[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.

[Reactive Yersinia arthritis]

Yersinia enterocolitica is the cause of acute enteritis in 2 to 3 per cent of cases. In adults it can be a "trigger" of reactive arthritis. Reactive arthritis is characterised by the appearance of sterile arthritis immediately after or during the infection outside the locomotor apparatus. Antibodies for 03 serotype were examined in Yersinia serum in hospitalized patients with the clinical picture of reactive arthritis, because Yersinia, as an intestinal infection provoked by this serotype, is usually the "trigger" of Yersinia reactive arthritis. The antibody titre of 1/160 was found in 33.7 per cent of examined 70 patients, and in 5.8 per cent of that in the control group. Clinical manifestations of reactive arthritis in the group of patients with Yersinia positive antibodies were examined. They were compared with group of patients with Yersinia negative antibodies in the serum.

Antibodies against Yersinia enterocolitica in patients with Reiter's syndrome

Reiter's syndrome can be induced by several different bacteria. A frequent cause in Finland is Yersinia enterocolitica serotypes 03 and 09, but these strains are rarely found in the United States. Although this does not exclude the possibility that U.S. patients with Reiter's syndrome have been infected with Yersinia, it is more likely that they develop Reiter's syndrome as a consequence of infection by non-Yersinia arthritis-causing organisms that share certain determinants with Yersinia organisms. We used radioimmunoprecipitation and sodium dodecyl sulfate-polyacrylamide gel electrophoresis to analyze the serum antibodies against iodine 125-labeled, detergent-solubilized serotype 03 Y. enterocolitica. Our results demonstrated that most serum samples of United States subjects precipitate three to five radioactively labeled Yersinia molecules. A Yersinia antigen of 88K appeared to be of possible discriminatory value. Protein A-reacting antibodies directed against this antigen were detected in only two of twenty-five patients with rheumatoid arthritis and only seven of 44 normal control subjects, compared with 18 of 27 patients with Reiter's syndrome (p less than 0.005) and eight of 16 patients with ankylosing spondylitis (p less than 0.01). Our results indicate that, despite the relatively rare occurrence of Y. enterocolitica serotypes 03 and 09 infection in the United States, examination of the immune response to the serotype 03 Yersinia strain is a promising approach to the study of Reiter's syndrome in the United States.

[Surface structure of the elementary bodies of Chlamydia]

The surface structure of chlamydial elementary bodies (strain PL-B577 causing enzootic abortion of ewes and strain CP-1 isolated from a patient with Reiter's syndrome), concentrated directly on the grid of an electron microscope, was studied by the method of negative staining. The surface of the cell wall of chlamydial elementary bodies in the preparations of crude cultures, not subjected to enzymatic purification, was formed by spherical subunits 4 nm in diameter. The surface of the cell wall of elementary bodies was found to have projections 10-20 nm long and 3-4 nm in diameter, as well as annular structures 15-22 nm in diameter in hexagonal arrangement, spaced at 45 nm and probably traversed by these projections. The number of such structures in a group was 12-15. These data correspond to the model representing the structure of the surface of chlamydiae, which was proposed by Matsumoto in 1979.

Chlamydia trachomatis infections in men with Reiter's syndrome

Chlamydia trachomatis was isolated from 9 of 19 men with acute, nondiarrheal Reiter's syndrome who had not recently taken antibiotics. None of 8 untreated men with other forms of arthritis were infected with this organism. Chlamydia trachomatis-specific antibody titers and cellular immune responses were positive significantly more often in 35 treated and untreated men with acute, nondiarrheal Reiter's syndrome than in 7 men with diarrhea-associated Reiter's syndrome and 8 men with other forms of arthritis. Mean peak chlamydial antibody titers and mean lymphocyte transformation stimulation indices were significantly higher in C. trachomatis-infected men with Reiter's syndrome than in C. trachomatis-infected men with uncomplicated nongonococcal urethritis. We concluded that C. trachomatis is capable of "triggering" Reiter's syndrome in susceptible men and that an exaggerated immune response to this organism may play a role in the pathogenesis of the disease.

Isolation of Chlamydia trachomatis from prostatic fluid in association with inflammatory joint or eye disease

We describe two patients, one with peripheral arthritis, sacro-iliitis, positive HLA B27, and autoantibodies to smooth muscle and gastric parietal cell; the other with aphthoid ulcers, geographical tongue, conjunctivitis, anterior uveitis, peripheral arthralgia, and diarrhoea with distal proctocolitis. Neither patient would have been diagnosed as having urethritis on the basis of accepted microscopic criteria. In both patients, however, Chlamydia trachomatis was isolated from the prostatic fluid, but not the urethra.

Musculoskeletal involvements in female sexual partners of males with Reiter's syndrome

To examine the occurrence of signs and symptoms of Reiter's syndrome (RS) in female sexual partners of males with RS we have investigated 43 female consorts of 42 males, originating from 72 consecutive patients suffering from RS or suspicion of RS (SRS). Anamnestic mono-, oligo- or polyarthritis occurred in 14 of the 43 females (32,6%) as compared to 28 out of 311 randomly selected interviewed controls (9,0%). Five of the 43 females had RS and 7 had SRS, (27,9%). However, the diagnosis could have been possible with only anamnestic information in 6 (14%) as compared to 7 out of 311 controls (2,3%). Taking into consideration the 30 males whose sexual partners were not investigated, the theoretically counted values still differ significantly from those of the controls (p less than 0.01). A history of urogenital and, on the other hand, nasopharyngeal or pulmonary infections involvements preceded equally frequently the first or further joint attacks. Evidence of chlamydial infection was found in 53,5% (32/43) of the partners while Yersinia antibodies measured by ELISA occurred with the same frequency as among healthy blood donors. We would like to stress the importance of various infectious involvements, especially sexually transmitted diseases, as etiological agents in joint attacks in females who are sexual partners of males with RS.

Urogenital involvements in female sexual partners of males with Reiter's syndrome

The occurrence of urogenital involvements in female sexual partners of males with Reiter's syndrome (RS) or suspicion of RS (SRS) was studied. The possible etiological role of Chlamydia trachomatis (Ct) was demonstrated by isolation and by immunofluorescence (IF) serology. Evidence of chlamydial infection (positive isolation and/or IF titre greater than or equal to 64) was found in 35 out of 56 (62,5%) males with RS and in 9 out of 16 (56,3%) males with SRS. 43 female sexual partners of these men were studied. Evidence of present or past chlamydial infection was demonstrated in 23 of these 43 females (53,5%). This was a significantly higher frequency than that evidenced among controls studied, 14/77 verified serologically and 3/81 by isolation, p less than 0.0025 and p less than 0.005, respectively. A history of dysuria occurred in 10 out of 43 female sexual partners and in only 20 out of 364 interviewed randomly selected controls (p less than 0.00025). Abnormal urinary findings were also more frequent among the sexual partners than among the controls (p less than 0.025). The results emphasize the role of Ct as a triggering factor in RS and stress the importance of urogenital investigations among couples with RS.

[Fiessinger-Leroy-Reiter's syndrome : serological conversion for Yersinia enterocolitica type 9, positive serodiagnosis for Shigella flexneri and Chlamydia]

A case of Reiter disease in a HLA B27 positive man with urethritis followed by polyarthritis is reported. During the disease, serologic conversion for Yersinia enterocolitica type 9 was detected as well as positive serologic tests for Shigella flexneri and Chlamydia. The features of reactive arthritis related to Yersinia and the etiologies of Reiter disease are recalled.

Bacteriological findings in 25 patients with Reiter's syndrome (reactive arthritis)

Extensive bacteriological testing was performed in 25 patients with complete or incomplete Reiter's syndrome. In 21 patients (84%), evidence of antecedent infection was found, based on culture and/or serological findings. Thus, infection with Chlamydia trachomatis (17 patients), Yersinia enterocolitica, serotype 3 (4 patients), and Campylobacter jejuni (1 patient) was identified.

[Rheumatism and urogenital infection]

The antiinfectious treatment of rheumatic diseases is certainly very old, but it has gained increased significance as a result of new bacteriological and immunological findings. Urogenital infection as a possible trigger mechanism in reactive arthritides and ankylosing spondylitis was investigated particularly thoroughly. Many experimental, immunological and clinical results indicate a pathogenetic role of infections with chlamydia or mycoplasma in inflammatory rheumatic diseases. However, numerous tests on cultures proved negative, and many serological-immunological findings are inconsistent. The "link" between urogenital infection and rheumatic diseases is still unknown. Of particular interest are the relations between chlamydial prostatitis and ankylosing spondylitis. Earlier findings on the induction of osteogenesis from undifferentiated connective tissue cells by epithelial cells from the prostate could be a basis for further research.

[Etiologic aspects of Reiter syndrome. Role of yersinial infections (author's transl)]

Reiter syndrome occurs as a reaction to various infections, either by intracellular microorganisms (Chlamydia, Mlycoplasma) or by intestinal bacteria (dysenteric bacilli, Salmonella, Campylobacter, Klebsiella, Yersinia). Four personal observations of Reiter syndrome following yersinial infections (Yersinia enterocolitis in two cases and Yersinia pseudotuberculosis in the two other cases) are reported. Data concerning the yersinial etiology of Reiter syndrome are reviewed.

Mycoplasmal arthritis in man

Naturally occurring mycoplasmal arthritis in various animals species and the ability to induce mycoplasmal arthritis experimentally have been the main reasons for searching for evidence of mycoplasmal infection in the joints of patients with rheumatoid arthritis. However, reliable reports of the isolation of mycoplasmas from synovial fluids and tissue of such patients do not exist, and measurements of specific antibodies have not proved rewarding. There is some evidence that infection by Mycoplasma pneumoniae occasionally has an arthritic sequela, although the microorganism has not been isolated from the joints of immunocompetent patients. In contrast, this and other mycoplasmas, including ureaplasmas, have been isolated from the arthritic joints of several hypogammaglobulinemic patients, and there is some evidence to indicate that the organisms are responsible for the disease. A relationship between mycoplasmas and sexually acquired Reiter's disease is unproven, but deserves thorough investigation in view of the link between ureaplasmas and nongonococcal urethritis. Furthermore, as new media and techniques become available, the possibility the mycoplasmas may have some role in rheumatoid arthritis should be reappraised.

Chlamydial isolations and serology in Reiter's syndrome

To assess the possible etiological link between genital infection due to Chlamydia trachomatis (CT) and Reiter's syndrome (RS) 24 men and 2 women with typical RS and 5 women with signs suggestive of RS (SRS) were examined. CT was isolated by irradiated McCoy cell culture technique and chlamydial indirect immunofluorescence serology was applied. Chlamydial isolation from the urethra was positive in 5 patients as well as from synovial fluid of the knee in one man. The serology was positive (titre greater than or equal to 64) in 17 (55%) of the 31 patients, including all 7 women. HLA-B27 antigen was detected in only 15 of 27 patients (55%). All except one of the 12 patients negative for HLA-B27 antigen had positive chlamydial serology. Among the patients were two married couples, both negative for B27 antigen and positive for chlamydial serology. The case report of the one couple, in which the wife had positive urethral chlamydial isolation, is given. Sexually acquired RS might easily be overlooked in women and be misdiagnosed as seronegative arthritis. The classification for RS associated with CT infection is discussed. The simultaneous treatment of the infection in sexual partners is emphasized.

[Ultrastructure of the initial stages of interaction between halprowiae (Chlamydiae) and host cells]

The initial stages of the interaction of halprowiae (strain CP-1), isolated in Reiter's syndrome, with a monolayer culture of cells L-929 were studied. The electron-microscopic examination of the cells every 2 hours during the first 24 hours after the inoculation allowed to follow the processes of adsorption, endocytosis of elementary bodies and their transformation into reticulate bodies by the "decondensation" of nucleoid, which indicated the beginning of the vegetative (reproductive) stage of the developmental cycle. During all the periods of observation halprowiae were enclosed into the membranes of phagocytic vacuoles formed by host cells. Besides, in other vacuoles (probably, phagolysosomes) halprowiae at various stages of destruction could be observed. 8--10 hours after inoculation the phagosomes containing reticulate bodies began to merge, thus forming an inoculation the phagosomes containing reticulate bodies began to merge, thus forming an intracytoplasmic inclusion. In this inclusion a new generation of the agent was formed by binary-like fission. At the beginning of the vegetative stage halprowiae seem to be highly sensitive to the action of exo- and endogenic factors which may cause their L-transformation. Depending on the reaction of the host cell at the initial stages of interaction with halprowiae, 3 ways of such interaction are seemingly possible: developmental cycle, destruction in phagolysosomes. L-transformation.

Chlamydial infections. Microbiological, clinical and diagnostic aspects

The agent of trachoma, originally regarded as a virus, was described by Halberstadter and von Prowacek in 1907. Since then, studies on Chlamydiae have shown that they are procaryocytic organisms that infect eucaryocytic cells as obligate intracellular parasites. Infections caused by these pathogenic agents occur in a wide range of avian and mammalian species. Chlamydiae are also responsible for several diseases in man, and there is a rapidly growing awareness of their public health significance. The aims of this review are to describe the microbiology and laboratory diagnosis of Chlamydiae and to reflect the clinical spectrum of human chlamydial diseases.

[Irradiated cell cultures applied to group A "chlamydiae" isolation (author's transl)]

The irradiated Mc Coy cell cultures method modified by Darougar et al. has been used to investigate the frequency of Chlamydiae in non-specific genital tract disease, in Reiter's disease and in patients suffering from conjonctivits associated with non-specific urethritis. Isolates were obtained from 104 men of the 660 suffering from acute urethritis, and from 18 men of the 67 suffering from conjonctivitis associated with urethritis. Fourteen female sexual contacts of these men were tested: Chlamydiae was isolated from 9. Seven patients suffering from acute Reiter's disease were tested: Chlamydiae was isolated from 4. These patients were tested by complement fixation and titers of 1/8 or more were only obtained in the 4 isolated positive cases, the three other cases remaining negative. Isolates of Chlamydiae were obtained from 10 women of the 67 women suffering from exocervicitis. No isolate was obtained, from 27 control patients.

[Morphology of Halprowia (Chlamydia) isolated in Reiter's syndrome]

Morphology and ultrastructure of Halprowia arthritidis, strain SR-1 (HSR), isolated from the synovial fluid of a patient with Reiter's syndrome, was studied in the membranes of the yolk sacs of the developing chick embryos and the L-cell culture. In acridine orange staining for light and fluorescent microscopy there was revealed intracellular cytoplasmic inclusions containing HSR structures at various stages of its reproduction characteristic of halprowia (chlamydia). The direct immunofluorescent method demonstrated the presence of a characteristic HSR antigen not only in the developed inclusions, but also at the early stages of infection, when the morphological HSR structures could not be found by light microscopy. The ultrastructure of the HSR inclusions and forms in the cycle of development (of the initial and elementary bodies) of the SR-1 strain was typical of other halprowia. A peculiar structure of a complex of cell wall and cytoplasmic membrane of the elementary body was described. Taking into consideration the biological characteristics of HSR revealed earlier it can be considered to be a typical representative of Halprowiales s. Chlamydiales. The data obtained on other halprowia, pointing out the fact that criteria of compactness and diffuseness of inclusions, the presence of absence of glycogen in the inclusions could not serve as taxonomic signs in classification of halrpowia, were confirmed on a model of the SR-1 studied.

Failure to show mycoplasmas and cytopathogenic virus in rheumatoid arthritis

Synovial needle biopsies, joint aspirates, and joint tissue obtained at open operation from 41 cases of rheumatoid arthritis were inoculated onto PPLO media, L-form medium, and cell cultures for the isolation of mycoplasmas, L-form bacteria, and viruses. Medium suitable for the isolation of 'T' strain mycoplasmas was not employed. No mycoplasmas, L-form bacteria, or cytopathogenic viruses were shown. Similar specimens from nine patients diagnosed as having Reiter's disease were examined in a like manner and yielded only one Mycoplasma hominis type 1 isolate from a knee joint biopsy. It is concluded that known strains of mycoplasma and bacterial L-forms do not play a direct role in early and established cases of rheumatoid arthritis. Some of the cell cultures used in this study contained mycoplasma contaminants. Bacterial contaminants were also encountered in occasional batches of L-form medium.

Reiter's disease in three boys

Three cases of Reiter's disease occurring in boys under the age of 16 are reported. One of these presented with a Salmonella enteritidis diarrhoea. This conforms to the 'dysenteric' form of Reiter's disease usually seen in Europe and rarely reported in England. Another presented with a monarticular arthritis of the knee, and the third has developed a chronic relapsing erosive arthritis as a result of sexually acquired Reiter's disease--an occurrence not previously reported in this age group. We draw attention to the frequency of diarrhoea in these children and the sex incidence of 1 female to 4--5 males, which agrees more with Reiter's disease of dysenteric origin than that acquired venereally.

[Study of the sensitivity of Halprowia (microorganisms of the OLT group) isolated in joint pathology to antibiotics and sodium sulfapyridazine in in ovo experiments]

Sensitivity to antibiotics and sodium sulfapiridasin of the microorganisms of group OLT, i. e. Halprowia and Chlamidia isolated from the joint fluid and synovial of the affected joints in patients with rheumatoid or non-specific infectious arthritis and Raiter syndrome was studied in ovo. The data provided determination of the spectrum of their sensitivity to various drugs. The antibiotics of the tetracycline group, i. e. olemorphocycline, tetracycline and rondomycin were shown to have the highest inhibitory effect. Penicillin and ampicillin only delayed the death of the infected embryons. As for kanamycin and streptomycin used in the doses tested, the agents were not sensitive to them. The isolates were also resistant to sodium sulfapiridasin which once more confirmed the questionable value of this criterion for differentiation of Halprowia.

Virological studies in Reiter's disease

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