The evolution of spondyloarthropathies in relation to gut histology. III. Relation between gut and joint

OBJECTIVE

To study prospectively the clinical evolution of different forms of spondyloarthropathy (SpA) in relation to the evolution of gut histology in consecutive ileocolonoscopic biopsy specimens.

METHODS

Ileocolonoscopy was performed in 49 patients with SpA (34 men, 15 women). They also underwent clinical, laboratory, and radiological examinations. Two to 9 years later, a 2nd and sometimes a 3rd or 4th ileocolonoscopy was performed, and the other examinations were repeated.

RESULTS

At first ileocolonoscopy, 34 patients (69%) showed inflammatory gut lesions. At the 2nd ileocolonoscopy, 16 patients (32%) were in clinical remission; none were found to have inflammatory gut lesions. Of the 33 patients with persistent locomotor inflammation, 14 had persistent inflammatory gut lesions, predominantly the chronic type. Of these 14 patients, 6 had developed inflammatory bowel disease (IBD). None of the 15 patients with an initially normal gut histology had gut inflammation at 2nd examination. Of the 9 with initially acute lesions, 3 developed chronic lesions (1 Crohn's disease). Initial chronic lesions in 25 patients persisted in 9, of whom 5 had developed IBD. Seven of the 19 patients with non-SpA ankylosing spondylitis (non-AS-SpA) developed ankylosing spondylitis (AS); all had initially presented inflammatory gut lesions, which persisted at 2nd examination. In the 11 patients with more than 2 consecutive ileocolonoscopies, clinical remission was always associated with normal gut histology, and flares of the joint disease were related temporally to the reappearance of gut inflammation.

CONCLUSION

This study demonstrates the close relationship between gut and locomotor inflammation in SpA. Clinical remission was always associated with normal gut histology, whereas active locomotor inflammation was usually associated with the presence of gut inflammation. Absence of gut inflammation in the SpA is a good prognostic indicator, since gut inflammation or IBD never develops in these patients. Evolution of non-AS-SpA to full blown AS or of uncomplicated SpA to a form of IBD was always associated with gut inflammation at disease onset.

The evolution of spondyloarthropathies in relation to gut histology. I. Clinical aspects

OBJECTIVE

To study prospectively the clinical evolution of different forms of spondyloarthropathy (SpA) (excluding inflammatory bowel disease, IBD): reactive arthritis, undifferentiated SpA, and ankylosing spondylitis (AS).

METHODS

Ileocolonoscopy was performed on 217 patients with SpA (149 men, 68 women). They also underwent clinical, laboratory, and radiological examinations. Two to 9 years later, 123 patients (84 men, 39 women) who had been regularly monitored were reviewed and given the same examinations. For the remaining 94 patients clinical data were obtained by telephone.

RESULTS

At the time of clinical review, 53 (43%) of the regularly monitored patients were in clinical remission. The remission rate was higher in patients with non-ankylosing spondylitis SpA (non-As-SpA) than in patients with AS (19%). Fourteen patients with non-AS-SpA had developed AS; 4 of them also had IBD. IBD was also found in 4 patients with AS and in 3 patients from the telephone group. The prevalence of HLA-B27 was significantly higher in all SpA subgroups, while HLA-BW62 was elevated in the undifferentiated SpA. At review, HLA-B27 was significantly more prevalent in patients with persistent locomotor inflammation compared to patients in clinical remission, while HLA-BW62 was predominant in the latter group.

CONCLUSION

Patients with SpA, especially those with non-AS-SpA, have a good longterm prognosis. However, patients with non-AS-SpA may develop AS. Six percent of the patients with SpA in whom manifestations of IBD are absent will develop this disease. This confirms the hypothesis that some of these patients with SpA initially have a form of subclinical Crohn's disease, of which locomotor inflammation is the only clinical expression. HLA-B27 positivity predisposes to a more severe course of locomotor inflammation, while HLA-BW62 has a protective effect but is associated with gut inflammation.

Standardization of nutrient media for isolated human articular chondrocytes in gelified agarose suspension culture

Human articular cartilage cells were cultured in 1.5% agarose in Dulbecco's modified Eagle's medium (DMEM) with 10% fetal calf serum or in serum-free DMEM with 0.15% bovine serum albumin. 35S-aggrecan synthesis in serum-free DMEM was between 20% and 30% of the value observed in DMEM supplemented with 10% fetal calf serum. The extent to which different growth or differentiation factors were able to restore 35S incorporation in aggrecan in serum-free DMEM was determined: human serum transferrin had no effect on aggrecan synthesis levels; bovine pancreas insulin, insulin-like growth factor (IGF)-1 and IGF-2 restored 35S-aggrecan synthesis to 35-50% of the control levels. The effects were dose-dependent, to level off at 100 ng/mL for the three factors. No cumulative or synergistic activities were observed when these factors were combined. Transforming growth factor (TGF)-beta, at concentrations ranging from 10-50 ng/mL stimulated aggrecan synthesis to approximately 50% of the control values in the chondrocytes obtained from two out of four donors, while the cells of the other two maintained within the range of the control levels. In th presence of insulin (100 ng/mL) 10 ng/mL of TGF-beta stimulated aggrecan synthesis to more than 90% of the control level in the chondrocytes of all donors.

Comparison of aceclofenac with diclofenac in the treatment of osteoarthritis

A multicentre randomised, double-blind, parallel group, general practice study was undertaken to investigate the efficacy and safety of aceclofenac (200 patients, 100 mg twice daily and placebo once daily) in comparison with diclofenac (197 patients, 50mg three times daily) in patients with osteoarthritis of the knee. The treatment period of twelve weeks was preceded by a washout period of two weeks duration. At end point, patients in both aceclofenac and diclofenac-treated groups exhibited significant improvement in pain intensity (p = 0.0001). Although both treatment groups showed significant improvement in all investigators' clinical assessments (joint tenderness, swelling, pain on movement, functional capacity, overall assessment), there were no significant differences between the groups. There was, however, a trend towards greater improvement in complete knee movement and reduced pain on movement with aceclofenac. In patients with initial flexion deformity, aceclofenac was significantly more effective than diclofenac in improving knee flexion after 2-4 weeks treatment. Patients' subjective assessment of pain relief demonstrated significantly greater efficacy with aceclofenac. At end point, 71% of patients in the aceclofenac group reported improvement in pain intensity as compared to 59% treated with diclofenac (p = 0.005). Tolerability of aceclofenac was better than with diclofenac as fewer patients experienced gastrointestinal adverse events. In particular, the incidence of treatment related diarrhoea was less with aceclofenac (1%) than the diclofenac (6.6%). In summary, this study supports a therapeutic role for aceclofenac in arthritis and suggests that it is an alternative NSAID to diclofenac in the treatment of osteoarthritis.

The role of T cells in rheumatoid arthritis

The most striking arguments in favor of a T cell dependent nature of RA are the strong association of the disease with selected class II HLA haplotypes (the "shared epitope" hypothesis) and the fact that, in experimental animal models such as adjuvant arthritis, the disease can be transferred by isolated T cell lines. It is true that T cell activation at the site of inflammation is not excessive. However, there is now unequivocal evidence for focal synthesis of IL-2 and IFN-gamma in the RA synovial membrane and one may realise that a limited but specific T cell activation may be sufficient to induce or perpetuate the immune process. This same argument may explain the lack of clear TCR restriction at the sites of inflammation. Until now, no antigen has been demonstrated to initiate and/or perpetuate RA. Different antigens though have been incriminated in the pathogenesis of RA, including cartilage antigens (collagen, proteoglycans, chondrocyte antigens), heat shock proteins or exogenous (viral/bacterial) antigens. Unless one can pick up the right antigen and clone the relevant T cells, it will be very hard to directly prove a T cell-dependent nature of the disease.

Churg-Strauss syndrome presenting as polymyositis

Churg-Strauss syndrome is a vasculitis-based pathology, predominantly characterized by asthma and eosinophilia. Histopathologically, the vessel wall infiltration contains a substantial proportion of eosinophils and extravascular granulomata can be demonstrated. We report a case of Churg-Strauss syndrome presenting as polymyositis.

Numerical scoring systems for the progression of osteoarthritis of the finger joints

We developed methods to assess and to score progression of osteoarthritis (OA) of the distal and proximal interphalangeal (DIP and PIP) and metacarpophalangeal (MCP) finger joints. Thirty-six patients with osteoarthritis (OA) of the finger joints were followed for five years. Anteroposterior radiographs of the hands were obtained at the start of this prospective study and at yearly intervals. The scoring systems used were based on: -1- the increase in incidence of OA during consecutive years in previously normal joints. -2- the radiological progression of the anatomical lesions (changes in osteophyte growth, loss of joint space, subchondral cysts or sclerosis) in pathological finger joints. -3- the consecutive pathological phases recognized in the course of the disease. Significant increases in both the numbers of affected DIP, PIP and MCP joints per subject and the anatomical progression of the disease in the different finger joints of each individual patient were recorded during the 5-year follow-up. In approx. 40% of the patients the classical picture of OA was complicated by manifest erosive changes, which preceded a period in which repair phenomena in the 'eroded' finger joints led to generation of a new subchondral plate covered by cartilaginous tissue. Huge osteophytes were then responsible for the nodular aspect of the affected finger joints. OA of the finger joints in our patients was progressive in nature and went through predictable phases. Recognition and scoring of these phases allowed faster assessment of OA progression and led to the same conclusions as scoring the anatomical progression.

Gut inflammation in psoriatic arthritis: a prospective ileocolonoscopic study

OBJECTIVE

Some forms of psoriatic arthritis (PsA) are classified as spondylarthropathy, and subclinical gut inflammation is found in spondylarthropathies. Our study was designed to determine if inflammatory gut lesions were also present in PsA, and if the prevalence of subclinical gut involvement was different in the subgroups of this disease. The relationship with HLA subtypes was also determined.

METHODS

Ileocolonoscopy was performed on 64 patients with PsA (37 men, 27 women).

RESULTS

Inflammatory gut lesions were found in 10 of the 64 patients (16%): in 3 of the 15 patients (20%) with oligoarthritis and in 7 of the 23 patients (30%) with axial involvement. None of the 26 patients with polyarthritis showed these lesions. The prevalence of HLA-B27, Bw62, and B17 was significantly raised in our total group of patients with PsA. HLA-B27 and Bw62 were significantly more prevalent in patients with gut inflammation, 60 and 50%, respectively.

CONCLUSION

Gut inflammation is only present in PsA subgroups that belong to the spondylarthropathy concept. This suggests that the gut plays a role in the pathogenesis of locomotor inflammation in these subgroups. The prevalence of gut inflammation in psoriatic spondylarthropathy is significantly lower than in nonpsoriatic spondylarthropathies. Consequently, not only the gut but also the skin may be a portal of entry for causative antigens in PsA.

Coculture of human articular chondrocytes with peripheral blood mononuclear cells as a model to study cytokine-mediated interactions between inflammatory cells and target cells in the rheumatoid joint

A model for the coculture of chondrocytes in gelified agarose with mononuclear cells was developed to serve as an in vitro equivalent for cytokine-mediated events at the cartilage-synovial pannus junction in destructive arthropathies. Chondrocytes cultured in agarose keep their phenotypic stability. They release cartilage-specific aggrecans into the surrounding artificial matrix. When activated with lipopolysaccharide for 1 h, mononuclear cells release Interleukin 1 beta and Tumor Necrosis Factor alpha, thereby stimulating the chondrocytes to produce Interleukin 6, to diminish incorporation of 35S into aggrecans, and to degrade these intercellular macromolecules. This coculture model is a useful tool for studying interactions between inflammatory cells and target cells. To demonstrate its usefulness, the effect of three anti-inflammatory drugs (piroxicam, sulphasalazine, and hydrocortisone) on cytokine release by mononuclear cells, and subsequently on chondrocyte aggrecan metabolism was studied. The drugs were unable to abrogate Interleukin 1 and Tumor Necrosis Factor alpha release by activated mononuclear cells. Therefore, these pharmacological agents did not protect the artificial target tissue against cytokine-mediated degradation.

Cervical spine involvement in rheumatoid arthritis: a clinical, neurological and radiological evaluation

OBJECTIVE

This study was designed to reveal any correlation between radiological signs and clinical findings of cervical spine involvement in rheumatoid arthritis (RA).

METHODS

Fifty patients with definite rheumatoid arthritis were evaluated for cervical spine involvement by a clinical neurological examination, a somatosensory evoked potential (SEP) study and different radiological techniques including tomograms, computerized tomography (CT) and magnetic resonance imaging (MRI).

RESULTS

Anterior atlantoaxial subluxation was a common finding, frequently associated with superior migration of the dens and subaxial subluxation. Two patients presented a posterior atlantoaxial subluxation due to complete erosion of the dens. Both had cervical cord compression and one of them had hypoglossal nerve paresis. The delineation of peridental pannus formation was clearly demonstrated by MRI. In the majority of cases cervical cord compression was caused by pannus formation or by vertical atlantoaxial subluxation.

CONCLUSION

The correlation between the severity of the radiological findings and the clinical-neurological signs was poor. A 4-limb SEP study appeared to be a useful screening method for the detection of cervical medullary compression.

[Viable meniscus transplantation]

The integrity of the semilunar cartilages has proved to be the best safeguard against mechanical degenerative changes. One can postulate that restoring normal congruency between the femur and tibia with intact menisci would be the ideal solution to many mechanical knee problems. Several semilunar cartilages have been transplanted with good functional results in medial and lateral compartmental meniscal disease. However, this form of chondroprotection in the load-bearing area of the femur and tibia can only be properly evaluated after 10 to 20 years of follow-up. In order to obtain functional results, meniscal allografts have to be incorporated in the knee joint by intimate meniscofemoral synovial bonding. The synovial fibroblasts must grow into the collagen meshwork of the meniscal allograft. Such ingrowth has been shown in freeze-dried and deep-frozen meniscal allografts. However, in a small number of transplants shrinking has been observed on repeat arthroscopy at 6 months. Satisfactory incorporation of meniscal allografts has been obtained with fresh allografts, but availability remains a problem when this method is used for meniscal substitution. For this reason viable meniscal allograft implantation was initiated in a series of 25 patients and the value of this method studied. The meniscal allograft can be kept in an adequate semisynthetic nutrient medium for approximately 2-3 weeks without apparent loss of viability, during which period the appropriate recipient can be selected and prepared, a thorough laboratory screening can be conducted, and the culture results and disease transmission factors can be evaluated. In this way, live transplant hazards can be avoided, resulting in a higher success rate.

An optimized method for routine HLA-B27 screening using flow cytometry

Flow cytometry and monoclonal antibodies are promising tools for HLA-antigen detection. Previous approaches have been hampered by the lack of a carefully standardized system for calibration and sample analysis. A new system for HLA-B27 screening was developed using a FACScan flow cytometer, software for automated calibration and analysis, calibration beads, and the anti-HLA-B27-FITC/anti-Leu4-PE (CD3) monoclonal antibodies. The median fluorescence channel result for the HLA-B27-FITC signal of CD3+ T lymphocytes is compared to a decision marker. Values lower than this threshold are read as HLA-B27 negative and those above are recommended for retesting with the classic microcytotoxicity assay on the presumption of HLA-B27 positivity. The anti-HLA-B27 antibody reacts with all six HLA-B27 subtypes and shows a weaker binding to HLA-B7. The screening test results were compared with those from the microcytotoxicity assay for HLA-typing in studies involving several European centers. The observed sensitivity was 100% (95% Cl:98.6-100) and the specificity was 97.4% (95% Cl: 96.4-98.3). Other performance studies verified the reproducibility and reliability of results obtained with the screening system.

Comparative and combined effects of interleukin 6, interleukin 1 beta, and tumor necrosis factor alpha on proteoglycan metabolism of human articular chondrocytes cultured in agarose

OBJECTIVE

To study the effects of recombinant tumor necrosis factor alpha (TNF-alpha), interleukin 1 beta (IL-1 beta) and interleukin 6 (IL-6) on proteoglycan metabolism of isolated chondrocytes.

METHODS

Human articular cartilage cells were cultured in agarose gel. In these culture conditions, chondrocytes keep their phenotypic stability. They release cartilage specific proteoglycans into the surrounding artificial matrix. Proteoglycan synthesis was measured by the incorporation of 35sulfate (35S).

RESULTS

TNF-alpha and IL-1 beta depressed proteoglycan synthesis and induced proteoglycan degradation. The effects of both cytokines were additive, when used in submaximal doses. No mutual induction of TNF-alpha and IL-1 beta was shown, but both cytokines stimulated the chondrocytes to release IL-6, up to 100,000 pg/ml. Equal amounts of human recombinant IL-6 did not affect proteoglycan synthesis. IL-6 did not alter proteoglycan quality, nor did it modulate the IL-1 beta activities on proteoglycan metabolism.

CONCLUSION

These findings illustrate the role of IL-1 beta and TNF-alpha in cartilage degradation and suggest that the role of the large amounts of IL-6 released in response to IL-1 in chronic arthritis is not directly protective with regard to proteoglycan metabolism.

Current concepts in psoriatic arthritis

Psoriatic arthritis is an inflammatory arthropathy associated with psoriasis and characterized by absence of rheumatoid factor. Any form of psoriasis can be complicated by joint inflammation. Four groups have been identified: pauciarticular psoriatic arthritis, psoriatic spondylitis, symmetrical polyarticular psoriatic arthritis and arthritis mutilans. The etiology of psoriatic arthritis remains unclear. Genetic, immunologic and environmental factors are thought to be important in the development of the disease. The role of cytokines and adhesion molecules in the mechanism of joint destruction is highlighted, and recent therapeutic strategies are discussed.

Gut inflammation in children with late onset pauciarticular juvenile chronic arthritis and evolution to adult spondyloarthropathy--a prospective study

Ileocolonoscopy with biopsy of the colon and terminal ileum was performed prospectively on 12 patients under age 16 with late onset juvenile chronic arthritis (JCA). Inflammatory gut lesions were seen in 9 of these 12 patients; 4 were of the acute type, 5 of the chronic type. Chronic gut inflammation was related to axial inflammatory complaints, inflammatory serum variables, thrombocytosis and sacroiliac radiological abnormalities. A 2nd ileocolonoscopy was performed on 5 of the 12 patients, and a 3rd ileocolonoscopy on 2 of these with persistent synovitis. Gut inflammation and joint inflammation were related; moreover, all 5 patients had chronic inflammatory lesions by the time of the last investigation, one presented with Crohn's disease. The 12 patients were reviewed 3 to 9 years after the first ileocolonoscopy. Four patients were in remission, including the 3 patients with initial normal gut histology. Five patients had developed ankylosing spondylitis (AS), a 6th patient possible AS. Axial inflammatory complaints, a family history of spondyloarthropathies, HLA-B27 positivity, early sacroiliac and peripheral joints radiographic changes, persistence of inflammatory serum variables, thrombocytosis and chronic inflammatory lesions on gut biopsy, are predictive factors in juveniles for evolution to AS. Late onset pauciarticular JCA represents a form of spondyloarthropathy similar to adolescent forms. Persistent gut inflammation could play a role in the pathogenesis of the disease and persistent synovitis.

Prevalence of inflammatory rheumatic diseases in an adolescent urban student population, age 12 to 18, in Belgium

In order to determine the prevalence of inflammatory rheumatic diseases in an urban secondary school student population, a questionnaire dealing with past or present joint, tendon, axial, gastrointestinal, ocular and dermatological symptoms was completed by 2,990 students of secondary schools in Antwerp and Ghent. The parents were asked to complete a questionnaire regarding the family medical history. From these 2,990 students, 524 were selected for further investigation by a rheumatology resident, who checked the answers to the first questionnaire and performed a clinical examination. Forty-one adolescents with a presumptive history or present symptoms of inflammatory rheumatic diseases were retained. These students were examined by the medial staff of the rheumatology department; if necessary, a complementary biochemical and radiological examination was performed. Five cases of definite juvenile chronic arthritis (JCA) (with polyarticular onset in 1 case and late pauciarticular onset in 4 cases) and 4 cases of presumptive late pauciarticular onset JCA were detected, resulting in a prevalence of 167 per 100,000 for definite JCA and of 301 per 100,000 for possible JCA. This prevalence rate is higher than that generally described. This method of investigation effectively allows the detection of milder and spontaneously remitting cases of JCA. It further enabled us to definite case and 4 presumptive cases of various previously undiagnosed forms of JCA.

A prospective study of patients with spondyloarthropathy with special reference to HLA-B27 and to gut histology

Ileocolonoscopy was performed on 357 patients meeting the European Spondylarthropathy Study Group criteria for spondyloarthropathy. HLA loci A, B and C were determined in all patients; HLA-B27 was detected in 196 and was absent in the 161 remaining patients. A number of clinical, laboratory and radiological variables were determined before ileocolonoscopy and compared between the HLA-B27+ and HLA-B27- patients. The HLA-B27+ patients were mainly men, with significantly more family members with spondyloarthropathies. Clinical evidence of tendinitis and uveitis was more frequently found in these patients. Like several authors, we found that these patients were more severely affected since they presented more severe radiological involvement of the sacroiliac joints. Syndesmophytes, bamboo spine and erosive joint lesions were more frequent in this group, the hip involvement being of the concentric type. In HLA-B27+ patients ankylosing spondylitis was more prevalent, while in the B27- patients enterogenic, urogenital or undifferentiated spondyloarthropathy was diagnosed. The HLA-B27- patients experienced more episodes of diarrhea, and Crohn-like inflammatory gut lesions were more frequently seen on ileocolonoscopy. In this group a number of patients probably had a form of subclinical Crohn's disease of which the locomotor symptoms were the only clinical expression.

A double-blind study to determine the duration of action of flurbiprofen in a sustained release preparation

This double-blind, placebo-controlled, parallel-group study proves that the duration of activity of a sustained-release preparation of flurbiprofen 200 mg covers a full 24 hour period. In a group of 24 patients with clinically active rheumatoid arthritis a statistically significant increase of pain was noted 37 hours after the last active dose. The increase in disease symptoms was inversely related to the plasma flurbiprofen levels and was rapidly reversed with one active dose of sustained release flurbiprofen.

Detection and identification of antinuclear autoantibodies in the serum of normal blood donors

The occurrence of antinuclear antibodies (ANA) in the serum of 485 healthy volunteer blood donors was assessed. Sixty two sera displayed nuclear immunofluorescence staining on Hep-2 cells using a polyvalent anti-Ig conjugate. In general, the titer of these antibodies was low (42/62 sera displaying a titer lower than or equal to 1:80). In only 23 sera were the ANA of the IgG isotype, which is the more disease-related immunoglobulin class of autoantibodies. In order to define the frequency of antibodies to extractable nuclear antigens and dsDNA within this population, sera were further analyzed by counterimmunoelectrophoresis. Western blot and the Crithidia luciliae assay. One serum displayed weak antids DNA reactivity; another serum had anti-SSA/Ro activity. On Western blot several patterns were found. They could not be identified with any of the available reference antisera.

T cell receptor V beta usage in rheumatoid nodules: marked oligoclonality among IL-2 expanded lymphocytes

Rheumatoid arthritis is an autoimmune disease which is characterized by chronic polyarthritis and joint destruction as well as by extra-articular manifestations, typically including the appearance of rheumatoid nodules. Although the pathogenesis of the disease is unknown, substantial evidence suggests that it is T cell-mediated. In contrast to experimental models, the disease-mediating T cells in the human situation have never been isolated or identified. We expanded T lymphocytes from human rheumatoid nodules by IL-2 stimulation and observed a marked oligoclonality among these expanded lymphocytes. This tendency towards oligoclonality was not seen in IL-2-expanded lymphocytes from peripheral blood. We hypothesize that this oligoclonal expansion reflects a clonally restricted in situ preactivation of lymphocytes and that precisely these preactivated cells are involved in the pathogenesis of the rheumatic process.

Enteropathic arthritis, uveitis, Whipple's disease, and miscellaneous spondyloarthropathies

Enteropathic arthritides, uveitis, and Whipple's disease all belong to the category of spondyloarthropathies. The exact mechanism of relationships among joint, tendon, and axial involvement in the spondyloarthropathies, and gut and eye involvement, is unsolved. Different hypotheses have been proposed to explain the role of enterogenic bacteria in interfering with the HLA system and causing inflammatory reactions in these organs. The microorganism responsible for Whipple's disease (Tropheryma whippelii) has been identified by sequencing the largest part of a bacterial 16S ribosomal RNA, followed by polymerase chain reaction amplification. Late-onset pauciarticular juvenile chronic arthritis should be included in the category of the spondyloarthropathies. New cases of ankylosing spondylitis associated with diffuse idiopathic skeletal hyperostosis have been reported.