage is largely asymptomatic. Overall, evidence indicates that NSAID induced gastropathy is responsible for a significant proportion of serious ulcer complications and associated mortality. More data are needed to establish multivariate risk profiles permitting optimal management of patients receiving chronic NSAID therapy.

A three year comparative study of auranofin and gold sodium thiomalate in rheumatoid arthritis

One hundred twenty-one patients with active RA were randomly assigned to receive 6 mg auranofin (AF)/day (60 patients) or 50 mg gold sodium thiomalate (GST)/week (62 patients) in a double-blind fashion. There were no intergroup differences with respect to sex, age, duration (median 2 years), stage and activity of the disease. In the case of "striking improvement" after 24 weeks a dose reduction to 50 mg GST/month or 4 mg AF/day was allowed and carried out in all GST patients and no AF patient. The serum gold levels were 5 times higher with weekly GST, they approached those of the AF group with monthly GST injections. The clinical parameters--number of swollen joints, activity index, articular index, grip strength, ESR--improved significantly in both groups, but grip strength, articular index and ESR improved more pronounced in the GST group. The X-ray progression (hands and forefeet) was significantly greater in the AF group. Forty-eight AF patients (80%) and 39 GST patients (36%) completed the first year. Thereafter the study was continued as an open study but the patients were allowed to switch from GST to AF. After the first and second year 14/7 GST patients switched to AF. The second/third year was completed by 37/22 AF pat. (62%/37%) and by 15/8 GST pat. (24%/13%). Skin reactions were more common with GST (41.9%/26.7%), diarrhoea was more common with AF (36.7%/19.4%), proteinuria occurred in 10% in both groups, leucopenia and thrombocytopenia were rare in both groups (1.7%). The withdrawal rate due to adverse events was 10%/26% in the AF/GST group during the first year (p less than 0.05) and 25%/32% over the three year period (n.s.).

CONCLUSION

Both AF and GST are effective in the long-term treatment of RA, but GST is more so in radiological progression and ESR.

Yersinia enterocolitica in the synovial membrane of patients with Yersinia-induced arthritis

Using a monospecific rabbit antibody against Yersinia enterocolitica outer membrane protein 1, we examined synovial biopsy specimens from 7 patients with Yersinia-induced arthritis. Yersinia were demonstrated in the synovial membrane by indirect immunofluorescence in 4 patients with Yersinia-induced arthritis, but not in 6 control patients with Salmonella-induced arthritis or with rheumatoid arthritis. These findings suggest the persistence of Yersinia in the joints of patients with Yersinia-induced arthritis.

[Concept and criteria of spondylarthritis]

Since several rheumatic disease share common features, they led to the concept of the spondarthritides: ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritides, juvenile oligoarthritis (type II), and questionable pustolotic arthro-osteitis and Behçet's disease. Furthermore undifferentiated spondarthritides have to be considered. They occur more frequently than ankylosing spondylitis. Definite ankylosing spondylitis is classified according to the New York-criteria, which, however, do not identify the early stage of the disease. In these cases early diagnostic criteria proved to be useful. In a multicenter study the so-called ESSG-criteria were recently introduced for the classification of the whole group of spondarthritides. They are also helpful for the nosological classification of undifferentiated spondarthritides.

[Chlamydia-induced arthritis: diagnosis--follow-up--therapy]

Chlamydia-induced arthritis (CIA) is an inflammatory reactive arthritis caused by extraarticular infection with Chlamydia trachomatis. CIA presents as peripheral arthritis or spondylarthropathy. Extraarticular manifestations are present in most but not all cases, Reiter's syndrome occurs only in a minority of patients. Detection of Chlamydia trachomatis in genitourinary smears and demonstration of serum-antibodies against chlamydial antigens lead to diagnosis. Analysis of synovial fluid reveals nonpurulent inflammatory synovitis and, in some cases, chlamydial antigen has been demonstrated in synovial specimens. The therapy of CIA combines physical medicine, NSAID and shortterm antibiotic treatment of the genitourinary infection. Whether longterm antibiotic therapy or-in chronic cases--DMARDs are successful, needs further investigation.

[Yersinia-induced arthritis: new knowledge of pathogenesis, diagnosis and therapy]

Yersinia infections have been identified in rising incidence as the cause of acute or subacute intestinal or extraintestinal diseases in the past two decades. Immunopathological manifestations of Yersinia infections, e.g. Yersinia-induced arthritis, have evoked special interest among clinicians and microbiologists. Beneath epidemiological and clinical characteristics this review focuses on recent progress in pathogenesis and serological and immunohistological diagnosis of Yersiniosis. Possible consequences for newly therapeutical approaches in chronic Yersinia-induced arthritis and spondarthritis were discussed.

[Rheumatologic emergencies]

Contrary to the widely assumed opinion there exist rheumatological emergency situations that affect patients hazardously. These cover complications of the antirheumatic therapy as well as complications of the disease itself. The paper gives an overview of rheumatological emergency situations and tries a systemic approach to a rheumatological emergency medicine.

[Nosologic concept and new developments in the etiopathogenesis of reactive arthritis]

Reactive inflammatory arthritis is caused by extraarticular infection with different arthritogenic microorganisms. The causative bacteria can not be cultured from synovial specimens, but bacterial antigens have been demonstrated in cells of synovial fluid and synovial membrane, respectively. Thus, latent intraarticular infection may be the cause of reactive arthritis. A model of the etiopathogenesis of reactive arthritis is described on the basis of recent immunological and microbiological findings.

[Mycoplasmas and arthritis]

Since 1898 Mycoplasmas are known triggers of different diseases in various animal species. In man they can cause among others non-gonococcal urethritis. In addition they are discussed as triggering agents of arthritis. Besides septic arthritides in immunocompromised patients with hypogammaglobulinemia, they might be causative agents in sexually acquired reactive arthritis, as in Reiter's syndrome. Various diagnostic tests are available. Antibiotic therapy is derived from experience with urogenital infections, proved investigations are pending.

Evaluation of early diagnostic criteria for ankylosing spondylitis in a 10 year follow-up

A set of early diagnostic (ED) criteria comprising clinical data, ESR, radiological spinal signs, and the risk factor HLA B27 was evaluated after 5 and 10 years in a follow-up of 54 patients with an initial diagnosis of possible ankylosing spondylitis (AS). After 10 years 32 patients (59%) had developed definite AS according to the New York criteria, 10 individuals (19%) had possible or undifferentiated spondylarthropathy (SA), whereas in 12 patients (22%) other diagnoses were stated. ED criteria had a high discriminatory significance for the development of AS after 5 and 10 years (P less than 0.005, P less than 0.001 respectively). In this respect they were more valuable than B27 determination alone (P less than 0.01) or the ED criteria without HLA B27 (P less than 0.05). Furthermore, patients with still possible or undifferentiated SA had a higher mean score at the first examination than individuals with other final diagnosis (P less than 0.05). Thus, the ED criteria were useful for the identification of patients developing definite AS and of individuals in the AS related group of possible or undifferentiated SA.

German drug monitoring studies with nabumetone

Although randomised controlled comparative trials concerning the efficacy of the drug tested can produce reliable results in a limited number of selected patient groups, drug monitoring studies involving 10,000 patients or more are the methods of choice to detect rare adverse events. The aim of this drug monitoring study was to evaluate the efficacy and safety of dispersible nabumetone tablets. 8865 patients (46.2% male, 53.5% female, mean age 55 years, range 14.95) were involved in the investigation carried out by 1172 general practitioners. The disease indications comprised osteoarthritis (69.8%), soft-tissue rheumatism (11.3%), rheumatoid arthritis (9.9%) and soft tissue injuries (7.7%). Most of the patients (67.3%) received a daily dose of nabumetone 1 g for up to 6 weeks. Efficacy was evaluated at baseline, and after 1 week, 3 weeks and 6 weeks of treatment. With regard to global efficacy, overall improvement (symptoms resolved or markedly improved) was assessed in 82% of the patients. Elimination or at least significant improvement of pain on movement occurred in 95%, pain on pressure in 90% and pain at rest in 89% of the patients with symptoms. In relation to swelling, morning stiffness and joint mobility, elimination or at least significant improvement occurred in 79%, 80% and 82% of patients, respectively. 1846 patients (20.8%) had frequent periods of NSAID-related symptoms before treatment with nabumetone. A total of 1174 adverse events occurred in 850 patients (9.6%), most comprising minor gastrointestinal complaints. Considering that at least 25,000 patients have been documented in 2 German drug monitoring studies, it is therefore unlikely that any unexpected side effects will occur in the future. Consequently, nabumetone can be classified as an effective and safe NSAID.

[Clinical and serological characterization of Chlamydia-induced arthritis]

Chlamydia-induced arthritis was diagnosed in 32 patients (18 men and 14 women; mean age 33 [17-54] years). 13 were HLA-B27 positive. In 19 patients the arthritis was largely confined to one joint. Enthesopathies occurred in 14 patients, and in 13 sacroiliitis was diagnosed radiologically. The most frequent extra-articular changes affected the urogenital system (26 cases). The full Reiter syndrome was present in seven patients (four men, three women). All patients had serum antibodies against Chlamydia. In 16 patients Chlamydia was diagnosed as the causative organism by urogenital swab. Chlamydia-induced arthritis differs from other arthritides in the high proportion of HLA-B27 negative patients.

[Preventive and therapeutic effect of estrogen administration in adjuvant arthritis]

Using adjuvant arthritis as a model for human rheumatoid arthritis, we examined prophylactic and therapeutic effects for different doses of estrogen (0.5-5.0 mg estradiol 3x/week) in 40 male Long Evans rats compared to 16 control animals. More than 2.5 mg estradiol resulted in significantly reduced inflammatory activity, both in animals treated before or after induction of arthritis (Mann Whitney U-test, p less than 0.05).

[Social medicine results of expert assessment of work disability]

Disability for work is both a medical and a socioeconomic problem. Hence, a great number of publications on this item can be found in scientific literature. These evaluations are mostly based on case statistics. Individualised evaluations, that means, personal statistics, are comparatively rare. This is also a matter for the medical advisory service of the German sickness insurance (MDK), charged with sociomedical expertising for disability to work, particularly in respect of an assured curative effect and additional aftercare measures if necessary. An individualised evaluation (follow-up study) of expertises of disability with regard to frequency of prescribed additional measures is presented.

Specific serum IgA-antibodies in chlamydial-induced arthritis

A cohort analytic study was performed to investigate serum IgA-class antibodies against Chlamydia in 24 patients with chlamydial-induced arthritis (CIA). IgA-class antibodies against chlamydial antigens were positive (titre greater than or equal to 1:16) in 23 of the 24 IgG-positive CIA-patients (96%) in contrast to 16 of 40 patients (40%) with other rheumatic diseases (ankylosing spondylitis n = 6; undifferentiated arthritis n = 11; rheumatoid arthritis n = 12; degenerative joint disease n = 11), also positive for IgG-class chlamydial antibodies. Both the presence of specific IgA-antibodies and their geometric mean titre (1:28 vs. 1:4) differed significantly (p less than 0.001) between the two groups.

NSAIDs: new approaches to limiting gastropathy

An extensive literature search on non-steroidal anti-inflammatory drug (NSAID)-induced gastropathy in rheumatic conditions has been carried out. A reduced incidence of gastropathy has been observed among newly developed NSAIDs such as etodolac and the non-acidic nabumetone. An alternative prophylactic therapy to avoid NSAID-induced gastroduodenal mucosal damage which has been successfully tested in several trials is co-medication with the prostaglandin analogue misoprostol. The cytoprotective agent sucralfate also appears to be effective. Recent observations of Campylobacter pylori infections in NSAID-induced gastropathy introduces the question as to whether simultaneous antibacterial medication should be routinely administered during NSAID therapy. At present the invasive technique of endoscopy is used to ascertain gastroduodenal mucosal damage. However, a new technique which merely requires blood sampling is being investigated. This involves measurement of serum levels of the precursor molecules for the gastric enzyme pepsin, pepsinogen I and II. In future this assay could constitute a non-invasive method for detecting gastroduodenal mucosal damage.

Benign polyarthritis and undifferentiated arthritis an epidemiological terra incognita

Introduction of new diagnostic criteria and the development of HLA-typing and microbiological--serological techniques have aided in classifying and differentiating inflammatory rheumatic diseases. Reviewing epidemiological prevalence studies shows that inflammatory rheumatic diseases are often so called benign polyarthritides and that arthritides, classified as definite and probable rheumatoid arthritis (RA), may belong to a group of benign or undifferentiated arthritides. Own data show that only 25% of patients of an early synovitis out-patient clinic have definite or probable RA, 25% have an undifferentiated arthritis. The term "undifferentiated" refers to the heterogeneity of diseases included. We conclude that few epidemiologic studies exist concerning undifferentiated arthritis and spondarthritis and combined efforts are needed to distinguish RA from the multitude of other well characterized or yet unknown arthritides.

[Fever in rheumatic diseases--the spectrum of causes and diagnostic guidelines]

The review presents a systematic approach to the diagnostic problem of fever in combination with inflammatory rheumatic symptoms, specifically, in regards to: actual concepts of the pathogenesis of fever in various rheumatic diseases, fever as expression of disease activity, fever as a warning sign of complications in the course of disease and its treatment (infections, drug-induced fever, fever following drug withdrawal, secondary neoplasias), fever and inflammatory rheumatic symptoms as manifestation of non-rheumatic diseases. Based on the literature and information provided by pharmaceutical companies, a survey is given on the frequency of fever as a negative side-effect of the most commonly used drugs in rheumatology.

HLA antigens in ankylosing spondylitis associated with Crohn's disease. Increased frequency of the HLA phenotype B27,B44

In a consecutive case study 231 patients with Crohn's disease were investigated for ankylosing spondylitis (AS) and HLA-A, B, C, DR antigen association. Eighteen patients (7.8%) had definite AS according to the New York criteria; 13 (72%) were HLA-B27 positive. The phenotype B27,B44 was seen in 8 patients (44%) compared to only 3 (1%) of 300 controls (p less than 10(-7), and 1 (0.5%) of 213 patients with Crohn's disease without AS (p less than 10(-7). We conclude that patients with the phenotype B27,B44 are highly at risk (relative risk = 68.8) for the common manifestation of Crohn's disease and AS.

Clinical features and prognosis of patients with possible ankylosing spondylitis. Results of a 10-year followup

Eighty-eight patients with possible ankylosing spondylitis (AS) were selected for this followup study. They showed normal or at most suspicious radiographic findings of the sacroiliac joints. After 5 years' followup, 24, and after 10 years 32 patients (59% of the 54 finally available, 36% of the 88 original patients) had definite AS. In 12 individuals, AS could be excluded. Of the 10 remaining patients, 6 still had possible, and 4 had undifferentiated spondyloarthropathy. A comparison between HLA-B27 positive and negative patients showed a significantly increased frequency of definite AS or possible and undifferentiated spondyloarthropathy (p less than 0.05) in the group of HLA-B27 positive patients. The development of AS was characterized by a prolonged course: radiological sacroiliitis became evident after at least 9 +/- 6 years, radiological signs of spinal involvement after 11 +/- 6 years mean disease duration. After 18 +/- 6 years 25 (78%) of 32 patients with AS still maintained good or sufficient functional capacity, indicating a good functional prognosis in the great majority of the patients.

Auranofin and gold sodium thiomalate in the treatment of rheumatoid arthritis: a one-year, double-blind, comparative multicenter study

In a 48-week, double-blind trial, 122 patients were randomly assigned to treatment with auranofin (60) and gold sodium thiomalate (GST) (62) at five centers. Both groups showed significant improvement (P less than 0.05) from baseline in parameters of disease activity. Results of the covariance analysis for all patients who completed the trial showed no significant differences (P less than 0.05) in efficacy between the two groups. The proportions of patients showing 50% or greater improvement in tender joints, swollen joints, activity index, severity of pain, general health rating, and erythrocyte sedimentation rate (ESR) were similar for both auranofin-treated and GST-treated patients who completed the 48-week trial. When all patients who entered the trial were evaluated, a slightly greater proportion of patients on auranofin had improved. Diarrhea occurred more frequently with auranofin (32%) compared to GST (19%), whereas rash and pruritus were twice as common in those patients treated with GST compared to those treated with auranofin. The withdrawal rate due to adverse reactions was 10% for auranofin vs 26% for GST. It was concluded that the efficacy of auranofin was comparable to that of injectable gold and was better tolerated, as evidenced by the lower withdrawal rate from adverse events for the auranofin patients.

Undifferentiated arthritis and spondylarthropathy as a challenge for prospective follow-up

Diagnosis of arthritis with recent onset is still an unresolved problem. In 1984 we started an outpatient clinic for patients with early arthritis of less than one year duration. Of a total of 226 patients seen 149 (66%) had definite (n = 76; 34%) or probable (n = 73; 32%) inflammatory rheumatic disease, and 77 (34%) had degenerative or extraarticular rheumatic disease. Thirtynine patients were classified as undifferentiated arthritis. This undefined arthritis was often monoarticular (12%) and oligoarticuler (44%). One patient met 5 ARA-criteria for rheumatoid arthritis, 14 (36%) met 3-4 ARA-criteria and 25 (64%) only 1-2 ARA-criteria. ESR was elevated in only 23 (59%) patients, rheumatoid factor was positive in 7 (19%) patients and HLA-B27 was positive in 9 (23%) patients. Seventeen (44%) patients had a history of recent infections preceding the beginning of joint symptoms. Thus undifferentiated arthritis represents a heterogeneous group of diseases. Despite diagnostic progresses in recent years a high proportion of early arthritis cannot be diagnosed definitely.

Outcome of possible ankylosing spondylitis in a 10 years' follow-up study

Of 88 selected patients with possible ankylosing spondylitis (AS) 54 (61%) participated in two phases of a 10 years' follow-up study. Thirty-two (59%) developed definite AS according to the New York criteria, 10 (19%) had possible/undifferentiated seronegative spondylarthropathy (SSA) and 12 patients had other diagnoses. Only 3 (9%) of 35 patients with sacroiliitis did not fulfill the New York criteria for definite AS until the last examination. Sacroiliitis and radiological spinal signs of AS appeared rather late above a mean age of 40 years and after a mean disease duration of more than 10 years. After 18 years mean disease duration 25 (78%) of 32 AS patients had good or sufficient functional capacity indicating an overall good functional prognosis. HLA B27 typing proved to be useful in patients with possible early AS: 29 (71%) of 41 B27 positive and 3 (23%) of 13 B27 negative patients developed definite AS (p less than 0.005). A combination of the B27 test with data of the history, clinical, laboratory, and radiological examination proposed as early diagnostic criteria detected patients with the outcome diagnosis of definite AS with even higher significance (p less than 0.001). These criteria were also useful in the identification of patients with possible or undifferentiated SSA. The recently recognized entity of undifferentiated SSA should only be diagnosed after long term follow-up.

[Clinical studies with salazopyrine--consequences and perspectives]

The efficiency of sulphasalazine (SASP) as a long-acting antirheumatic drug for rheumatoid arthritis is now well established by placebo-controlled studies and comparative trials with injectable gold and D-penicillamin. Early treatment effect and better tolerance suggest the use of SASP especially for early treatment of rheumatoid arthritis. Severe and advanced disease, in which gold and/or D-penicillamin were not effective or toxic, may also be treated with SASP. Open questions are the effect on the radiological progression and the differential indication to antimalarials, oral gold and methotrexat. Positive results of two placebo-controlled studies in ankylosing spondylitis for the first time open the perspective of a long-acting antiphlogistic therapy in this disease. Further open trials observed promising treatment effects of SASP in reactive and juvenile rheumatoid arthritis. Therefore, future clinical studies have to establish indication, benefit-risk-relation and treatment modalities also in these rheumatic disorders.

Undifferentiated arthritis and spondylarthropathy as a major problem of diagnosis and classification

Epidemiologically-based studies have shown that 20-50% of all cases of early arthritis cannot be classified. More recent data came from experiences with an outpatient clinic especially for early arthritis. Of 149 patients with inflammatory rheumatic disease, 39 (26%) were diagnosed as undifferentiated arthritis and 22 (15%) had a probable diagnosis. Therefore, despite diagnostic progress in recent years, only half of all cases can be diagnosed definitely. Follow-up studies of patients with HLA-B27 positive arthritis and undifferentiated spondylarthropathy show the difficulties of early diagnosis and the heterogeneity of disease course and prognosis. Early diagnostic criteria combining the result of the HLA-B27 test with history, symptoms, erythrocyte sedimentation rate and radiological spinal signs can predict or exclude the development of ankylosing spondylitis (AS) at an early stage of the disease in three-quarters of patients, but the diagnosis of AS should not be excluded before 5 to 10 years' observation.

[Effect of gold (III) on prostaglandin E2-stimulated adenyl cyclase in chick fibroblasts and osteoblasts]

Gold (III) (Au(III) up to 0.25 microM increased prostaglandin E2-sensitive chick osteoblast and fibroblast adenylate cyclase activity without affecting 5'-guanylylimidodiphosphate-stimulated enzyme activity. Au (III) at 5-50 microM inhibited hormone- and nucleotide-mediated activation of adenylate cyclase. This process is time-dependent, irreversible and can not be explained by desensitivation of the PGE2-receptor. Basal adenylate cyclase activity was not influenced by Au (III) in the given concentrations. Pretreatment of membranes with 5'-guanylylimidodiphosphate prior to incubation with Au (III) prevented the inhibitory effect of Au (III) on adenylate cyclase, similar to the incubation experiments with NEM instead of Au (III). Our data suggest that Au (III) at low concentrations unspecifically stimulates PGE2-sensitive adenylate cyclase by binding to sulfhydryl groups of the receptor protein and that Au (III) at high concentrations specifically inhibits PGE2-sensitive adenylate cyclase by binding to sulfhydryl groups of the N-Protein and/or of the catalytic unit.

Clinical features of inflammatory joint and spine manifestations in Crohn's disease

167 patients with Crohn's disease were investigated for joint and spine inflammation. Arthritis was observed in 23 patients (14%), sacroiliitis in 24 (14%), and sacroiliitis in combination with arthritis in 11 patients (7%). 15 patients (9%) had ankylosing spondylitis; 9 of them were HLA-B27 positive (60%). A parallel pattern in the course of bowel disease and joint inflammation was observed in 22 out of 34 patients with arthritis (59%). An association between the localization of Crohn's disease and the type of spondylarthritis could not be demonstrated. Patients with arthritis alone developed erythema nodosum (35%) or aphthous stomatitis more often (21%) than patients without spondylarthritis+ (6% and 12%, respectively). Other extra-intestinal manifestations of Crohn's disease did not reveal any association with the development of spondyloarthritis.

Studies on the SV40-like papovavirus SV40-GBM. III. Propagation at low multiplicities of infection in various human cell lines

At low multiplicity several human cell lines supported the lytic infection with SV40-GBM better than that with the wild type SV40. The efficiency of viral DNA replication differed in the cell lines used suggesting that specific host cell factors may determine the rate of viral DNA synthesis. Furthermore, the emergence of different DNA defects during propagation of the virus indicates that host cell factors in question might also influence the composition of the viral DNA population.

[Familial Mediterranean fever. Immunogenetic and rheumatologic aspects of the disease in a Turkish sibship]

A family study was performed in 24 members of a Turkish sibship with familial Mediterranean fever (FMF) with 5 patients affected in 3 generations. The well-known autosomal-recessive inheritance of the disease was masked by a pseudodominant appearance, reflecting the striking frequency of congenial marriages. The immunogenetic investigation excluded a linkage between the expression of the disease and the HLA system. The arthritis of FMF was characterized typically by monarticular attacks in large joints of the lower limb. Frequently this manifestation led to diagnostic problems, particularly at the onset of the disease. No patient presented the clinical or radiological signs of sacroileitis. An observation of the disease process up to 3 years showed a benign prognosis of FMF-arthritis in 3 of 4 patients. Neither long-lasting functional impairment nor radiological signs of erosion had to be recognized. One patient suffered from a necrosis of the femoral head, possibly caused by the recurrent inflammation of the hip joint. Laboratory findings reflected the clinical picture of relapsing acute inflammation in an uncharacteristic manner. Their diagnostic significance exists mainly for the exclusion of other diseases.

[Synovitis in familial Mediterranean fever]

Arthroscopy done on a 24-year-old turkish male with familial Mediterranean fever (FMF) and arthritis of the knee joint provided morphological data during the acute stage of FMF-arthritis. Main finding is a heavy granulocytic infiltration of the subsynovial stratum, similar to that seen in non-specific purulent inflammation, accompanied by marked ectasis and hyperaemia of the synovial vessels. In the microbiologically sterile synovial fluid cell counts and lactate values are found as in bacterial arthritis. The typical history and the characteristic course of the disease are indicators for the diagnosis. Serological, immunological and radiological findings are non-specific. The efficacy of prophylactic colchicine in symptomatic therapy could be verified but it is essential that the drug is taken regularly and that the patient is instructed accordingly. Investigation of other members of the family showed a high frequency of intermarriages and the presence of this autosomal-recessive inherited disease in three generations.

Evaluation of early diagnostic criteria including HLA-B27 for ankylosing spondylitis in a follow-up study

Early diagnostic criteria, a combination of the HLA-B27 test with clinical data, ESR and radiological signs, were evaluated in a 5-6 year follow-up study of 77 patients with possible ankylosing spondylitis (AS) and 45 with other rheumatic diseases. 34 (44%) with possible AS at first examination developed definite AS according to the New York criteria and 29 (38%) were classified as still possible AS. From these data a sensitivity of 82%, a specificity of 68%, a positive predictive value of 50% and a negative predictive value of 91% were calculated. Therefore the early diagnostic criteria, although of limited value for the diagnosis of definite AS, may clearly define patients at risk of AS or unclassified seronegative spondylarthropathies.