ANKYLOSING SPONDYLITIS IS CAUSED BY KLEBSIELLA

Stress proteins in the pathogenesis of spondyloarthritis

Spondyloarthritis is an autoinflammatory rheumatic disease in which arthritis and osteoproliferation lead the patients who suffer from it to chronic disability. This disease is associated with the expression of class I MHC molecule HLA-B27, which tends to be misfolded in the endoplasmic reticulum and, therefore, expressed in aberrant forms. This phenomena lead to endoplasmic reticulum stress, which in time, evokes a whole response to cellular injury. Under these conditions, the molecules involved in restoring cell homeostasis play a key role. Such is the case of the "heat-shock proteins", which usually regulate protein folding, but also have important immunomodulatory functions, as well as some roles in tissue modeling. In this review, we attempt to summarize the involvement of cell stress and heat-shock proteins in the homeostatic disturbances and pathological conditions associated with this disease.

Cervical Epidural Injection in the Management of Refractory Pain and Stiffness in Spondyloarthropathy: A Case Report Series

OBJECTIVES

The primary objective of this case series was to report the use of cervical epidural steroid injection in the management of neck pain and stiffness secondary to spondyloarthropathy in cases refractory to conservative therapy.

METHODS

This was a case report series on three patients with diagnosis of spondyloarthropathy who presented with severe stiffness and non-radicular axial neck pain refractory to conservative therapy. All patients received cervical epidural steroid injections with significant improvement of their axial neck pain and stiffness.

RESULTS

Cervical epidural steroid injections may be effective to improve the axial neck pain and stiffness in patients with diagnosis of spondyloarthropathy refractory to conservative management. Thus, we believe that epidural steroid injections should be considered in the management of patients with spondyloarthopathies.

Microbiota and arthritis: correlations or cause?

PURPOSE OF REVIEW

The microorganisms that colonise our bodies, the commensal 'microbiota', respond to changes in our behaviour and environment, and can also profoundly affect our health. We can now investigate these organisms with unprecedented depth and precision, revealing that they may contribute to the pathogenesis of diseases including arthritis. Here we discuss the changes occurring in the microbiota in people with arthritis, and how manipulation of the microbiota may provide an additional pathway for therapy.

RECENT FINDINGS

We highlight two important aspects of the recent literature. First we describe changes in the microbiota identified in people with arthritis; these correlations give insights into the microbial changes that may contribute to symptoms of arthritis. We then discuss attempts to ameliorate arthritis by manipulating the microbiota. This is a rapidly developing area of research. There are tantalising hints that interventions targeting the microbiota may become therapeutically viable for some types of inflammatory arthritis.

SUMMARY

Our commensal microbial communities respond to changes in our health, and are altered in people with arthritis. Understanding the complex relationships between the microbiota and the body may enable us to deliberately manipulate these organisms and provide additional therapeutic options for people with arthritis.

Ankylosing spondylitis is linked to Klebsiella--the evidence

Ankylosing spondylitis (AS) is a chronic inflammatory spinal and large-joint arthritic and potentially disabling condition, mainly affecting males of young age groups. Extensive literature based on the results of various genetic, microbiological, molecular and immunological studies carried out by independent research groups suggests that Klebsiella pneumoniae is the main microbial agent being implicated as a triggering and/or perpetuating factor in the etiopathogenesis of AS. Novel diagnostic markers and criteria based on the association with high anti-Klebsiella antibodies could be used in the detection of AS patients during early stages of the disease, and together with the current treatments might help in implementing the use of new therapeutic anti-microbial measures in the management of AS. Prospective longitudinal studies with the use of anti-microbial measures in patients with AS are required to establish the therapeutic benefit of this microbe-disease association.

Molecular mimicry may contribute to pathogenesis of ulcerative colitis

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with mucosal inflammation and ulceration of the colon. There seems to be no single etiological factor responsible for the onset of the disease. Autoimmunity has been emphasized in the pathogenesis of UC. Perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) are common in UC, and recently two major species of proteins immunoreactive to pANCA were detected in bacteria from the anaerobic libraries. This implicates colonic bacterial protein as a possible trigger for the disease-associated immune response. Autoantibodies and T-cell response against human tropomyosin isoform 5 (hTM5), an isoform predominantly expressed in colon epithelial cells, were demonstrated in patients with UC but not in Crohn's colitis. We identified two bacterial protein sequences in NCBI database that have regions of significant sequence homology with hTM5. Our hypothesis is that molecular mimicry may be responsible for the pathogenesis of UC.

Widespread scleredema accompanied with a monoclonal gammopathy in a patient with advanced ankylosing spondylitis

Scleredema is a rare cutaneous mucinosis characterized by chronic diffuse induration of the skin, and it is occasionally associated with a monoclonal gammopathy (MG). Ankylosing spondylitis (AS) is noted to be another, chronic systemic inflammatory disorder of the axial skeleton that may accompany the MG. However, patients with scleredema and AS accompanied with a MG have not been reported in the literature. We here report a 40-yr-old man with scleredema and advanced AS accompanied with a MG of IgA-kappa protein. Widespread, long-standing scleredema has been developed over 10 yrs after the initial manifestation of AS. It is uncertain whether the coexistence of scleredema and AS is more than coincidental.

Insights into the Role of Infection in the Spondyloarthropathies

Certain infections play an important role in the pathogenesis of the human leukocyte antigen (HLA)-B27-associated reactive arthritis. Whether infections play a role in other forms of spondyloarthropathies is not as clear. The role of HLA-B27 as an antigen-presenting molecule is important in the pathogenesis of these diseases. Recent evidence has been obtained indicating that this molecule may have other functions unrelated to antigen-presentation in the interaction of reactive arthritis-triggering microbes and host. This paper reviews the recent studies on the role of infection in the spondyloarthropathies.

Autoantibodies to brain components and antibodies to Acinetobacter calcoaceticus are present in bovine spongiform encephalopathy

Bovine spongiform encephalopathy (BSE) is a neurological disorder, predominantly of British cattle, which belongs to the group of transmissible spongiform encephalopathies together with Creutzfeldt-Jakob disease (CJD), kuru, and scrapie. Autoantibodies to brain neurofilaments have been previously described in patients with CJD and kuru and in sheep affected by scrapie. Spongiform-like changes have also been observed in chronic experimental allergic encephalomyelitis, at least in rabbits and guinea pigs, and in these conditions autoantibodies to myelin occur. We report here that animals with BSE have elevated levels of immunoglobulin A autoantibodies to brain components, i.e., neurofilaments (P < 0.001) and myelin (P < 0.001), as well as to Acinetobacter calcoaceticus (P < 0.001), saprophytic microbes found in soil which have sequences cross-reacting with bovine neurofilaments and myelin, but there were no antibody elevations against Agrobacterium tumefaciens or Escherichia coli. The relevance of such mucosal autoantibodies or antibacterial antibodies to the pathology of BSE and its possible link to prions requires further evaluation.

Somatic serogroups, capsular types, and species of fecal Klebsiella in patients with ankylosing spondylitis

The purpose of the present study was to find out whether patients with ankylosing spondylitis (AS) carry fecal Klebsiella strains that belong to serotypes or species specific for AS. Somatic serotypes (O groups), capsular (K) serotypes, and biochemically identified species were determined for fecal klebsiellae isolated from 187 AS patients and 195 control patients. The controls were patients with fibromyalgia or rheumatoid arthritis. The 638 isolates of Klebsiella that were obtained represented 161 strains; 81 from AS patients and 80 from the controls. The average number of Klebsiella strains per patient was 1.7 for the AS group and 1.5 for the control group. The most common O group was O1, which was observed for isolates from 23 of 187 AS patients and 24 of 195 control patients. Next in frequency was group O2, which was observed for isolates from 17 AS patients and 15 control patients. Regarding the K serotypes, 59 different types were identified, revealing a heterogeneous representation of Klebsiella strains, without a predominance of any serotype. By biochemical identification, Klebsiella pneumoniae was the most frequently occurring species, being found in 45 AS patients and 45 control patients. Next in the frequency was K. oxytoca, which was observed in 26 AS patients and in 29 control patients. K. planticola and K. terrigena occurred in only a minority of patients. Altogether, when analyzed either separately or simultaneously according to O groups, K serotypes, and biochemically identified species, no evidence of the existence of AS-specific Klebsiella strains was obtained. These findings do not indicate participation of Klebsiella in the etiopathogenesis of AS.

Aetiological agents: their molecular biology and phagocyte-host interaction

Inflammatory joint disease can develop following an extra-articular infection. The term reactive arthritis was coined in order to differentiate this arthritis, which is often characterized by lack of culturable organisms in the joint, from septic arthritides. Bacteria known to trigger reactive arthritis include Campylobacter, Chlamydia, Salmonella, Shigella and Yersinia. Demonstration of bacteria or bacterial macromolecules in the joint has elicited the idea that reactive arthritis is a sterile process induced and maintained by antigenic material in the synovium. Continued synthesis of antigens to maintain synovial inflammation probably requires establishment of persistent bacterial infection in the joint, or at the primary site of infection. In the case of Chlamydia trachomatis, viable, metabolically-active organisms have been demonstrated to exist for extended periods in the joints of patients with reactive arthritis. In this chapter, we review the aetiological agents, and their molecular biology and phagocyte-host interactions, that are involved in reactive arthritis and spondylarthropathy.

Host-microbe interaction in HLA-B27-associated diseases

The mechanisms leading to the development of HLA-B27-associated diseases, spondyloarthropathies, are unknown. One of them, reactive arthritis, is clearly caused by an infection, and joint inflammation develops soon after or during an infection elsewhere in the body. In other forms of spondyloarthropathies, such as ankylosing spondylitis, association with infection is suggested but it is not as clear. Pathogenetic mechanisms of reactive arthritis are a focus of great interest as causative infections and strong genetic association are known. How HLA-B27 determines the appearance of joint complications after certain infections is not clear. Several theories have been proposed to explain the association, and they usually include the idea that interaction between microbe and host is abnormal and inefficient in HLA-B27-positive subjects in whom reactive arthritis develops.

Ig A antibodies to klebsiella in ankylosing spondylitis

In this study anti-klebsiella Ig A values were compared in 40 patients with definite diagnosis of ankylosing spondylitis and a control group of 40 healthy subjects. Anti-Klebsiella Ig A antibody values were significantly higher in patients with ankylosing spondylitis as compared to the control group (p < 0.001). Correlation between these antibodies and erythrocyte sedimentation rate, CRP, serum Ig A, HLA B 27, age, sex and disease duration was searched, but no correlation was found. In our opinion, these results support the suggestion that inflammatory response in ankylosing spondylitis is triggered by Klebsiella but is insufficient to prove the causal relationship between ankylosing spondylitis and Klebsiella.

A comparative study of HLA genes in HLA-B27 positive ankylosing spondylitis and HLA-B27 positive peripheral reactive arthritis

OBJECTIVE

To determine whether HLA-B27 positive patients with ankylosing spondylitis (AS) and reactive arthritis (ReA) share additional HLA factors that confer disease susceptibility.

METHODS

HLA class I antigens were typed serologically, and class II antigens molecularly, in samples taken from 33 patients with AS, 30 patients with ReA, and 55 healthy HLA-B27 positive controls.

RESULTS

There was no major difference between the HLA alleles in AS and ReA patients, but deviations were observed when compared with healthy controls, especially between the antigens that were probably encoded by genes in the non-B27 chromosome.

CONCLUSION

These results suggest that both HLA class I and class II genes may influence the pathogenesis of HLA-B27 positive ReA, whereas class I antigens seem to be the major additional genetic factors in HLA-B27 positive AS.

The use of a low starch diet in the treatment of patients suffering from ankylosing spondylitis

The majority of ankylosing spondylitis (AS) patients not only possess HLA-B27, but during active phases of the disease have elevated levels of total serum IgA, suggesting that a microbe from the bowel flora is acting across the gut mucosa. Biochemical studies have revealed that Klebsiella bacteria, not only possess 2 molecules carrying sequences resembling HLA-B27 but increased quantities of such microbes are found in fecal samples obtained from AS patients and such patients have Crohn's like lesions in the ileo-caecal regions of the gut. Furthermore AS patients from 10 different countries have been found to have elevated levels of specific antibodies against Klebsiella bacteria. It has been suggested that these Klebsiella microbes, found in the bowel flora, might be the trigger factors in this disease and therefore reduction in the size of the bowel flora could be of benefit in the treatment of AS patients. Microbes from the bowel flora depend on dietary starch for their growth and therefore a reduction in starch intake might be beneficial in AS patients. A "low starch diet" involving a reduced intake of "bread, potatoes, cakes and pasta" has been devised and tested in healthy control subjects and AS patients. The "low starch diet" leads to a reduction of total serum IgA in both healthy controls as well as patients, and furthermore to a decrease in inflammation and symptoms in the AS patients. The role of a "low starch diet" in the management of AS requires further evaluation.

Acute anterior uveitis: clinical and experimental aspects

Acute anterior uveitis (AAU) or iritis is an inflammatory disorder of the anterior structures of the eye that may be associated with a number of disease entities. A significant proportion of patients will have no evidence of an underlying disorder and are labeled as idiopathic. Within this group approximately 50% will possess the human leukocyte antigen, HLA-B27, and some will have an associated spondyloarthropathy such as ankylosing spondylitis or Reiter's syndrome. Nevertheless, a number of HLA-B27-positive patients have no apparent underlying rheumatic disorder. The potential interplay of HLA-B27 and certain infective agents in the pathogenesis of AAU is discussed with particular reference to Yersinia species. Presentation of a uveitogenic peptide, similar to the arthritogenic peptide model in spondyloarthropathies, may be a mechanism involved in the development of AAU. Experimental models in animals have increased our understanding of the roles of retinal proteins and bacterial peptides, as well as T cells and cytokines, in the pathogenesis of uveitis. As in animal models of arthritis, certain retinal peptides (in conjunction with adjuvant therapy) can induce uveitis in animals. The treatment of isolated AAU usually involves topical medication and the prognosis is good. Occasional cases, especially those associated with systemic disorders, may require the addition of systemic corticosteroids or other immunosuppressive medications.

Serum IgA anti-Klebsiella antibodies in ankylosing spondylitis patients from Catalonia

IgA antibodies against Klebsiella pneumoniae were measured by immunofluorescence in 84 Catalan patients with ankylosing spondylitis (AS), 41 patients with non-inflammatory arthropathies (NIA) and 22 patients with rheumatoid arthritis (RA). Patients with AS showed higher levels of anti-klebsiella IgA antibodies (IgA-Kp) than NIA and RA patients (4.7 +/- 1.6 U vs 3.7 +/- 1.5 U and 3.1 +/- 1.4 U respectively, p = 0.001). In AS patients a significant correlation between IgA-Kp and levels of C-reactive protein was observed. Although no clear correlation was found between IgA anti-klebsiella and total serum IgA levels, a significant correlation between IgA anti-klebsiella and serum levels of secretory IgA was detected (r: 0.43, p = 0.003). In conclusion, some patients with AS disclosed raised levels of Klebsiella antibodies in sera and this is related to an increase of secretory IgA level. Analysis about the relationship between response to klebsiella and the presence of gut inflammation in AS patients could be of interest.

Association between reactive arthritis and antecedent infection with Shigella flexneri carrying a 2-Md plasmid and encoding an HLA-B27 mimetic epitope

OBJECTIVE

To determine whether Shigella flexneri strains that cause enteric infection and are associated with reactive arthritis (ReA) carry a 2-Md plasmid, pHS-2, which encodes an HLA-B27 mimetic epitope.

METHODS

Plasmid DNA from Shigella isolates was characterized by DNA-DNA hybridization, restriction endonuclease digestion, and sequencing.

RESULTS

S flexneri strains associated with ReA carried a 2-Md plasmid homologous to pHS-2.

CONCLUSION

The finding of pHS-2 in additional Shigella strains associated with ReA underscores its potential importance in the etiology of the disease.