Isolation of Mycoplasma pneumoniae from the synovial fluid of a hypogrammaglobulinaemic patient in a survey of patients with inflammatory polyarthritis

Galacto-Oligosaccharides as an Anti-Infective and Anti-Microbial Agent for Macrolide-Resistant and -Sensitive Mycoplasma pneumoniae

The worldwide increase in the incidence of antibiotic resistance of the atypical bacterium Mycoplasma pneumoniae (MP) challenges the treatment of MP infections, especially in children. Therefore, alternative strategies for the treatment of MP infections are warranted. Galacto- and fructo-oligosaccharides (GOS and FOS) are a specific group of complex carbohydrates that were recently shown to possess direct anti-pathogenic properties. In this study, we assessed whether GOS and FOS exert anti-microbial and anti-infective effects against MP and, especially, macrolide-resistant MP (MRMP) in vitro. The MIC values of GOS for MP and MRMP were 4%. In contrast, the MIC values of FOS for both MP and MRMP were 16%. A time-kill kinetic assay showed that FOS possess bacteriostatic properties, while for GOS, a bactericidal effect against MP and MRMP was observed after 24 h at a concentration of 4x MIC. In co-cultures with human alveolar A549 epithelial cells, GOS killed adherent MP and MRMP and also concentration-dependently inhibited their adherence to A549 cells. Further, GOS suppressed (MR)MP-induced IL-6 and IL-8 in A549 cells. None of the aforementioned parameters were affected when FOS were added to these co-cultures. In conclusion, the anti-infective and anti-microbial properties of GOS could provide an alternative treatment against MRMP and MP infections.

Mycoplasma pneumoniae Infections and Primary Immune Deficiencies

Mycoplasma pneumoniae (M. pneumoniae) is one of the leading causes of community-acquired pneumonia in children and is also implicated in a variety of reactive extrapulmonary diseases. Recurrent and/or severe respiratory infections are one of the most frequent manifestations of several types of primary immunodeficiency. Here, we reviewed the medical literature to assess the potential relevance of M. pneumoniae in the infections observed in children affected with combined, humoral, and innate primary immune deficiencies. M. pneumoniae does not result to be epidemiologically prevalent as a cause of pneumonia in children affected by primary immunodeficiencies, but this infection can have a persistent or severe course in this category of patients. Indeed, the active search of M. pneumoniae could be useful and appropriate especially in children with humoral immune deficiencies. Indeed, most cases of M. pneumoniae infection in primary immunodeficiencies are described in patients affected by a/hypo-gammaglobulinemia.

Mycoplasma pneumoniae carriage evades induction of protective mucosal antibodies

Background

Mycoplasma pneumoniae is the most common bacterial cause of pneumonia in children hospitalised for community-acquired pneumonia (CAP). Prevention of infection by vaccines may be an important strategy in the presence of emerging macrolide-resistant M. pneumoniae. However, knowledge of immune responses to M. pneumoniae is limited, complicating vaccine design.

Methods

We studied the antibody response during M. pneumoniae respiratory tract infection and asymptomatic carriage in two different cohorts.

Results

In a nested case–control study (n=80) of M. pneumoniae carriers and matched controls we observed that carriage by M. pneumoniae does not lead to a rise in either mucosal or systemic M. pneumoniae-specific antibodies, even after months of persistent carriage. We replicated this finding in a second cohort (n=69) and also found that during M. pneumoniae CAP, mucosal levels of M. pneumoniae-specific IgA and IgG did increase significantly. In vitro adhesion assays revealed that high levels of M. pneumoniae-specific antibodies in nasal secretions of paediatric patients prevented the adhesion of M. pneumoniae to respiratory epithelial cells.

Conclusions

Our study demonstrates that M. pneumoniae-specific mucosal antibodies protect against bacterial adhesion to respiratory epithelial cells, and are induced only during M. pneumoniae infection and not during asymptomatic carriage. This is strikingly different from carriage with bacteria such as Streptococcus pneumoniae where mucosal antibodies are induced by bacterial carriage.

Antibodies against M. pneumoniae, the most common bacterial cause of pneumonia in children, are able to prevent adhesion of M. pneumoniae to epithelial cells, but are only induced during infection and not during asymptomatic carriagehttps://bit.ly/3CNdAhM

Arthritis associated with Mycoplasma pneumoniae in a pediatric patient: A case report

INTRODUCTION

Mycoplasma pneumoniae (MP) infection in infants is usually overlooked and it might result in important complications if left untreated. MP-induced arthritis is probably the least common extrapulmonary manifestation and frequently leads to delays in the diagnosis.

PATIENT CONCERNS

We report the case of a 2-year-old female child admitted in our clinic for prolonged fever (onset 2 weeks before the admission), for which the general practitioner established the diagnosis of acute pharyngitis and recommended antibiotics. But the fever persisted and the patient was referred to a pediatrician.

DIAGNOSIS

The laboratory tests revealed leukocytosis with neutrophilia, elevated C-reactive protein and liver cytolysis. The blood and urine cultures, as well as the serological hepatitis B and C, toxoplasmosis, Epstein Barr virus, Rubella, Herpes virus, and cytomegalovirus were negative. The chest X-ray established the diagnosis of pneumonia. The fever persisted for approximately 2 weeks after admission. On the 2nd week of admission, the patient began to experience gait difficulties complaining of pain in the right hip and ankle. The cardiology and pneumology consults revealed no pathological findings. The evolution was favorable after the initiation of Levofloxacin and MP infection was detected as we suspected. Moreover, the ultrasound of the hip revealed a mild joint effusion, while the ankle joint appeared to be normal at ultrasound. Thus, we established the diagnosis of hip and ankle arthritis based on the clinical and ultrasound findings.

INTERVENTIONS

Levofloxacin by vein was continued for 5 days, replaced afterwards with clarithromycin orally for 2 weeks.

OUTCOMES

The gait difficulties persisted for approximately 5 months from the initial diagnosis, and improved once the titer of immunoglobulin M anti-MP antibodies lowered considerably. After more than 8 months, the patient was completely asymptomatic and the immunoglobulin M anti-MP was close to the normal range.

CONCLUSION

The awareness of MP-induced arthritis in children represents the cornerstone in preventing diagnostic delays and initiating the proper treatment.

Recurrent Multifocal Mycoplasma orale Infection in an Immunocompromised Patient: A Case Report and Review

A young woman with mixed connective tissue disease complicated by erosive arthritis, secondary hypogammaglobulinemia due to rituximab, and a history of many infectious complications developed multiple nonhealing wounds, polyarticular joint pain, and leukocytosis. Radiographic studies demonstrated multiple scattered areas of osteomyelitis and complex abscesses. Purulent fluid drained from multiple sites did not yield a microbiologic diagnosis by standard culture technique, but Mycoplasma orale was ultimately identified using 16 S ribosomal RNA gene amplification and sequencing. We describe this unique case and review the literature.

The Role of B Cells in Carriage and Clearance of Mycoplasma pneumoniae From the Respiratory Tract of Mice

Background

Carriage of Mycoplasma pneumoniae (Mp) in the nasopharynx is considered a prerequisite for pulmonary infection. It is interesting to note that Mp carriage is also detected after infection. Although B cells are known to be involved in pulmonary Mp clearance, their role in Mp carriage is unknown.

Methods

In this study, we show in a mouse model that Mp persists in the nose after pulmonary infection, similar to humans.

Results

Infection of mice enhanced Mp-specific immunoglobulin (Ig) M and IgG levels in serum and bronchoalveolar lavage fluid. However, nasal washes only contained elevated Mp-specific IgA. These differences in Ig compartmentalization correlated with differences in Mp-specific B cell responses between nose- and lung-draining lymphoid tissues. Moreover, transferred Mp-specific serum Igs had no effect on nasal carriage in B cell-deficient μMT mice, whereas this enabled μMT mice to clear pulmonary Mp infection.

Conclusions

We report the first evidence that humoral immunity is limited in clearing Mp from the upper respiratory tract.

Antibodies to Protein but Not Glycolipid Structures Are Important for Host Defense against Mycoplasma pneumoniae

Antibody responses to Mycoplasma pneumoniae correlate with pulmonary M. pneumoniae clearance. However, M. pneumoniae-specific IgG antibodies can cross-react with the myelin glycolipid galactocerebroside (GalC) and cause neurological disorders. We assessed whether antiglycolipid antibody formation is part of the physiological immune response to M. pneumoniae We show that antibodies against M. pneumoniae proteins and glycolipids arise in serum of M. pneumoniae-infected children and mice. Although antibodies to M. pneumoniae glycolipids were mainly IgG, anti-GalC antibodies were only IgM. B-1a cells, shown to aid in protection against pathogen-derived glycolipids, are lacking in Bruton tyrosine kinase (Btk)-deficient mice. M. pneumoniae-infected Btk-deficient mice developed M. pneumoniae-specific IgG responses to M. pneumoniae proteins but not to M. pneumoniae glycolipids, including GalC. The equal recovery from M. pneumoniae infection in Btk-deficient and wild-type mice suggests that pulmonary M. pneumoniae clearance is predominantly mediated by IgG reactive with M. pneumoniae proteins and that M. pneumoniae glycolipid-specific IgG or IgM is not essential. These data will guide the development of M. pneumoniae-targeting vaccines that avoid the induction of neurotoxic antibodies.

Pathogenesis and Treatment of Neurologic Diseases Associated With Mycoplasma pneumoniae Infection

Mycoplasma pneumoniae is mainly recognized as a respiratory pathogen, although it is associated with the development of several extra-respiratory conditions in up to 25% of the cases. Diseases affecting the nervous system, both the peripheral (PNS) and the central nervous system (CNS), are the most severe. In some cases, particularly those that involve the CNS, M. pneumoniae-related neuropathies can lead to death or to persistent neurologic problems with a significant impact on health and a non-marginal reduction in the quality of life of the patients. However, the pathogenesis of most of the M. pneumoniae-related neuropathies remains undefined. The main aim of this paper is to discuss what is presently known regarding the pathogenesis and treatment of the most common neurologic disorders associated with M. pneumoniae infection. Unfortunately, the lack of knowledge of the true pathogenesis of most of the cases of M. pneumoniae-mediated neurological diseases explains why treatment is not precisely defined. However, antibiotic treatment with drugs that are active against M. pneumoniae and able to pass the blood-brain barrier is recommended, even though the best drug, dosage, and duration of therapy have not been established. Sporadic clinical reports seem to indicate that because immunity plays a relevant role in the severity of the condition and outcome, attempts to reduce the immune response can be useful. However, further studies are needed before the problem of the best therapy for M. pneumoniae-mediated neurological diseases can be efficiently solved.

Novel aspects on the pathogenesis of Mycoplasma pneumoniae pneumonia and therapeutic implications

Mycoplasma pneumoniae (Mp) is a leading cause of community acquired pneumonia. Knowledge regarding Mp pneumonia obtained from animal models or human subjects has been discussed in many different reports. Accumulated expertise concerning this critical issue has been hard to apply clinically, and potential problems may remain undiscovered. Therefore, our multidisciplinary team extensively reviewed the literature regarding Mp pneumonia, and compared findings from animal models with those from human subjects. In human beings, the characteristic pathological features of Mp pneumonia have been reported as alveolar infiltration with neutrophils and lymphocytes and lymphocyte/plasma cell infiltrates in the peri-bronchovascular area. Herein, we demonstrated the novel aspects of Mp pneumonia that the severity of the Mp pneumonia seemed to depend on the host innate immunity to the Mp, which might be accelerated by antecedent Mp exposure (re-exposure or latent respiratory infection) through up-regulation of Toll-like receptor 2 expression on bronchial epithelial cells and alveolar macrophages. The macrolides therapy might be beneficial for the patients with macrolide-resistant Mp pneumonia via not bacteriological but immunomodulative effects. This exhaustive review focuses on pathogenesis and extends to some therapeutic implications such as clarithromycin, and discusses the various diverse aspects of Mp pneumonia. It is our hope that this might lead to new insights into this common respiratory disease.

Diagnosis of ureaplasma urealyticum septic polyarthritis by PCR assay and electrospray ionization mass spectrometry in a patient with acute lymphoblastic leukemia

We report a case of polyarthritis with axial involvement in a young female patient treated for acute lymphoblastic leukemia. Detection in the hip fluid of Ureaplasma urealyticum by broad-range PCR followed by electrospray ionization mass spectrometry allowed the diagnosis of septic arthritis and ad integrum recovery upon adapted antibiotic therapy.

Pathogenesis of neurologic manifestations of Mycoplasma pneumoniae infection

Mycoplasma pneumoniae has been associated with various neurologic manifestations, but exactly how the organism can cause such a wide variety of diseases is a long-standing mystery. In this respect, although pneumonia has been considered the hallmark of Mycoplasma pneumoniae infection, emerging accumulations of data have revealed that the infection can cause a number of extrapulmonary manifestations even in the absence of pneumonia. The importance of host immune response in the pathomechanism of pneumonia has been established, but the pathomechanisms of extrapulmonary manifestations remain largely unknown. For this review, extrapulmonary manifestations due to M. pneumoniae infection were classified into three categories: a direct type, in which locally induced cytokines must play a role; an indirect type, in which immune modulation such as autoimmunity must play a role; and a vascular occlusion type, in which vasculitis or thrombosis (either or both, and with or without systemic hypercoagulable state) must play a role. This classification was then applied within a literature review for neurologic manifestations. Most neurologic manifestations due to M. pneumoniae infection could be reasonably classified into and explained by one of the three types of pathomechanisms.

Four cases of arthritis associated with Mycoplasma pneumoniae infection

BACKGROUND

Mycoplasma pneumoniae infection is diagnosed commonly by marked elevation of serum antibodies, but this requires several days and consequently M. pneumoniae infection might be overlooked in some cases. Recently an ImmunoCard Mycoplasma rapid diagnosis test (IC) has been developed and used clinically. One of the advantages of this diagnosis test is that clinicians can recognize the infection by a single administration at the beginning of treatment.

METHODS

A total of 1033 children aged 1-15 years (average 2.0 years) were examined. The diagnosis of M. pneumoniae infection was made mainly on the basis of a positive reaction to the IC. Also where possible, particle agglutination (PA) was performed as a confirmatory test. Diagnosis was made on the basis of a fourfold or greater rise in the PA antibody titer by paired sera or an initial single PA titer >1:320. Arthritis was diagnosed mainly on clinical symptoms. Additionally, ultrasonography (US) was conducted to confirm arthritis. In using US, arthritis was defined as an enlargement of the low echoic section or fluid retention inside the articular capsule.

RESULTS

IC was used in 1033 patients and results were positive in 348 (33.6%). Of these 348, there were 70 cases of pneumonia (20.1%) and four cases of arthritis (1.1%). IC was positive in all of the cases of arthritis, and in two of the four arthritis patients the PA titers were also useful for diagnoses. In three of four cases, US was performed and lesions were observed in two of three cases. Three of the four arthritis patients were infants and only one of these three had pneumonia.

CONCLUSIONS

Using IC as a screening test, occult M. pneumoniae infections were discovered that would otherwise have been overlooked. These included two patients with US-proved arthritis. Arthritis in the absence of pneumonia may not be an unusual manifestation in infants infected by this organism.

Osteoarticular infectious complications in patients with primary immunodeficiencies

PURPOSE OF REVIEW

To describe the incidence and management of various infectious arthritides in selected primary immunodeficiency states.

RECENT FINDINGS

Joint complications have been a well recognized finding in patients with primary immunodeficiencies for many years. Many are clearly infectious in etiology, but other apparently noninfectious joint abnormalities similar to rheumatoid arthritis have been shown to be due to an underlying infectious trigger. In humoral immunodeficiencies such as common variable immunodeficiency and X-linked agammaglobulinemia, bacterial organisms are the most common causes of infectious arthritis, but mycoplasmas and ureaplasmas are also of particular importance. In nonhumoral immunodeficiencies, noninfectious inflammatory arthritides are more prevalent, although microbiologic organisms have been reported in some cases of arthritis. Lack of appropriate culturing techniques and documentation of infectious agents may underestimate the prevalence of low-virulence infections in these patients.

SUMMARY

Infectious arthritis is a significant comorbidity associated with primary immunodeficiencies and can be the presenting feature for some patients. Prompt examination for common as well as atypical organisms is not only important for the treatment but also crucial to the understanding of the exact etiology of arthritides as a whole in these disorders.

Bone and joint disease associated with primary immune deficiencies

Primary immune deficiencies (PIDs) are characterized by functional and/or quantitative abnormalities of one or more immune system components. Several bone and joint abnormalities can occur in patients with PID, with arthritis being the most common. Joint manifestations, of which arthritis is the most common, occur chiefly in humoral PIDs (agammaglobulinemia, common variable immunodeficiency, hyper-IgM syndromes, and IgA deficiency) and occasionally in other PIDs (chronic granulomatous disease and Wiskott-Aldrich syndrome). Monoarthritis or oligoarthritis is the usual pattern, although polyarthritis may occur, occasionally with nodules suggesting rheumatoid arthritis. Arthritis in patients with PID is usually infectious in nature, the most common causative organism being Mycoplasma, followed by Staphylococcus, Streptococcus, and Haemophilus. These bacteria can induce not only synovial infections, but also aseptic arthritogenic inflammatory responses. Arthritis having no demonstrable relation to chronic infection has been reported also and ascribed to dysimmunity-driven mechanisms that exhibit a number of specific features. Bone lesions are far less common and usually due to infections complicating humoral PID. Distinctive bone manifestations occur in a number of rare PIDs (e.g., hyper-IgE syndrome and Di George syndrome) and in syndromes characterized by spondyloepiphyseal dysplasia. Familiarity with PID syndromes both enhances the diagnostic capabilities of physicians and provides insight into the pathophysiology of bone and joint abnormalities associated with immune dysfunction. In children and occasionally in adults, a combination of bone and/or joint manifestations and hypogammaglobulinemia may indicate PID. When there is no evidence of lymphoproliferative disease, infection, or iatrogenic complications, investigations for PID should be obtained. PID-related arthritis is a unique model for studying the pathogenesis of presumably postinfectious arthritis and of inflammatory joint diseases including rheumatoid arthritis.

Relationship between rheumatoid arthritis and Mycoplasma pneumoniae: a case-control study

OBJECTIVE

Rheumatoid arthritis (RA) has a complex and multifactorial aetiology. Infectious agents could start this disease. The majority of the characteristics of this infirmity can be observed in chronic arthritis produced by mycoplasmas in animals. In this study the association between Mycoplasma pneumoniae and RA has been evaluated.

METHODS

A case-control study was performed. Sera taken from 78 RA patients and from 156 controls were analysed to ascertain the levels of immunoglobulin G (IgG) against M. pneumoniae. Other variables, like age, gender, work status, history of pneumonia, etc., were recorded in a questionnaire.

RESULTS

The presence of antibodies against M. pneumoniae was associated with RA (odds ratio=2.34, P<0.001).

CONCLUSIONS

The results suggest that M. pneumoniae could be a cofactor in the pathogenesis of RA; however, more studies need to be done.

Mycoplasma pneumoniae and its role as a human pathogen

Mycoplasma pneumoniae is a unique bacterium that does not always receive the attention it merits considering the number of illnesses it causes and the degree of morbidity associated with it in both children and adults. Serious infections requiring hospitalization, while rare, occur in both adults and children and may involve multiple organ systems. The severity of disease appears to be related to the degree to which the host immune response reacts to the infection. Extrapulmonary complications involving all of the major organ systems can occur in association with M. pneumoniae infection as a result of direct invasion and/or autoimmune response. The extrapulmonary manifestations are sometimes of greater severity and clinical importance than the primary respiratory infection. Evidence for this organism's contributory role in chronic lung conditions such as asthma is accumulating. Effective management of M. pneumoniae infections can usually be achieved with macrolides, tetracyclines, or fluoroquinolones. As more is learned about the pathogenesis and immune response elicited by M. pneumoniae, improvement in methods for diagnosis and prevention of disease due to this organism may occur.

Endocarditis and Ureaplasma urealyticum osteomyelitis in a hypogammaglobulinemic patient. A case report and review of the literature

We report a hypogammaglobulinemic patient who developed chronic polyarthritis and osteomyelitis due to Ureaplasma urealyticum. He also had mitral valve endocarditis of uncertain origin. Patients with primary antibody deficiency show increased susceptibility to mycoplasma infections. Early diagnosis and treatment is very important in order to prevent potentially debilitating complications.

Common variable immunodeficiency presenting as a Mycoplasma hominis septic arthritis

A case is reported of common variable immunodeficiency (CVID) presenting as an acute septic arthritis due to Mycoplasma hominis. The diagnosis was not considered until the hypogammaglobulinaemia was discovered and the synovial fluid cultured specifically for mycoplasmas. The importance of diagnosing immunodeficiency states and searching for mycoplasmas in 'bacteriologically culture negative' cases is emphasized.

Bilateral chronic conjunctivitis and corneal scarring in a boy with X-linked hypogammaglobulinaemia

We report an unusual case of bilateral chronic conjunctivitis and corneal scarring in a boy with X-linked hypogammaglobulinaemia (XLH) who did not respond to the usual antibacterial and antiviral therapy. An immunofluorescence test for Chlamydia trachomatis from an eye swab was strongly positive. Within days of commencement of local and systemic tetracycline therapy, he showed marked improvement. Since conjunctival follicle formation, which depends on the presence of a B-cell population, may not occur in XLH, clinical examination in chlamydia conjunctivitis may be misleading and lead to a delay in diagnosis and treatment with resulting corneal complications, unless laboratory evidence of chlamydia infection is specifically sought.

Mycoplasma pneumoniae and Mycoplasma genitalium mixture in synovial fluid isolate

A mycoplasma cultured from synovial fluid specimens from a patient with pneumonia and subsequent polyarthritis was identified initially as Mycoplasma pneumoniae. In retrospective studies, the culture was shown also to contain Mycoplasma genitalium. In this paper, the laboratory techniques employed in the identification and separation of the two species are presented, and evidence to implicate postinfectious autoimmunity is provided. An increasing number of reports of M. genitalium in human tissue sites and difficulties in isolation and identification of the organism in the clinical laboratory suggest the need for more extensive application of rapid and specific detection systems for both M. genitalium and M. pneumoniae in the clinical laboratory.

Intranasal inoculation of Mycoplasma pulmonis in mice with severe combined immunodeficiency (SCID) causes a wasting disease with grave arthritis

Mycoplasma pulmonis or Myc. pneumoniae were inoculated intranasally to C.B-17 scid/scid mice (severe combined immunodeficient (SCID) mice). Immunocompetent C.B-17 mice were inoculated as controls. During the observation period of 5 weeks the mice were killed and necropsied. Mycoplasma pulmonis was recovered from all of the inoculated mice, and dissemination to various tissues increased with time. SCID mice, unlike immunocompetent mice, did not show lung lesions but exhibited severe inflammatory changes of the joints. Mycoplasma pulmonis, however, was isolated both from the lungs and the articular lesions. In addition, SCID mice infected for more than 3 weeks suffered from a pronounced loss of weight and emaciation. In the experiment with Myc. pneumoniae the agent could be reisolated, but lesions were not found in any of the infected mice. Mycoplasma pulmonis infection in SCID mice may be useful as a model of arthritis in immunodeficient humans.

Mycoplasmas and ureaplasmas in patients with hypogammaglobulinaemia and their role in arthritis: microbiological observations over twenty years

OBJECTIVES

To study the occurrence of mycoplasmas and ureaplasmas in patients with hypogammaglobulinaemia and the relationship of these micro-organisms to septic arthritis.

METHODS

Over a period of about 20 years, 53 men and 38 women with hypogammaglobulinaemia, most of whom were less than 50 years old, were examined clinically and microbiologically. Mycoplasmas and ureaplasmas were sought in the throat, urogenital tract and joints by standard cultural methods, although not consistently in the three sites of all patients.

RESULTS

Arginine-hydrolysing mycoplasmas and ureaplasmas occurred with similar frequency in the sputum/throat of the hypogammaglobulinaemic patients, but no more often than might be expected in immunocompetent patients. Ureaplasmas, however, dominated in the urogenital tracts of both men and women, being found in 75% of vaginal specimens. Arginine-hydrolysing mycoplasmas occurred two to six times more frequently and ureaplasmas two to three times more frequently in urine specimens from hypogammaglobulinaemic patients than they did in such specimens from sex- and age-matched non-venereal disease, hospital patients or healthy subjects; these differences were statistically significant (p < 0.05). Enhanced mucosal colonisation probably increases the chance of spread to distant sites, such as the joints. Of the 91 patients, 21 (23%) had septic arthritis involving one or more joints. Mycoplasmas and/or ureaplasmas, but not bacteria, were isolated from the joints of eight (38%) of these patients. However, dissemination to joints apparently had not occurred in some despite the opportunity by virtue of mycoplasmal or ureaplasmal colonisation at a mucosal site. Sometimes antibiotic therapy failed clinically, and microbiologically and recommendations for management are outlined.

CONCLUSIONS

Hypogammaglobulinaemic patients appear to be more susceptible to colonisation of mucous membranes, especially of the urogenital tract, with mycoplasmas and ureaplasmas than are immunocompetent individuals. These micro-organisms are responsible for about two fifths of the septic arthritides occurring in these patients.

Hypogammaglobulinemia and rheumatic disease

Primary hypogammaglobulinemia describes a heterogeneous group of immunoglobulin disorders mainly composed of X-linked agammaglobulinemia, common variable immunodeficiency, and selective immunoglobulin (Ig) A deficiency. The most serious problems are related to recurrent infections with high-grade encapsulated bacteria. However, a wide variety of rheumatologic disorders also occur in association with hypogammaglobulinemic states. Septic arthritis with usual bacterial pathogens such as Staphylococcus aureus, and unusual bacteria such as Mycoplasma and Ureaplasma species, have been described in these patients. An aseptic nonerosive polyarticular arthritis that resembles rheumatoid arthritis is seen in 10% to 30% of hypogammaglobulinemic patients. Autoimmune disorders such as immune thrombocytopenic purpura, immune hemolytic anemia, juvenile rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis, Sjögren's syndrome, essential mixed cryoglobulinemia, chronic active hepatitis, and sarcoidosis have been reported in hypogammaglobulinemic patients. Finally, to complicate matters, many disease-modifying antirheumatic drugs, including gold, D-penicillamine, sulfasalazine, azathioprine, and cyclophosphamide, cause symptomatic hypogammaglobulinemia in some patients.

Lumbar pain caused by Mycoplasma infection

A 45-year-old woman was admitted to hospital following acute onset of lower back pain. Clinical and laboratory investigations established a lumbar paraspinal soft tissue infection with Mycoplasma hominis associated with severe spondylarthrosis at L5/S1. A relationship to a recently performed hysterectomy must be considered.

Clinical and biological characteristics of Ureaplasma urealyticum induced polyarthritis in a patient with common variable hypogammaglobulinaemia

Persistent infectious polyarthritis caused by Ureaplasma urealyticum in a patient with common variable hypogammaglobulinaemia is described. The patient developed a symmetrical, destructive polyarthritis and tenosynovitis associated with a markedly depressed synovial fluid glucose concentration and characteristic soft tissue abscesses. The ureaplasma organism developed resistance to multiple antibiotics and persisted for five years. The organism was identified repeatedly in many joints by culture, confirmed by DNA hybridisation, and mycoplasma-like structures were shown in synovial tissues by electron microscopy.

Molecular distinctions among clinical isolates of Mycoplasma pneumoniae

Restriction enzyme fingerprinting of genomic DNA and Southern blots probed with subclones of the Mycoplasma pneumoniae cytadhesin P1 gene were used to characterize clinical isolates of M. pneumoniae. On the basis of the examination of 29 individual M. pneumoniae isolates, two distinct groups were established. Group 1, which displayed a 12-kilobase band following DNA digestion with HindIII, consisted of strain M129-B16 and three others obtained in the state of Washington during the 1960s. The remaining M. pneumoniae strains belonged to group 2, which lacked the 12-kilobase band and included samples from the 1940s, 1970s, and 1980s. This category also included the only M. pneumoniae strain isolated from the synovial fluid of an arthritic patient.

Infective conjunctivitis and corneal scarring in three brothers with sex linked hypogammaglobulinaemia (Bruton's disease)

The ocular findings in three brothers with Bruton's disease are reported. All three boys had purulent conjunctivitis, but the two older brothers also developed marked corneal scarring with visual impairment. Haemophilus influenzae was cultured from conjunctival swabs; it was resistant to neomycin but sensitive to chloramphenicol. Tear analysis showed that the three subjects had normal levels of lysozyme but no detectable IgA.

Septic osteomyelitis and polyarthritis with ureaplasma in hypogammaglobulinemia

We describe a hypogammaglobulinemic woman with a one-year history of destructive septic osteomyelitis and polyarthritis with positive cultures for Ureaplasma urealyticum from joint exudate and blood. The clinical course was complicated by subcutaneous abscesses from which both U. urealyticum and Mycoplasma hominis were grown. Multiple routine cultures had been negative, except for sporadic findings of Staphylococcus epidermidis before specific cultures for mycoplasmas were performed. Therapy with beta-lactam antibiotics, clindamycin, rifampicin, fusidic acid and aminoglycosides had been given without obvious clinical effect. Intravenous doxycycline treatment instituted after microbiological diagnosis had a dramatic effect on the clinical course. The clinical suspicion of mycoplasma and ureaplasma as etiologic agents of orthopaedic infections in hypogammaglobulinemic patients is mandatory in order to perform appropriate cultures.

Primary hypogammaglobulinaemia and arthritis

Arthritis may be the first clinical manifestation of primary hypogammaglobulinaemia. In 16 years of 281 patients who had immunodeficiency, 30 had arthritis at presentation. It was more common in Bruton's disease (15 (22%) of 69 patients) than in other forms of immunodeficiency (15 (7%) of 212 patients). Non-septic arthritis was more prevalent than septic arthritis, particularly monoarticular arthritis in Bruton's disease and pauciarticular disease in common variable immunodeficiency. Boys in whom a diagnosis of Bruton's disease was delayed were likely to develop recurrent infections complicated by arthritis. The measurement of serum immunoglobulin concentrations readily differentiates immunodeficiency from conditions such as Still's disease and dictates subsequent management.

Increased susceptibility to Mycoplasma infection in patients with hypogammaglobulinemia

The incidence and morbidity of Mycoplasma infections were examined in a group of 23 patients with hypogammaglobulinemia. Among this group of patients, 18 had one or more episodes of acute respiratory illness during which Ureaplasma urealyticum, Mycoplasma orale, or Mycoplasma pneumoniae were isolated from sputum. Resolution only followed institution of specific antibiotic therapy and elimination of the Mycoplasma. In addition to respiratory illness, U. urealyticum was isolated from the urine of two patients with urinary tract infection and from an area of cellulitis in another patient. M. pneumoniae was isolated from the joint of a patient with arthritis. In six patients with chronic lung disease, Mycoplasma was frequently isolated and clinical improvement, albeit transient, coincided with negative Mycoplasma culture results. These findings emphasize the unique susceptibility to Mycoplasma infection in patients with hypogammaglobulinemia.

Analysis of T-cell cultures and clones from a patient with classic rheumatoid arthritis--evidence for the existence of autoreactive T-cell clones in blood and synovial fluid

Using lectin-free IL-2 as the only initial stimulus, bulk cultures and T-cell clones were established from synovial fluid (SFL) and peripheral blood lymphocytes (PBL) of a patient with rheumatoid arthritis (RA). The cloning efficiency of growing bulk cultures was 3%-4% as evaluated by Poisson statistics and was not enhanced by the addition of autologous synovial fluid or serum. The majority of the cloned T cells expressed the OKT8+ phenotype; several clones were OKT4+ and one clone expressed OKT8+ and OKT4+ antigens. None of the cloned T cells exhibited high NK or lectin-dependent cytotoxicity, although bulk cultures had high NK activity. In primed lymphocyte typing responses, bulk cultures and two T-cell clones established from rheumatoid SFL and PBL showed consistent autoreactivity, which we have never before observed with MLC-derived bulk cultures and T cell clones. One of the autoreactive rheumatoid T-cell clones (B25) was found to provide strong helper activity to autologous B cells in the absence of mitogen. Attempts to reveal reactivity of RA-derived T-cell clones to microbial antigens have so far only been successful with Mycoplasma pneumoniae preparations. Careful analysis of this reactivity revealed, however, that Mycoplasma pneumoniae induces a stimulator cell-dependent mitogenic effect rather than an antigen-specific MHC-restricted T-cell proliferation.

Dermatologic conditions reported in patients with rheumatoid arthritis

Dermatologists, while becoming increasingly involved in the diagnosis and management of patients with connective tissue diseases, have left rheumatoid arthritis relatively unexplored. An increased awareness of possible pathomechanisms of rheumatoid arthritis may allow for generalizations that lead to increased understanding of other connective tissue disorders. The types of cutaneous disorders that occur in association with rheumatoid arthritis include: vasoreactive dermatoses (e.g., various forms of vasculitis), which may occur secondary to the circulating immune complexes present in rheumatoid arthritis; autoimmune bullous disorders, which may occur in the setting of a suppressor T cell defect in rheumatoid arthritis; and various miscellaneous cutaneous associations. Hopefully, this review will lead to an increased understanding of both rheumatoid arthritis and the wide array of cutaneous associations of rheumatoid arthritis.

Primary late-onset hypogammaglobulinaemia associated with inflammatory polyarthritis and septic arthritis due to Mycoplasma pneumoniae

A case is reported of primary late-onset hypogammaglobulinaemia associated with a chronic seronegative, nonerosive arthritis, which was complicated by an episode of septic arthritis due to Mycoplasma pneumoniae. The patient had subcutaneous nodules which have not been regarded previously as a feature of the chronic arthritis associated with hypogammaglobulinaemia. The diagnosis of septic arthritis was delayed for 2 months until synovial fluid was specifically cultured for mycoplasmas. This delay resulted in considerable joint destruction. The importance of searching for mycoplasmas in similar cases is emphasised.