The role of pregnancy in the course and aetiology of rheumatoid arthritis

Pathogenesis and therapy of rheumatoid arthritis

Rheumatoid arthritis is a chronic disabling disease affecting at least 1% of the population on a worldwide basis. Research aimed at understanding the pathogenesis of this disease led to the identification of TNFalpha as a major pro-inflammatory cytokine expressed in the inflamed joints of patients with rheumatoid arthritis. Subsequently, in vitro studies provided evidence to suggest that TNFalpha played an important role in driving the expression of additional pro-inflammatory cytokines, such as IL-1, GM-CSF, IL-6, and IL-8, in synovial cell cultures. Another important finding that confirmed the pathological significance of TNFalpha was that mice genetically engineered to overexpress TNFalpha spontaneously developed arthritis. Subsequently, the therapeutic effect TNFalpha blockade was tested in animal models prior to clinical trials in human patients, which provided unequivocal verification of the validity of TNFalpha as a therapeutic target. Anti-TNFalpha therapy is now accepted as a fully-validated treatment modality for rheumatoid arthritis.

Ex vivo effect of estrogen and progesterone compared with dexamethasone on cell-mediated immunity of HIV-infected and uninfected subjects

To define the effect of estrogen and progesterone concentrations achieved during hormonal contraceptive therapy (HCT) on cell-mediated immunity (CMI) of HIV-infected and uninfected subjects, peripheral blood mononuclear cells (PBMCs) from varicella-zoster virus (VZV)-seropositive individuals were treated with 0.1 ng/mL of estradiol, 33 ng/mL of norgestrel, and 13 ng/mL of dexamethasone and tested for VZV CMI. Estrogen and progesterone decreased VZV lymphocyte proliferation and T helper (Th) 1/inflammatory cytokine secretion, albeit less than dexamethasone. Progesterone decreased the expression of CD69 activation marker on CD8 and CD14 cells and increased the expression of Fas ligand (CD178) on CD14 monocytes, suggesting that induction of apoptosis may contribute to the inhibitory effect of this hormone. Cytokine production of separated CD4, CD8, and CD14 cells confirmed the effect of progesterone on all 3 cellular types, whereas the effect of estrogen was restricted to CD14 monocytes. The estrogen- and progesterone-mediated inhibition of Th1/inflammatory cytokines was greater in HIV-infected subjects (35% decrease for both hormones) compared with uninfected subjects (12% and 19% for estrogen and progesterone, respectively), whereas the effect on proliferation and PBMC phenotype did not differ by HIV status. Overall, HCT concentrations of estrogen and progesterone downregulated ex vivo VZV CMI of HIV-infected and uninfected subjects.

The Immunology of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is represents the most common chronic inflammatory joint disease and is still a major medical challenge because of unsolved issues related to the etiologic and pathogenetic questions. Intensive research has been conducted over the last years that focused on the inappropriate activation of the immune system: although T cells have long been deemed to play a central role in the origin and propagation of joint inflammation, data accumulated so far have widened this perspective recognizing the contribution of other cells, as well as the major histocompatibility complex class II proteins and a composite set of costimulatory signals responsible for the production of proinflammatory cytokines and other soluble mediators implicated in tissue destruction typical of the disease. This paper will provide an insight into the immune system in RA, dissecting cellular and humoral aspects both in serum and in synovium of patients.

Castration of male C57L/J mice increases susceptibility and estrogen treatment restores resistance to Theiler's virus-induced demyelinating disease

Intracerebral inoculation of Theiler's murine encephalomyelitis virus (TMEV) results in immune-mediated demyelination in selective mouse strains. We have previously demonstrated that the males of C57L mice are significantly more susceptible to TMEV-induced demyelinating disease. To assess further the hormonal influence for this gender-associated differential susceptibility, estrogen-treated, castrated C57L mice were infected with TMEV and compared with sham-operated and/or placebo-treated mice. Interestingly, castration further elevated the susceptibility to virally induced demyelinating disease compared with sham-castrated control mice, and prolonged treatment of castrated mice with estrogen restored the resistance to the level of control mice. These results strongly suggest that sex hormone levels contribute to the gender-biased susceptibility to TMEV-induced demyelinating disease. Mice treated with estrogen showed a significantly decreased level of virus-specific Th1 responses both in the periphery and in the CNS. In addition, in vitro estrogen treatment was able to inhibit viral replication directly in macrophages, consistent with the lower level of viral RNA in microglia/macrophages in the CNS from castrated estrogen-treated mice compared with controls. Also, estrogen treatment inhibited VCAM-1 expression induced by tumor necrosis factor-alpha in cerebral vascular endothelial (CVE) cells via inhibition of nuclear factor-kappaB (NFkappaB), which is produced in various glial cells upon TMEV infection. Overall, estrogen treatment appears to exert its effects on viral replication, induction of immune responses, as well as infiltration of activated immune cells into the CNS via inhibition of NFkappaB function.

[Pregnancy in patients with rheumatoid arthritis and inflammatory spondylarthropathies]

The activity of a rheumatic disease can be influenced by pregnancy and puerperium. Prospective studies have shown an improvement in joint involvement in rheumatoid arthritis in two thirds to three quarters of pregnancies. After birth, an exacerbation is common. In spondylarthropathies there is no relevant change in disease activity. The fetal outcome is not impaired in patients with rheumatoid arthritis and inflammatory spondylarthropathies. Every pregnancy in women with a rheumatic disease should be considered as high-risk, and such pregnancies require close collaboration between rheumatologists and obstetricians.

Novel approaches to treatment of autoimmune neuroinflammation and lessons for drug development

Drug development, and especially that intended for central nervous system (CNS) disorders, still poses a challenge. We investigated both the use of bifunctional compounds designed for multiple targeting and enhanced CNS permeability, and of recombinant alpha-fetoprotein (AFP), a natural pregnancy-associated immunomodulating protein for the treatment of CNS inflammation. Bifunctional compounds showed a novel pharmacokinetic profile due to the conjugation, yet retained, and even improved pharmacodynamics. AFP was well tolerated and decreased various aspects of neuroinflammation, including disease severity, axonal loss and damage, T-cell reactivity, and antigen presentation. Our results show that both strategies may serve as future drug modalities.

A randomised, double-blind, placebo-controlled trial of a recombinant version of human alpha-fetoprotein (MM-093) in patients with active rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) tends to remit during pregnancy, with more patients achieving remission in the third trimester, coinciding with an increase in levels of alpha-fetoprotein (AFP). In vitro and animal studies have shown that AFP has immunomodulatory properties. MM-093 is a non-glycosylated, recombinant version of human AFP.

OBJECTIVE

To assess the safety, tolerability and clinical effects of MM-093 during a 12-week, randomised, double-blind, placebo-controlled study.

METHODS

12 patients with RA, who had active disease and were on stable doses of methotrexate, received weekly subcutaneous injections of placebo or 21 mg of MM-093. Assessments were carried out at baseline and weekly thereafter.

RESULTS

Baseline characteristics were similar in both groups. There was one dropout in the placebo group, due to flare of disease. Treatment with MM-093 was well tolerated. No serious adverse event was observed. By day 85, MM-093 produced a significant mean improvement from baseline in Disease Activity Score 28 (DAS28; 0.913 vs 0.008, p = 0.033) and patient's global assessment (28.9% vs -36.3%, p = 0.02) compared with placebo.

CONCLUSION

This is the first randomised, controlled trial of MM-093, a recombinant version of human AFP, in patients with RA. MM-093 was well tolerated. Evidence of efficacy was observed, suggesting that MM-093 may have therapeutic potential in RA.

Specific Isolation of Placenta-Derived Exosomes from the Circulation of Pregnant Women and Their Immunoregulatory Consequences

PROBLEM

One immunoregulatory pathway receiving little attention is placental exosome release. In normal pregnancy, as factors linked with early immunomodulation decline, placental exosomes become critical in modulating T-cell activation, suppressing effector T cells by enhancing lymphocyte apoptosis and CD3-zeta loss.

METHOD OF STUDY

Placental exosomes were specifically isolated from the maternal peripheral circulation by a chromatographic/immunosorbent procedure. Exosomal suppression of T-cell signaling molecules on unfractionated T cells and T subsets was analyzed by Western immunoblot. The role of Fas ligand (FasL) was defined by use of Fas-blocking antibody.

RESULTS

While exosomes of lymphoid origin could be demonstrated in all women, placenta-derived exosomes were only identified in pregnant patients. Placental exosomes suppressed T-cell expression of CD3-zeta and JAK3, while inducing SOCS-2. This downregulation of CD3-zeta was partially reversed by pre-incubating T cells with ZB4 antibody. Using T subsets, the level of CD3-zeta on CD8+ cells was inhibited 1.43-fold more than in CD4+ cells. On CD4+ CD25+ cells, CD3-zeta was not significantly inhibited.

CONCLUSION

Placental exosomes suppressed T-cell signaling components; however, while exosomal FasL is an important contributor, it does not appear to be the sole mediator. The additional expression of PD-L1 may explain immunoregulatory consequences of exosomes with low or absent FasL.

T cell activation as starter and motor of rheumatic inflammation

Rheumatic inflammation is driven by sustained specific immunity against self-antigens, resulting in local inflammation and cellular infiltration and, subsequently, in tissue damage. Although the specific autoantigen(s) eliciting the detrimental immune reactions in rheumatic diseases have rarely been defined, it has become clear that the mechanisms resulting in the destruction of tissue and the loss of organ function during the course of the diseases are essentially the same as in protective immunity against invasive microorganisms. Of fundamental importance in initiating, controlling, and driving these specific immune responses are CD4 T cells. Currently available data provide compelling evidence for a major role of CD4 T cells in the initiation and perpetuation of chronic rheumatic inflammation. Consequently, T cell-directed therapies have been employed with substantial clinical success in the treatment of rheumatic diseases. Here, we review current knowledge based on which CD4 T cells can be implicated as the motor of rheumatic inflammation.

Potential scope of action of tissue kallikreins in CNS immune-mediated disease

The objective of this study was to define the potential scope of action of tissue kallikreins in T cell-mediated disease of the CNS. We demonstrate quantitatively the differential expression of all 15 human tissue kallikreins within brain, spinal cord and immune compartments. In human Jurkat T cells we demonstrate differential regulation of select kallikreins by CD3 receptor, Concanavilin A (Con A), interleukin 2 (IL2), and lipopolysaccharide (LPS)-mediated activation and by exposure to steroid hormones, dexamethasone, norgestrel, androstan and estradiol. The patterns of co-expression and co-regulation described point to novel effector roles for select tissue kallikreins in neurological disorders involving T cells, such as multiple sclerosis.

Patterns of exacerbations of chronic non-infectious uveitis in pregnancy and puerperium

PURPOSE

To determine patterns of exacerbations of recurrent non-infectious uveitis during pregnancy and puerperium.

DESIGN

Retrospective cohort study.

METHODS

The medical records of 32 women with a history of chronic non-infectious uveitis, who were pregnant during their follow-up at the Ocular Immunology and Uveitis Service of the Massachusetts Eye and Ear Infirmary, from 1983 through 2003, were reviewed. The uveitis relapse rate during pregnancy was compared to the relapse rate during pregnancy-free periods in these women and to the relapse rate in a control group of women of childbearing age with recurrent non-infectious uveitis.

RESULTS

Among the 32 women who were pregnant during follow-up (40 pregnancies), the rate of flare-ups during pregnancy (1.0 recurrence per year) was lower than that observed during non-pregnant periods (2.4 per year; p<0.001) and lower than that observed in the non-pregnant control group (3.1 per year; p<0.001). Flare-ups were most frequent in the first trimester of pregnancy and decreased markedly in the second and third trimesters (2.3, 0.5, and 0.4 recurrences per year, respectively; p<0.001).

CONCLUSIONS

Pregnancy is associated with lower numbers of flare-ups of non-infectious uveitis compared to the non-pregnant state. If flare-ups do occur during pregnancy, they happen predominantly in the first trimester.

Genetic variation associated with preterm birth: a HuGE review

Preterm birth (PTB) is a major public health concern because of its high prevalence, associated mortality and morbidity, and expense from both short-term hospitalization and long-term disability. In 2002, 11.9% of U.S. births occurred before 37 weeks gestation. Epidemiologic studies have identified many demographic, behavioral, and medical characteristics associated with PTB risk. In addition, recent evidence indicates a role for genetic susceptibility. We reviewed 18 studies published before June 1, 2004, that examined associations between polymorphisms in the maternal or fetal genome and PTB risk. Studies of a polymorphism in tumor necrosis factor-alpha, a proinflammatory cytokine, showed the most consistent increase in the risk of PTB. Environmental factors such as infection, stress, and obesity, which activate inflammatory pathways, have been associated with PTB, suggesting that environmental and genetic risk factors might operate and interact through related pathways. This review highlights maternal and fetal genetic susceptibilities to PTB, the potential relationships with environmental risk factors, and the need for additional well-designed studies of this critical public health problem.

Amelioration of autoimmune neuroinflammation by recombinant human alpha-fetoprotein

Alpha-fetoprotein (AFP) is a 65-kDa oncofetal glycoprotein found in fetal and maternal fluids during pregnancy. Clinical remissions during pregnancy have been observed in several autoimmune diseases, such as multiple sclerosis (MS), and have been attributed to the presence of pregnancy-associated natural immune-reactive substances, including AFP which can exert immunomodulatory effects on immune cells. In this study, we tested the effect of recombinant human AFP (rhAFP) isolated from transgenic goats, which contain the genomic DNA for hAFP, on experimental autoimmune encephalomyelitis (EAE), the animal model used for the study of MS. RhAFP treatment markedly improved the clinical manifestations of EAE, preventing central nervous system (CNS) inflammation and axonal degeneration. RhAFP exerted a broad immunomodulating activity, influencing the various populations of immune cells. T cells from treated mice had significantly reduced activity towards the encephalitogenic peptide of myelin oligodendrocyte glycoprotein (MOG), exhibiting less proliferation and reduced Th1 cytokine secretion. Moreover, AFP affected the humoral response, causing an inhibition in MOG-specific antibody production. The expression of CD11b, MHC class II and the chemokine receptor CCR5 was also down-regulated. This is the first study demonstrating reduced inflammation and axonal damage exerted by recombinant AFP. In light of our findings, rhAFP may serve as a potential candidate for treatment of MS and other autoimmune diseases.

Ocular toxoplasmosis in pregnancy

PURPOSE

To describe the course of ocular toxoplasmosis during pregnancy.

METHODS

This study was a retrospective, non-comparative case series of four pregnant women who were treated for ocular toxoplasmosis during pregnancy.

RESULTS

All of the participants had severe and treatment-resistant toxoplasmic retinochoroiditis during pregnancy, leaving three of them with decreased visual acuity in spite of aggressive therapy. Delivery of the infant appeared to help the recovery in two patients.

CONCLUSIONS

Pregnant state may provoke the recurrence of ocular toxoplasmosis.

Childbearing decisions and family size among women with rheumatoid arthritis

OBJECTIVE

To estimate childbearing trends relative to age and stage of family development and to report on childbearing decisions among women with rheumatoid arthritis (RA).

METHODS

Information about childbearing history and decisions was collected through structured telephone interviews with an existing cohort of married women with RA (n = 411), and was examined according to women's age at RA diagnosis and when RA was diagnosed relative to when children were born.

RESULTS

Almost all women (91.2%) reported at least 1 pregnancy; the majority (85.4%) reported at least 1 live birth. The odds of any pregnancy or a live birth were not significantly different according to age at diagnosis; however, women diagnosed at age < or =18 had fewer pregnancies and fewer children. Similarly, women diagnosed with RA prior to the birth of their first child had the fewest pregnancies and children. Few women (8%) reported being advised to limit family size, although approximately 20% reported that RA had affected their childbearing decisions. Being advised to limit family size was associated with fewer pregnancies and fewer children (P < 0.0001). Consideration of RA in childbearing decisions was more common among women diagnosed with RA at an early age. Women who reported that RA affected childbearing decisions were not less likely to have any pregnancy or any children, but had significantly fewer pregnancies and children.

CONCLUSION

Lower birth rates among women with RA may at least in part reflect choices by women to limit family sizes. Future research into the link between RA and fertility should take women's childbearing choices into account.

Transaldolase is part of a supramolecular complex containing glucose-6-phosphate dehydrogenase in human neutrophils that undergoes retrograde trafficking during pregnancy

Previous studies have shown that glucose-6-phosphate dehydrogenase (G6PDase) and 6-phosphogluconate dehydrogenase form a supramolecular complex in human neutrophils that undergoes retrograde trafficking in cells from pregnant women, but anterograde trafficking in cells from nonpregnant individuals. Using fluorescence resonance energy transfer techniques, we now demonstrate that transaldolase (TALase), a key regulatory enzyme in the nonoxidative branch of the hexose monophosphate shunt, is in close physical proximity with G6PDase, but not with lactate dehydrogenase, thus suggesting the formation of a TALase-G6PDase complex. Moreover, immunofluorescence microscopy demonstrated that TALase undergoes anterograde trafficking in neutrophils from nonpregnant individuals, whereas retrograde trafficking is found during pregnancy. However, pregnancy did not affect lactate dehydrogenase distribution. Colchicine treatment blocked the retrograde distribution of TALase, suggesting that microtubules are involved in TALase trafficking. We suggest that TALase is part of a supramolecular hexose monophosphate shunt complex, which likely increases the efficiency of the shunt via substrate channeling. We further suggest that TALase's retrograde motion contributes to uncoupling the shunt from its source of glucose-6-phosphate at the plasma membrane, thereby blunting nicotinamide adenine dinucleotide phosphate (reduced form) production and downstream oxidant production by neutrophils.

The role of the T cell in autoimmune inflammation

T cells, in particular CD4⁺ T cells, have been implicated in mediating many aspects of autoimmune inflammation. However, current evidence suggests that the role played by CD4⁺ T cells in the development of rheumatoid inflammation exceeds that of activated proinflammatory T-helper (Th)1 effector cells that drive the chronic autoimmune response. Subsets of CD4⁺ T cells with regulatory capacity, such as CD25⁺ regulatory T (Treg) cells and Th2 cells, have been identified, and recent observations suggest that in rheumatoid arthritis the function of these regulatory T cells is severely impaired. Thus, in rheumatoid arthritis, defective regulatory mechanisms might allow the breakdown of peripheral tolerance, after which the detrimental Th1-driven immune response evolves and proceeds to chronic inflammation. Here, we review the functional abnormalities and the contribution of different T cell subsets to rheumatoid inflammation.

Estrogen as an immunomodulator

Estrogen's role in the sex differences observed in autoimmune diseases such as systemic lupus, multiple sclerosis, and rheumatoid arthritis have remained unclear. Complicating the understanding of the immunomodulatory effects of estrogen are (1) the effects of estrogen on multiple components of the immune response; (2) its varied effects on different systems in which it appears pro-autoimmune, as in murine lupus, or anti-inflammatory, as in EAE; and (3) its effects on other hormones which are potentially immunomodulatory. Recent reports have shed light on the role of estrogen in the modulation of lymphocyte survival and expansion and in the elaboration of Th1 versus Th2 cytokines and on the mechanisms by which estrogen can activate via multiple signaling and genomic pathways in immune cells.

Purification and characterization of a recombinant version of human α-fetoprotein expressed in the milk of transgenic goats

Alpha-Fetoprotein (AFP) is a 68 kDa glycoprotein expressed at high levels by the fetal liver and yolk with transcription repressed to very low levels after birth. Transfer of fetal AFP through the placenta into the circulation of the mother is correlated with remission of rheumatoid arthritis, multiple sclerosis, and other autoimmune disorders. AFP is therefore under development as a biopharmaceutical for the treatment of autoimmune diseases. The clinical evaluation of AFP requires the production of hundreds of grams of highly purified and biologically active protein. We have produced goats that express a form of the human AFP transgene under the control of the beta-casein promoter. In this form of rhAFP, the single N-linked glycosylation site was removed by mutagenesis (N233Q). Here, we describe a purification protocol for this recombinant human (rh)AFP from the milk of these transgenic goats. A three-column procedure was developed to produce gram quantities of highly purified rhAFP. Near- and far-UV circular dichroism spectra of human umbilical cord blood AFP and rhAFP were essentially identical, suggesting that the structure is not affected by removal of the glycosylation site. Furthermore, the cell binding and pharmacokinetics of purified rhAFP were similar to human AFP isolated from cord blood. Our results demonstrate that an active form of rhAFP can be produced on industrial scale by expression in transgenic goat milk.

Effects of pregnancy on health: certain aspects of importance for women with cystic fibrosis

More women with cystic fibrosis (CF) now reach reproductive age and wish to become pregnant. Although women with CF have reduced fertility, many of them can become mothers. A pregnancy ought to be carefully planned since several studies have shown that pregnancy is well tolerated if good medical care is provided, and the CF woman is in a stable good condition. A short review of the implications of pregnancy for women with CF is presented. A suggested schedule for pregnant women with CF is given.

Alterations in T-cell signal transduction molecules associated with recurrent spontaneous pregnancy loss

Clinical evidence suggests that cell-mediated immunity is altered during pregnancy and that failure to suppress the maternal immune response can lead to placentation failure, resulting in partial or total rejection of the fetus. In contrast to women experiencing recurrent spontaneous abortions (RSA), normal uncomplicated pregnancies are associated decreased T-cell proliferation and production of Th1 cytokines and increased T-cell apoptosis. This study addresses a circulating factor in normal pregnancy that may mediate these events. Sera were obtained from three groups: pregnant women who have uncomplicated term deliveries (Group 1, n = 8), pregnant women with a history of RSA, who subsequently abort (Group 2, n = 10), and age-matched non-pregnant female controls (Group 3, n = 8). Pregnancy sera were obtained between 10 and 12 weeks of gestation. Using chromatography, a CD3-zeta inhibitory factor (or analogous fraction) was isolated from each patient within each group and incubated with cultured T-cells, Jurkat and HUT-78 cells. Apoptosis was assayed by a cell-death ELISA and IL-2 production by cytokine-specific ELISA. Apoptosis regulatory proteins and signaling molecules were analyzed by western immunoblotting. Group 1 material induced a significant increase in apoptosis versus Groups 2 and 3. No significant apoptosis was observed between Groups 2 and 3. Material from Group 1 resulted in an increase in the bax expression compared to Groups 2 and 3 (P < 0.001), while no significant differences were observed in the expression of bcl-2. IL-2 secretion was inhibited 2.8-fold by material from Group 1 compared to Groups 2 and 3. Group 1 material decreased the expression of CD3-zeta, JAK3 and STAT5 compared to Groups 2 and 3 (as defined by densitometric units). Circulating materials from normal pregnancies are associated with increased lymphoid apoptosis, possibly through increased bax, and diminished production of the Th1 cytokine, IL-2. Our findings indicate that women experiencing RSA fail to suppress CD3-zeta and JAK3, suggesting a deficiency in this circulating factor that induces their suppression in normal pregnancy.

6-phosphogluconate dehydrogenase and glucose-6-phosphate dehydrogenase form a supramolecular complex in human neutrophils that undergoes retrograde trafficking during pregnancy

Neutrophils from pregnant women display reduced neutrophil-mediated effector functions, such as reactive oxygen metabolite (ROM) release. Because the NADPH oxidase and NO synthase produce ROMs and NO, the availability of their substrate NADPH is a potential regulatory factor. NADPH is produced by glucose-6-phosphate dehydrogenase (G-6-PDase) and 6-phosphogluconate dehydrogenase (6-PGDase), which are the first two steps of the hexose monophosphate shunt (HMS). Using immunofluorescence microscopy, we show that 6-PGDase, like G-6-PDase, undergoes retrograde transport to the microtubule-organizing centers in neutrophils from pregnant women. In contrast, 6-PGDase is found in an anterograde distribution in cells from nonpregnant women. However, lactate dehydrogenase distribution is unaffected by pregnancy. Cytochemical studies demonstrated that the distribution of 6-PGDase enzymatic activity is coincident with 6-PGDase Ag. The accumulation of 6-PGDase at the microtubule-organizing centers could be blocked by colchicine, suggesting that microtubules are important in this enzyme's intracellular distribution. In situ kinetic studies reveal that the rates of 6-gluconate turnover are indistinguishable in samples from nonpregnant and pregnant women, suggesting that the enzyme is functionally intact. Resonance energy transfer experiments showed that 6-PGDase and G-6-PDase are in close physical proximity within cells, suggesting the presence of supramolecular enzyme complexes. We suggest that the retrograde trafficking of HMS enzyme complexes during pregnancy influences the dynamics of NADPH production by separating HMS enzymes from glucose-6-phosphate generation at the plasma membrane and, in parallel, reducing ROM and NO production in comparison with fully activated neutrophils from nonpregnant women.

Sex and thyroid hormone status in women with rheumatoid arthritis: are there any effects of menopausal state and disease activity on these hormones?

There has been considerable interest in the role of hormones in the aetiopathogenesis of rheumatoid arthritis (RA). In this study, we aimed to investigate sex and thyroid hormone conditions according to menopausal state and disease activation in RA women. Fifty-four women with RA were included in the study. Age-matched 28 women with low back pain were used as controls. Sex and thyroid hormones were evaluated in all patients, which included the measurement of estradiol (E2), progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, thyroid-stimulating hormone (TSH), total (T) and free (F) triiodothyronine (T3) and (T) and (F) thyroxine (T4). The RA patients were subdivided according to their pre-menopausal and post-menopausal status and their disease activation conditions. Mean age was 45.68 (+/-12.5) in women (aged 22-70) with RA and 42.39 (+/-12.45) in controls (aged 22-62). There were no significant differences in sex hormones, but there were statistically significant higher levels of TT3 and TT4 in whole women with RA compared to controls. Lower concentrations of FSH were detected in active RA patients. There were statistically lower concentrations of LH and higher concentrations of TT3 and TT4 in pre-menopausal RA women, while lower concentrations of FSH were detected in post-menopausal RA women. TT3 and FT3 levels of pre-menopausal RA women were significantly higher than post-menopausal RA women. There were no significant differences for all other hormones studied. In conclusion, sex and thyroid hormones have been influenced in women with RA. Reproductive and menopausal conditions should be taken into consideration when sex and thyroid hormones studies are carried out in RA women.

Androgens are protective in experimental autoimmune encephalomyelitis: implications for multiple sclerosis

A gender difference prevails in some murine strains of experimental autoimmune encephalomyelitis (EAE), an animal model for multiple sclerosis (MS). Our results showed that castration of SJL males, a strain characterized by decreased susceptibility of males as compared to females, displayed increased disease severity. In contrast, castration had no effect on disease in C57BL/6 males, a strain in which no gender difference in EAE is observed. Regardless of whether endogenous androgens were protective in a given genetic background, supplemental androgen treatment was protective in gonadally intact males of both strains. These data provide a basis for the novel therapeutic use of supplemental testosterone for men with MS.

Labor induces a maternal inflammatory response syndrome

OBJECTIVE

We studied the effect of labor on maternal neutrophil phenotype.

STUDY DESIGN

Neutrophil apoptosis with inflammatory cytokines and the expression of CD11b, CD34 and toll-like receptor 4 (TLR4) were assessed with flow cytometry in women at uncomplicated vaginal delivery (VD), and elective cesarean section (ElCS) without labor, emergency cesarean section with (EmCSL+) or without (EmCSL-) labor.

RESULTS

Spontaneous neutrophil apoptosis is delayed in maternal neutrophils after VD, EmCSL+ or EmCSL- versus ElCS. In all groups lipopolysaccharide delayed apoptosis and increased CD11b expression. Elevated TLR4 expression in ElCS was associated with lipopolysaccharide responsiveness. CD34 was diminished in VD, indicating increased cell maturity.

CONCLUSION

Normal labor primes the neutrophil and may enhance antibacterial function by inducing a mild maternal inflammatory response syndrome. Delayed neutrophil apoptosis may promote the neutrophilia seen in women after VD. We suggest that labor of any duration may be immunologically beneficial to the parturient.

Immune Modulation in Multiple Sclerosis Patients Treated with the Pregnancy Hormone Estriol

The protective effect of pregnancy on putative Th1-mediated autoimmune diseases, such as multiple sclerosis and rheumatoid arthritis, is associated with a Th1 to Th2 immune shift during pregnancy. The hormone estriol increases during pregnancy and has been shown to ameliorate experimental autoimmune encephalomyelitis and collagen-induced arthritis. In addition, estrogens induce cytokine changes consistent with a Th1 to Th2 shift when administered in vitro to human immune cells and in vivo to mice. In a pilot trial, oral estriol treatment of relapsing remitting multiple sclerosis patients caused significant decreases in enhancing lesions on brain magnetic resonance imaging. Here, the immunomodulatory effects of oral estriol therapy were assessed. PBMCs collected longitudinally during the trial were stimulated with mitogens, recall Ags, and glatiramer acetate. Cytokine profiles of stimulated PBMCs were determined by intracellular cytokine staining (IL-5, IL-10, IL-12 p40, TNF-alpha, and IFN-gamma) and cytometric bead array (IL-2, IL-4, IL-5, IL-10, TNF-alpha, and IFN-gamma). Significantly increased levels of IL-5 and IL-10 and decreased TNF-alpha were observed in stimulated PBMC isolated during estriol treatment. These changes in cytokines correlated with reductions of enhancing lesions on magnetic resonance imaging in relapsing remitting multiple sclerosis. The increase in IL-5 was primarily due to an increase in CD4(+) and CD8(+) T cells, the increase in IL-10 was primarily due to an increase in CD64(+) monocytes/macrophages with some effect in T cells, while the decrease in TNF-alpha was primarily due to a decrease in CD8(+) T cells. Further study of oral estriol therapy is warranted in Th1-mediated autoimmune diseases with known improvement during pregnancy.

Immunosuppression in pregnancy: choices for infant and maternal health

Successful pregnancy outcomes are possible after all types of solid organ transplantation and thousands of successful pregnancies in such women have been reported. As immunosuppressive medications are required to maintain adequate graft and maternal survival, major concerns are the effect of these agents on the fetus and the effect of pregnancy on the well being of mother and graft, against a background of continuing advances and modifications in immunosuppressive therapy. Women should avoid unnecessary medications during pregnancy but clinicians worry most about teratogens; agents (environmental, pharmaceuticals or other chemicals) that cause abnormal development, whether this be an overt structural birth defect or more subtle derangements of embryonic or fetal development. A concern is that any agent or combination of agents and maternal condition(s) may be teratogenic, a risk that is increased in the transplant population. The goal of immunosuppression is to ensure graft and patient survival by preventing acute rejection. Combinations of agents allow for synergistic effects while minimising drug toxicities. No specific combination has been deemed optimal and the effects of more recently available combinations require further study. Although there are known theoretical risks to mother and fetus, successful pregnancies are now the rule in transplant recipients. This is without an apparent increase in the type or incidence of malformations in the newborns, and usually with no evidence of graft dysfunction and/or irreversible deterioration either related to prepregnancy graft problems or unpredictable gestational factors. For immunosuppression, what is best for the mother and her survival should ensure the best outcome for the fetus and, although no specific malformation pattern has been reported to date, there are some interesting trends worthy of continued analyses. A balance of good maternal and graft outcome with the lowest risk of fetal toxicity must be the goal of management.

Pregnancy alters glucose-6-phosphate dehydrogenase trafficking, cell metabolism, and oxidant release of maternal neutrophils

Pregnancy is associated with changes in host susceptibility to infections and inflammatory disease. We hypothesize that metabolic enzyme trafficking affects maternal neutrophil activation. Specifically, immunofluorescence microscopy has shown that glucose-6-phosphate dehydrogenase (G-6-PDase), the rate-controlling step of the hexose monophosphate shunt (HMS), is located near the cell periphery in control neutrophils but is found near the microtubule-organizing centers in cells from pregnant women. Cytochemical studies confirmed that the distribution of the G-6-PDase antigen is coincident with functional G-6-PDase activity. Metabolic oscillations within activated pregnancy neutrophils are higher in amplitude, though lower in frequency, than activated control neutrophils, suggesting limited HMS activity. Analysis of radioisotope-labeled carbon flux from glucose to CO(2) indicates that the HMS is intact in leukocytes from pregnant women, but its level is not enhanced by cell stimulation. Using extracellular fluorescent markers, activated pregnancy neutrophils were found to release reactive oxygen metabolites (ROMs) at a lower rate than activated control neutrophils. However, basal levels of ROM production in polarized pregnancy neutrophils were greater than in control neutrophils. Microtubule-disrupting agents reversed the observed changes in G-6-PDase trafficking, metabolic oscillations, and ROM production by maternal neutrophils. G-6-PDase trafficking appears to be one mechanism regulating ROM production by maternal neutrophils.

Pregnancy alters glucose-6-phosphate dehydrogenase trafficking, cell metabolism, and oxidant release of maternal neutrophils

Pregnancy is associated with changes in host susceptibility to infections and inflammatory disease. We hypothesize that metabolic enzyme trafficking affects maternal neutrophil activation. Specifically, immunofluorescence microscopy has shown that glucose-6-phosphate dehydrogenase (G-6-PDase), the rate-controlling step of the hexose monophosphate shunt (HMS), is located near the cell periphery in control neutrophils but is found near the microtubule-organizing centers in cells from pregnant women. Cytochemical studies confirmed that the distribution of the G-6-PDase antigen is coincident with functional G-6-PDase activity. Metabolic oscillations within activated pregnancy neutrophils are higher in amplitude, though lower in frequency, than activated control neutrophils, suggesting limited HMS activity. Analysis of radioisotope-labeled carbon flux from glucose to CO(2) indicates that the HMS is intact in leukocytes from pregnant women, but its level is not enhanced by cell stimulation. Using extracellular fluorescent markers, activated pregnancy neutrophils were found to release reactive oxygen metabolites (ROMs) at a lower rate than activated control neutrophils. However, basal levels of ROM production in polarized pregnancy neutrophils were greater than in control neutrophils. Microtubule-disrupting agents reversed the observed changes in G-6-PDase trafficking, metabolic oscillations, and ROM production by maternal neutrophils. G-6-PDase trafficking appears to be one mechanism regulating ROM production by maternal neutrophils.

Treatment of multiple sclerosis with the pregnancy hormone estriol

Multiple sclerosis patients who become pregnant experience a significant decrease in relapses that may be mediated by a shift in immune responses from T helper 1 to T helper 2. Animal models of multiple sclerosis have shown that the pregnancy hormone, estriol, can ameliorate disease and can cause an immune shift. We treated nonpregnant female multiple sclerosis patients with the pregnancy hormone estriol in an attempt to recapitulate the beneficial effect of pregnancy. As compared with pretreatment baseline, relapsing remitting patients treated with oral estriol (8 mg/day) demonstrated significant decreases in delayed type hypersensitivity responses to tetanus, interferon-gamma levels in peripheral blood mononuclear cells, and gadolinium enhancing lesion numbers and volumes on monthly cerebral magnetic resonance images. When estriol treatment was stopped, enhancing lesions increased to pretreatment levels. When estriol treatment was reinstituted, enhancing lesions again were significantly decreased. Based on these results, a larger, placebo-controlled trial of estriol is warranted in women with relapsing remitting multiple sclerosis. This novel treatment strategy of using pregnancy doses of estriol in multiple sclerosis has relevance to other autoimmune diseases that also improve during pregnancy.

Multiple sclerosis and pregnancy

Multiple sclerosis causes disability in young adults and, like most autoimmune diseases, affects women more commonly than men. The disease can therefore present at a time when many have, or are considering, starting a family. The effect of pregnancy on the outcome of multiple sclerosis is reviewed and the management of pregnant women who have multiple sclerosis is discussed.

Dominant IL-10 and TGF-beta mRNA expression in gammadeltaT cells of human early pregnancy decidua suggests immunoregulatory potential

PROBLEM

To examine the cytokine gene expression in gammadeltaT-cells from human early pregnancy decidua.

METHOD OF STUDY

The cytokine messenger RNA (mRNA) expression in isolated decidual T-cell receptor (TCR)gammadelta+/CD56+ and TCRgammadelta single positive cells was investigated with a panel of cytokine primers and probes selected to distinguish between T helper (Th)1, Th2, Th3 and regulatory T-cells (Tr1) type of immune response using real-time quantitative reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

TCRgammadelta+/CD56+ cells express almost exclusively the immunosuppressive cytokines interleukin-10 (IL-10) and transforming growth factor (TGF)-beta. The TCRgammadelta single positive cells enhance their transcription of IL-10 and TGF-beta, compared with the TCRgammadelta+ CD56+ cells and additionally express mRNA for IL-1beta and IL-6.

CONCLUSIONS

The present findings suggest that gammadeltaT cells in normal pregnancy create a cytokine milieu promoting immunotolerance to the fetus. We hypothesize that through the production of the immunosuppressive cytokines IL-10 and/or TGF-beta the gammadeltaT cells could function directly as regulatory T cells or induce the differentiation of Th0 TCRalphabeta+ cells into regulatory/suppresser cells.

Pregnancy and oral contraceptive use do not significantly influence outcome in long term rheumatoid arthritis

BACKGROUND

Oral contraceptives (OC) and pregnancy are known to have an influence on the risk of onset of rheumatoid arthritis (RA). Pregnancy itself has beneficial effects on the activity of the disease, with relapses post partum. It is not known, however, whether OC and pregnancies influence the ultimate outcome of RA.

OBJECTIVES

To explore whether OC use and pregnancies influence the 12 year outcome in RA as measured by radiological damage and disability.

METHODS

In a prospective inception cohort of 132 female patients with recent RA according to the 1987 American College of Rheumatology criteria-a cohort initially gathered to study the association between hormonal factors and the onset of RA-outcome was assessed in a follow up after 12 years. The outcome was evaluated in 112 (85%) women by the radiological damage of hands and feet as measured with the Sharp score modification van der Heijde (SHS), the damage of the large joints measured with the Larsen score (LS) of large joints (0-60), and the disability measured with the Health Assessment Questionnaire (HAQ). The median values of each outcome variable were calculated for several subgroups of patients stratified for OC use and pregnancies before and after onset of the disease and the tertiles of the total number of months of OC use and of pregnancies. The association of OC use and pregnancies before and after onset of the disease with the outcome variables was calculated using Spearman's rank correlation (r(s)). The combined influence of OC use and pregnancies on the SHS, LS, and HAQ at 12 years was estimated using ordinal polytomous logistic regression.

RESULTS

The median values of the SHS, LS, and HAQ showed a trend towards less radiological joint damage and less disability in women with long term OC use and multiple pregnancies. This difference, however, was not significant, except for the HAQ score in women with three or more pregnancies in life. There was no association between pregnancies, however defined, and any parameter of RA outcome after 12 years (maximum r(s)=-0.10). The only significant correlation was found between OC use before symptom onset and the LS (r(s)=-0.22, p<0.05). The combination of hormonal variables explained no more than a maximum of 3% of the variance of the 12 year outcome as measured by the SHS.

CONCLUSION

OC use and pregnancy do not significantly influence outcome in long term RA. There is, however, a trend for patients with multiple pregnancies and long term OC use to have less radiographic joint damage and a better functional level.

Gender issues and multiple sclerosis

Gender-related issues in multiple sclerosis include the important and widely accepted clinical observations that men are less susceptible to the disease than women and also that disease activity in multiple sclerosis is decreased during late pregnancy. This article reviews mechanisms underlying each of these clinical observations and discusses the role of sex hormones in each. Specifically, the protective role of testosterone in young men and the protective role of the pregnancy hormone estriol in pregnant women are discussed. Rationale for novel therapies in multiple sclerosis based on the protective roles of these sex hormones is presented.

Immunosuppressive effect of pregnancy on autoimmune hepatitis: a case report and review of literature

We report a case of autoimmune hepatitis with suppressed disease activity during pregnancy and relapse in puerperium. This is only the second report of such pregnancy-induced remission.

The balance of Th1/Th2 cytokines in rheumatoid arthritis

It has been suggested that rheumatoid inflammation is mediated by activated pro-inflammatory T helper type I cells. In contrast, immunomodulatory T helper type 2 cells and their cytokines, in particular interleukin-4, are rarely found. This chapter reviews the concept of the Th1/Th2 dichotomy and summarizes the functions of the signature cytokines of the T helper subsets. We discuss current knowledge of the immunopathogenesis of rheumatoid arthritis and its related animal model, collagen induced arthritis, with regard to the Th1/Th2 paradigm. The accumulating evidence for a T helper type 1 driven inflammation and the implications for future therapy are delineated.

Postpartum thyroiditis and autoimmune thyroiditis in women of childbearing age: recent insights and consequences for antenatal and postnatal care

Postpartum thyroiditis is a syndrome of transient or permanent thyroid dysfunction occurring in the first year after delivery and based on an autoimmune inflammation of the thyroid. The prevalence ranges from 5-7%. We discuss the role of antibodies (especially thyroid peroxidase antibodies), complement, activated T cells, and apoptosis in the outbreak of postpartum thyroiditis. Postpartum thyroiditis is conceptualized as an acute phase of autoimmune thyroid destruction in the context of an existing and ongoing process of thyroid autosensitization. From pregnancy an enhanced state of immune tolerance ensues. A rebound reaction to this pregnancy-associated immune suppression after delivery explains the aggravation of autoimmune syndromes in the puerperal period, e.g., the occurrence of clinically overt postpartum thyroiditis. Low thyroid reserve due to autoimmune thyroiditis is increasingly recognized as a serious health problem. 1) Thyroid autoimmunity increases the probability of spontaneous fetal loss. 2) Thyroid failure due to autoimmune thyroiditis-often mild and subclinical-can lead to permanent and significant impairment in neuropsychological performance of the offspring. 3) Evidence is emerging that as women age subclinical hypothyroidism-as a sequel of postpartum thyroiditis-predisposes them to cardiovascular disease. Hence, postpartum thyroiditis is no longer considered a mild and transient disorder. Screening is considered.

Pathogenesis of maternal-fetal syphilis revisited

Although congenital syphilis has been recognized for several centuries and an efficient treatment with penicillin became available more than a half-century ago, the disease is still with us. Inability to culture in vitro the causative agent, Treponema pallidum, and the lack of an adequate animal model have prevented exploration of the various immunopathological events affecting the natural course of congenital infection. The purpose of this review is to analyze the disease in the context of recent knowledge acquired from human and experimental animals, particularly from the guinea pig model of congenital and neonatal syphilis, and to describe how the infection interacts with the maternal-fetal unit and how it is further modulated by the conceptus' ontogenic development. We also attempt to elucidate several old immunologic concepts and misconceptions that have remained unchallenged for too long.

Gestational attenuation of Lyme arthritis is mediated by progesterone and IL-4

Infection of different strains of laboratory mice with the agent of Lyme disease, Borrelia burgdorferi, results in arthritis, the severity of which has been correlated with the dominance of Th1 cytokines. In this study, we demonstrate that changes in B. burgdorferi-specific immunologic responses associated with pregnancy can alter the outcome of Lyme arthritis in mice. Whereas nonpregnant female C3H mice consistently developed severe Lyme arthritis, pregnant mice had a marked reduction in arthritis severity that was associated with a slight reduction in IFN-gamma and markedly increased levels of IL-4 production by B. burgdorferi-specific T cells. Similar reductions in arthritis severity and patterns of cytokine production were observed in nonpregnant, progesterone-implanted mice. Ab neutralization of IL-4 in progesterone-implanted mice resulted in severe arthritis. Our results are consistent with the known shift toward Th2 cytokine expression at the maternal-fetal interface, and are the first to show a pregnancy-related therapeutic effect in an infectious model.

Sex hormones in experimental autoimmune encephalomyelitis: implications for multiple sclerosis

For decades, it has been known that females are more susceptible than males to multiple sclerosis (MS). It has also long been appreciated that during late pregnancy there is a decrease in MS disease activity. Interestingly, these two observations have also been made in an extensively used animal model for MS, experimental autoimmune encephalomyelitis (EAE) in SJL mice. Female mice are more susceptible to disease than male mice, and there is an improvement in disease during late pregnancy. In this review, the role of sex hormones in each of these two observations is characterized in this EAE model using castration and exogenous hormone treatment strategies. The gender difference in EAE susceptibility is due primarily to a protective effect of testosterone in male mice. The decrease in disease severity during late pregnancy appears to be due at least in part to high levels of estriol, which characterize this time period.

Lymphocyte responses to stress in postpartum women: relationship to vagal tone

Although women spend their lives in various phases of the reproductive cycle, including menstrual, pregnancy, postpartum, lactation and menopause, few studies have examined immune responses to stress in women as a function of events associated with reproduction. The objective of this study was to evaluate differential effects of breastfeeding (n = 16), bottlefeeding (n = 10) and non-postpartum (n = 10) status on lymphocyte responses to stressful tasks (public speaking and mental arithmetic). To measure cellular immune responses, lymphocyte proliferation to plant lectins, poke weed mitogen (PWM) and phytohemagglutinin (PHA) were used. The autonomic measures, heart rate, vagal tone, blood pressure and the hormones of the HPA axis, ACTH and cortisol, were measured and their possible roles in mediating lymphocyte proliferation responses were examined. Recently parturient women who were breastfeeding or bottlefeeding had attenuated stress-induced change in lymphocyte responses to PWM compared with non-postpartum women, tested in the follicular phase of their cycle (P < 0.05). Also, lymphocyte responses to PHA were higher in the breastfeeding group compared with non-postpartum controls (P < 0.05). Regression analyses revealed that an index of cardiac vagal tone, but not other autonomic or endocrine measures, was positively predictive of lymphocyte proliferation to PWM. To summarize, these findings suggest that lactation and parturition can influence lymphocyte proliferation and that activity in the vagal system may influence lymphocyte responses to stress.

Interferon-gamma and interleukin-4 mRNA expression by peripheral blood mononuclear cells from pregnant and non-pregnant cattle seropositive for bovine viral diarrhea virus

The acceptance of the fetal allograft by pregnant women and mice seems to be associated with a shift from a Th 1 dominated to a Th 2 dominated immune response to certain infectious agents. The goal of this study was to examine cytokine expression in peripheral blood mononuclear cells (PBMCs) from cattle immune to bovine viral diarrhea virus (BVDV) to determine whether pregnancy also has an influence on the type of immune response in this species. Forty-six heifers and cows between 14 months and 13 years of age were included in this study. Twenty-four were seropositive and 22 seronegative for BVDV. Eleven of the seropositive animals and 11 of the seronegative animals were in the eighth month of gestation, the remaining animals were virgin heifers. PBMC from these animals were analyzed for Interferon (IFN)-gamma and Interleukin (IL)-4 mRNA expression by real-time RT-PCR after stimulation with a non-cytopathic strain of BVDV. Additionally, an ELISA was performed to measure IFN-gamma in the supernatants of stimulated cell cultures. In BVDV seropositive animals, IFN-gamma mRNA levels were significantly higher than in BVDV seronegative animals and there was a significant positive correlation between the changes in IFN-gamma and IL-4 mRNA expression. There was, however, no significant difference in IFN-gamma and IL-4 mRNA levels between pregnant and non-pregnant animals. These results are inconsistent with BVDV inducing a Th1 or Th2 biased immune response. Furthermore, a shift in the cytokine pattern during bovine pregnancy was not evident.

The immune response during the luteal phase of the ovarian cycle: a Th2-type response?

OBJECTIVE

To test the hypothesis that during the luteal phase of the ovarian cycle, as compared with the follicular phase, the peripheral immune response is shifted toward a type-2 response.

DESIGN

Prospective study.

SETTING

Academic research setting.

PATIENT(S)

Women with regular menstrual cycles.

INTERVENTION(S)

Blood samples were collected between days 6 and 9 of the menstrual cycle and 6-9 days after the LH surge.

MAIN OUTCOME MEASURE(S)

Intracellular cytokine production of interferon (IFN)-gamma, interleukin (IL)-2, IL-4, and IL-10 after in vitro stimulation of lymphocytes as well as total white blood cell (WBC) count, differential WBC count, and plasma 17 beta-E(2) and P concentrations.

RESULT(S)

Mean plasma 17 beta-E(2) and P concentrations, WBC count, and mean granulocyte, monocyte, and lymphocyte counts were significantly increased in the luteal phase as compared with the follicular phase of the ovarian cycle. Production of type-1 cytokines (IFN-gamma and IL-2) and production of the type-2 cytokine IL-10 did not vary between the phases of the ovarian cycle. Production of the type-2 cytokine IL-4, however, was significantly increased in the luteal phase as compared with the follicular phase of the ovarian cycle.

CONCLUSION(S)

During the luteal phase of the ovarian cycle, the immune response is shifted toward a Th2-type response, as reflected by increased IL-4 production in this phase of the cycle. These results may suggest that increased levels of P and 17 beta-E(2) in the luteal phase of the ovarian cycle play a role in the deviation of the immune response toward a type-2 response.

Hormonal alterations in rheumatoid arthritis, including the effects of pregnancy

A number of hormonal abnormalities are present in RA patients. A major theme of these abnormalities seems to be that deficiencies in the production or action of gonadal (estrogens and androgens) and adrenal (corticosteroids and DHEA) hormones may be involved in regulating the onset, severity, and progression of RA. Differences in RA incidence and activity in the pregnant and postpartum periods provide the strongest support for this view. Hormonal changes during these periods clearly have the potential to exert profound effects on RA incidence and activity. The effect of pregnancy on RA activity is actually greater than the effect of some of the newer therapeutic agents. The striking increase in corticosteroids, estrogen, and progesterone during pregnancy may suppress RA onset or activity through the regulation of production or action of cytokines such as TNF alpha, IL-1, IL-6, IL-12, and IL-10. The relative adrenal- and gonadal-deficient environment of the postpartum period further supports the view that hormonal deficiencies predispose to the development or increased activity of RA. These observations justify the search for hormonal abnormalities in RA patients outside the pregnancy and postpartum periods. In particular, further studies on the period before the onset of disease are needed. Additional evidence does exist that a functional abnormality in the adrenal glands in RA patients results in dysregulation of corticosteroid and DHEA production. These abnormalities seem to be linked to aging and disease activity. It is still not established whether these abnormalities are primary or secondary, although data indicating adrenal hypofunction before the development of RA or within the first year of disease activity suggest a primary abnormality. Several hormonal abnormalities seem to be restricted by gender and age, particularly around perimenopause and menopause. These age- and gender-influenced effects may be the cause of some of the contradictory data reviewed here. Studies in the future should make greater efforts to segregate study populations by age, gender, and reproductive status. The identification of the specific hormonal abnormalities and patient populations that are at risk is important, because these factors may allow new therapeutic approaches that are less toxic than current regimens.

Neutrophil function in pregnancy and rheumatoid arthritis

BACKGROUND

Pregnancy exerts suppressive effects on rheumatoid arthritis (RA). An attenuation in neutrophil function in late pregnancy which may explain this amelioration has previously been reported.

OBJECTIVE

A longitudinal investigation of neutrophil activity in healthy pregnant women (n=9) and pregnant patients with RA (n=9), compared with age matched non-pregnant patients with RA (n=12) and healthy controls (n=22).

METHODS

Neutrophil activation was measured in response to the physiological receptor agonists, n-formyl-methionyl-leucyl-phenylalanine (fMLP) and zymosan activated serum (ZAS). Superoxide anion production (respiratory burst) was determined by lucigenin enhanced chemiluminescence (LUCL); secondary granule lactoferrin release by enzyme linked immunosorbent assay (ELISA); and CD11b, CD18, and CD62L expression by flow cytometric analysis.

RESULTS

Stimulated neutrophil LUCL was significantly reduced in both pregnant women with RA and healthy pregnant women in the second (fMLP 43% and 69%, ZAS 43% and 59%, respectively) and third trimesters (fMLP 24% and 44%, ZAS 32% and 38%, respectively). Responses returned to normal within eight weeks of delivery and unstimulated levels remained unchanged throughout pregnancy. Basal and stimulated CD11b, CD18, and CD62L expression showed no variations throughout gestation for both pregnancy groups. Likewise, stimulated lactoferrin release and plasma lactoferrin remained unchanged. Certain morphological differences in RA neutrophils were highlighted by the flow cytometric analysis. Moreover, resting neutrophils and stimulated cells from patients with RA, including pregnant subjects, showed a marked increase in LUCL, but a reduction in CD11b, CD18, and CD62L. Low dose prednisolone and methylprednisolone had no effect on neutrophil parameters over the period of treatment with non-steroidal anti-inflammatory drugs.

CONCLUSION

The attenuation to neutrophil respiratory burst in both healthy and RA pregnancies may offer an explanation for the pregnancy induced remission of this inflammatory disorder.

Is primary prevention of asthma possible?

The increased prevalence of asthma over the past quarter century has become a major public health problem for the industrialized world. Asthma is a disease process which has a strong heritable component which is impacted by multiple environmental factors. Given the rapid increase in asthma prevalence, it is difficult to ascribe the change to a genetic alteration. Therefore, the focus for understanding the changing prevalence of asthma must be on environmental factors. This article reviews factors which may contribute, in whole or in part, to the development of the disease process. In questioning whether it is possible to prevent development of a disease (primary prevention), it is critical to understand these factors. The environment may even have an impact on the fetus during intrauterine life. There does appear to be a "window of opportunity" in early life where a variety of factors, including food and inhalant allergen exposure, exposure to pollutants, and infection with both viral and bacterial agents, may be important in initiating the development of asthma and allergy. Potential approaches to primary prevention of asthma and allergy must consider each of these important factors. Given that asthma is a multifactorial disease with both complex genetic and environmental components, it is unlikely that any single intervention will significantly decrease the prevalence of asthma.

Variations in cytokine mRNA expression during normal human pregnancy

Epidemiological data provide evidence that disease activity of T cell-mediated, organ-specific autoimmune diseases is reduced during pregnancy. Although there are several experimental animal studies on the effect of pregnancy on the immune system, the situation in humans is less clear. We therefore performed a prospective analysis of cytokine mRNA expression in whole blood by a new on-line reverse transcriptase-polymerase chain reaction technique and of serum hormone levels during pregnancy in healthy women. The control group included age-matched non-pregnant healthy women. Quantitativecytokine mRNA expression revealed significantly reduced IL-18, interferon-gamma (IFN-gamma), and IL-2 mRNA levels in the first and second trimester in pregnancy compared with non-pregnant women. No difference between groups was detected for tumour necrosis factor-alpha (TNF-alpha) mRNA. IL-4 and IL-10 mRNA were detected at low levels in only 20% of pregnant women and were reduced to a statistically significant extent in the second and third trimester compared with the control group. Changes in IL-18 mRNA expression correlated inversely with serum values for human choriogonadotropin (HCG) and IL-10 serum levels correlated with increases in serum 17beta-oestradiol levels. These data indicate immunomodulatory effects of pregnancy at the cytokine level which may be related to the variations in the clinical course of organ-specific, T cell-mediated autoimmune diseases during pregnancy.

Pregnancy and early onset pauciarticular juvenile chronic arthritis

OBJECTIVES

To study interaction of early onset pauciarticular juvenile chronic arthritis (EOP-JCA) and pregnancy in the Polish population, in particular to confirm the ameliorating effect of pregnancy on disease activity reported by others and to analyse the factors that govern the occurrence of postpartum flare, with emphasis on the potential role of breast feeding.

METHODS

The reproductive outcome and disease status in 39 adult women with history of EOP- JCA was examined by means of a questionnaire and an interview. In all patients the disease onset occurred before the 6th birthday, 19 had persistent pauciarticular JCA (PeEOP-JCA) and 20 had extended pauciarticular JCA (ExEOP-JCA).

RESULTS

23 women had at least one successful pregnancy, seven had unsuccessful pregnancies but all of them had also one or more successful pregnancies. Among those who have never been pregnant (n=16) there was a higher frequency of eye disease and ExEOP-JCA compared with the rest of the group. In almost all cases pregnancy was associated with remission of disease activity, however a postpartum flare appeared after 22 pregnancies (52%). The flares were more frequent in women who had an active disease before pregnancy, had a flare after a previous pregnancy and/or were breast feeding.

CONCLUSIONS

In EOP-JCA patients pregnancy generally has a good outcome and induces amelioration of disease activity. After delivery, however, a flare of disease often appears, especially in women who were breast feeding, had a postparum flare previously or had an active disease before pregnancy. The pattern of interaction between disease and pregnancy found in EOP-JCA makes EOP-JCA similar in this respect to RA, but different from systemic lupus erythematosus and ankylosing spondylitis.