Reactive arthritis associated with Campylobacter jejuni enteritis

Campylobacter jejuni and Postinfectious Autoimmune Diseases: A Proof of Concept in Glycobiology

Glycans, one of the most diverse groups of macromolecules, are ubiquitous constituents of all cells and have many critical functions, including the interaction between microbes and their hosts. One of the best model organisms to study the host-pathogen interaction, the gastrointestinal pathogen Campylobacter jejuni dedicates extensive resources to glycosylation and exhibits a diverse array of surface sugar-coated displays. The first bacterium where N-linked glycosylation was described, C. jejuni can additionally modify proteins by O-linked glycosylation, has extracellular capsular polysaccharides that are important for virulence and represent the major determinant of the Penner serotyping scheme, and has outer membrane lipooligosaccharides that participate in processes such as colonization, survival, inflammation, and immune evasion. In addition to causing gastrointestinal disease and extraintestinal infections, C. jejuni was also linked to postinfectious autoimmune neuropathies, of which Guillain-Barré syndrome (GBS) and Miller Fisher syndrome (MFS) are the most extensively characterized ones. These postinfectious autoimmune neuropathies occur when specific bacterial surface lipooligosaccharides mimic gangliosides in the host nervous system. C. jejuni provided the first proof of concept for the involvement of molecular mimicry in the pathogenesis of an autoimmune disease and, also, for the ability of a bacterial polymorphism to shape the clinical presentation of the postinfectious autoimmune neuropathy. The scientific journey that culminated with elucidating the mechanistic details of the C. jejuni-GBS link was the result of contributions from several fields, including microbiology, structural biology, glycobiology, genetics, and immunology and provides an inspiring and important example to interrogate other instances of molecular mimicry and their involvement in autoimmune disease.

Microbiota from Specific Pathogen-Free Mice Reduces Campylobacter jejuni Chicken Colonization

Campylobacter jejuni, a prevalent foodborne bacterial pathogen, is mainly transmitted from poultry with few effective prevention approaches. In this study, we aimed to investigate the role of microbiota on C. jejuni chicken colonization. Microbiota from specific pathogen-free (SPF) mouse stools were collected as SPF-Aerobe and SPF-Anaerobe. Birds were colonized with SPF-Aerobe or SPF-Anaerobe at day 0 and infected with C. jejuni AR101 at day 12. Notably, C. jejuni AR101 colonized at 5.3 and 5.6 log₁₀ C. jejuni CFU/g chicken cecal digesta at days 21 and 28, respectively, while both SPF-Aerobe and SPF-Anaerobe microbiota reduced pathogen colonization. Notably, SPF-Aerobe and SPF-Anaerobe increased cecal phylum Bacteroidetes and reduced phylum Firmicutes compared to those in the nontransplanted birds. Interestingly, microbiota from noninfected chickens, SPF-Aerobe, or SPF-Anaerobe inhibited AR101 in vitro growth, whereas microbiota from infected birds alone failed to reduce pathogen growth. The bacterium Enterobacter102 isolated from infected birds transplanted with SPF-Aerobe inhibited AR101 in vitro growth and reduced pathogen gut colonization in chickens. Together, SPF mouse microbiota was able to colonize chicken gut and reduce C. jejuni chicken colonization. The findings may help the development of effective strategies to reduce C. jejuni chicken contamination and campylobacteriosis.

Microbiota attenuates chicken transmission-exacerbated campylobacteriosis in Il10-/- mice

Campylobacter jejuni is a prevalent foodborne pathogen mainly transmitting through poultry. It remains unknown how chicken-transmitted C. jejuni and microbiota impact on human campylobacteriosis. Campylobacter jejuni AR101 (Cj-P0) was introduced to chickens and isolated as passage 1 (Cj-P1). Campylobacter jejuni Cj-P1-DCA-Anaero was isolated from Cj-P0-infected birds transplanted with DCA-modulated anaerobic microbiota. Specific pathogen free Il10-/- mice were gavaged with antibiotic clindamycin and then infected with Cj-P0, Cj-P1, or Cj-P1-DCA-Anaero, respectively. After 8 days post infection, Il10-/- mice infected with Cj-P1 demonstrated severe morbidity and bloody diarrhea and the experiment had to be terminated. Cj-P1 induced more severe histopathology compared to Cj-P0, suggesting that chicken transmission increased C. jejuni virulence. Importantly, mice infected with Cj-P1-DCA-Anaero showed attenuation of intestinal inflammation compared to Cj-P1. At the cellular level, Cj-P1 induced more C. jejuni invasion and neutrophil infiltration into the Il10-/- mouse colon tissue compared to Cj-P0, which was attenuated with Cj-P1-DCA-Anaero. At the molecular level, Cj-P1 induced elevated inflammatory mediator mRNA accumulation of Il17a, Il1β, and Cxcl1 in the colon compared to Cj-P0, while Cj-P1-DCA-Anaero showed reduction of the inflammatory gene expression. In conclusion, our data suggest that DCA-modulated anaerobes attenuate chicken-transmitted campylobacteriosis in mice and it is important to control the elevation of C. jejuni virulence during chicken transmission process.

Is there an unrecognised role for Campylobacter infections in (chronic) inflammatory diseases?

Campylobacter species are one of the major causes of global bacterial-related diarrheal disease worldwide. The disease is most frequently associated with the ingestion of contaminated meat, raw milk, pets, contaminated water, and the organism may be frequently cultured from the faeces of chicken and other domesticated farm animals. Of the 17 established Campylobacter species, the most important pathogens for humans are Campylobacter jejuni (C. jejuni), Campylobacter coli (C. coli) and Campylobacter fetus (C. fetus), which are all associated with diarrheal disease. Further, C. jejuni and C. coli are also associated with the neuroparalytic diseases Guillain-Barré syndrome and Miller Fischer syndrome, respectively, whereas C. fetus is linked with psoriatic arthritis. The discovery of both “molecular mimicry” and translocation-related virulence in the pathogenesis of C. jejuni-induced disease, indicates that Campylobacter-related gastrointestinal infections may not only generate localized, acute intestinal infection in the human host, but may also be involved in the establishment of chronic inflammatory diseases. Indeed, pathogenicity studies on several Campylobacter species now suggest that molecular mimicry and translocation-related virulence is not only related to C. jejuni, but may play a role in human disease caused by other Campylobacter spp. In this review, the authors provide a review based on the current literature describing the potential links between Campylobacter spp. and (chronic) inflammatory diseases, and provide their opinions on the likely role of Campylobacter in such diseases.

Gastrointestinal and hepatic manifestations of rheumatoid arthritis

Rheumatoid arthritis (RA), characterized by inflammation of the synovium and surrounding structures, has a prevalence of 0.5-1%. Rheumatoid vasculitis (RV) is an inflammatory condition of the small- and medium-sized vessels that affects up to 5% of patients with RA with intestinal involvement in 10-38% of these cases. Clinically apparent RV of the gastrointestinal (GI) tract, while rare, is often catastrophic, resulting in ischemic ulcers and bowel infarction. Vasculitis of the colon may present as pancolitis clinically similar to ulcerative colitis. Rectal biopsies that include submucosal vessels are positive for vasculitis in up to 40% of cases. Abnormal esophageal motility in RA may result in heartburn and dysphagia. Chronic atrophic gastritis may be associated with hypergastrinemia and hypo- or achlorhydria, promoting small bowel bacterial overgrowth. RA is the most common cause of secondary amyloidosis with GI symptoms in 22% of affected patients. Although amyloid is usually found in the liver, it is rarely evident clinically. Felty's syndrome occurs in less than 1% of patients with RA and is characterized by neutropenia and splenomegaly. The liver may be involved with portal fibrosis or nodular regenerative hyperplasia. Liver histology is abnormal in 92% of RA patients at autopsy, although the changes are usually mild without associated hepatomegaly. Drug-induced liver disease may occur with aspirin, sulfasalazine, and methotrexate. Significant liver damage is rare if the drug is discontinued or the patient is properly monitored. RA can affect both the GI tract and the liver; changes are usually mild except with RV.

Pancreas affection in association with enteritis due to Campylobacter fetus ssp. jejuni

A woman with pancreas affection during diarrhoea due to Campylobacter fetus ssp. jejuni is presented. The patient recovered within 8 days without specific treatment. In addition, 5 other cases with pancreas affection associated with Campylobacter infection are cited.

Carditis and arthritis associated with Campylobacter jejuni infection

Three patients who developed carditis after enteritis caused by Campylobacter jejuni are reported. Two had perimyocarditis and one endocarditis. The cardiac sequelae persisted in two patients. Concomitant arthritis appeared in two of these patients, monoarthritis in one and polyarthritis in the other.

HLA-B27-negative arthritis related to Campylobacter jejuni enteritis in three children and two adults

Five out of 37 patients with proven Campylobacter jejuni enteritis developed arthritis. Two adult patients presented with classical Reiter's syndrome. One of the three children had reactive arthritis, and clinical suspicion of septic arthritis could not be confirmed in two. The acute synovitis subsided usually without treatment in all patients within 3-7 days, while arthralgia persisted longer in 4 patients. HLA-B27 was not present in the 5 patients with arthritis, but was found in 4 others. In Northern Norway, Campylobacter fetus ssp. jejuni is more frequently isolated from stool specimens than Salmonella, Shigella and Yersinia enterocolitica. Synovial fluid should be cultured following Campylobacter jejuni enteritis in arthritis patients.

Host-pathogen interactions in Campylobacter infections: the host perspective

Campylobacter is a major cause of acute bacterial diarrhea in humans worldwide. This study was aimed at summarizing the current understanding of host mechanisms involved in the defense against Campylobacter by evaluating data available from three sources: (i) epidemiological observations, (ii) observations of patients, and (iii) experimental observations including observations of animal models and human volunteer studies. Analysis of available data clearly indicates that an effective immune system is crucial for the host defense against Campylobacter infection. Innate, cell-mediated, and humoral immune responses are induced during Campylobacter infection, but the relative importance of these mechanisms in conferring protective immunity against reinfection is unclear. Frequent exposure to Campylobacter does lead to the induction of short-term protection against disease but most probably not against colonization. Recent progress in the development of more suitable animal models for studying Campylobacter infection has opened up possibilities to study the importance of innate and adaptive immunity during infection and in protection against reinfection. In addition, advances in genomics and proteomics technologies will enable more detailed molecular studies. Such studies combined with better integration of host and pathogen research driven by epidemiological findings may truly advance our understanding of Campylobacter infection in humans.

Campylobacter reactive arthritis: a systematic review

OBJECTIVE

To review the literature on the epidemiology of Campylobacter-associated reactive arthritis (ReA).

METHODS

A Medline (PubMed) search identified studies from 1966 to 2006 that investigated the epidemiology of Campylobacter-associated ReA. Search terms included: "reactive arthritis," "spondyloarthropathy," "Reiter's syndrome," "gastroenteritis," "diarrhea," "epidemiology," "incidence," "prevalence," and "Campylobacter."

RESULTS

The literature available to date suggests that the incidence of Campylobacter ReA may occur in 1 to 5% of those infected. The annual incidence of ReA after Campylobacter or Shigella may be 4.3 and 1.3, respectively, per 100,000. The duration of acute ReA varies considerably among reports, and the incidence and impact of chronic ReA from Campylobacter infection is virtually unknown.

CONCLUSIONS

Campylobacter-associated ReA incidence and prevalence varies widely among reviews due to case ascertainment differences, exposure differences, lack of diagnostic criteria for ReA, and perhaps genetics and ages of exposed individuals. At the population level it may not be associated with HLA-B27, and inflammatory back involvement is uncommon. Follow-up for long-term sequelae is largely unknown. Five percent of Campylobacter ReA may be chronic or relapsing (with respect to musculoskeletal symptoms).

Campylobacter jejuni infection during pregnancy: long-term consequences of associated bacteremia, Guillain-Barré syndrome, and reactive arthritist

Campylobacter jejuni infections are the main cause of foodborne gastroenteritis in the United States and other developed countries. Generally, C. jejuni infections are self-limiting and treatment is not necessary; however, infections caused by this organism can lead to potentially dangerous long-term consequences for some individuals. Bacteremia, Guillain-Barré syndrome (GBS; an acute flaccid paralytic disease), and reactive arthritis (ReA) are the most serious of the long-term consequences of C. jejuni infections. During pregnancy, foodborne infections may be hazardous to both the woman and the fetus. C. jejuni-induced bacteremia during pregnancy may lead to intrauterine infection of the fetus, abortion, stillbirth, or early neonatal death. Infection of a newborn by the mother during the birth process or shortly after birth may lead to neonatal enteritis, bacteremia, and/or meningitis. C. jejuni enteritis is the inducing antecedent infection in approximately 30% of cases of GBS. Thus, pregnant women infected with C. jejuni may contract GBS. GBS during pregnancy does not affect fetal or infant development and does not increase spontaneous abortion or fetal death; however, it may induce spontaneous delivery during the third trimester in severe cases. Reactive arthritis occurs in approximately 2% of C. jejuni enteritis cases and leads to the impaired movement of various joints. Pregnant women with C. jejuni-induced reactive arthritis can be expected to deliver a normal infant. A pregnant patient with GBS or ReA may be unable to care for a newborn infant because of the physical impairment induced by these diseases. Since C. jejuni infections put both fetuses and pregnant women at risk, pregnant women must take special care in food handling and preparation to prevent such infections.

Campylobacter-triggered reactive arthritis: a population-based study

OBJECTIVE

To study the incidence and clinical picture of Campylobacter-associated reactive arthritis (ReA) and other reactive musculoskeletal symptoms in the population.

METHODS

A questionnaire on enteric and extraintestinal, including specifically musculoskeletal, symptoms was sent to 870 consecutive patients with Campylobacter-positive stool culture and 1440 matched controls. Analysis of self-reported musculoskeletal symptoms with clinical examination was performed.

RESULTS

Forty-five of the patients (7%) had ReA and eight (1%) had reactive tendinitis, enthesopathy or bursitis. No child had ReA. The arthritis was oligo- or polyarticular, and, in most cases, mild. HLA-B27 was positive in 14% of ReA patients. Of the 45 ReA patients, 37 had C. jejuni and 8 had C. coli infection. No controls had ReA.

CONCLUSION

ReA is common following Campylobacter infection, with an annual incidence of 4.3 per 100000. At the population level, acute ReA is mild, more frequent in adults, and not associated with HLA-B27. Besides C. jejuni, C. coli can trigger ReA.

Molecular characterization of invasive and noninvasive Campylobacter jejuni and Campylobacter coli isolates

Campylobacter jejuni is one of the most common causes of bacterial diarrhea worldwide and is the primary bacterial cause of food-borne illness. Adherence to and invasion of epithelial cells are the most important pathogenic mechanisms of Campylobacter diarrhea. Molecular characterization of invasive and noninvasive Campylobacter isolates from children with diarrhea and symptom-free children was performed by random amplified polymorphic DNA techniques (RAPD). A distinct RAPD profile with a DNA band of 1.6 kb was observed significantly more frequently among invasive (63%) than among noninvasive (16%) Campylobacter isolates (P = 0.000005). The 1.6-kb band was named the invasion-associated marker (IAM). Using specifically designed primers, a fragment of 518 bp of the iam locus was amplified in 85% of invasive and 20% of noninvasive strains (P = 0.0000000). Molecular typing with a PCR-restriction fragment length polymorphism assay which amplified the entire iam locus showed a HindIII restriction fragment polymorphism pattern associated mainly with invasive strains. Although cluster analysis of the RAPD fingerprinting showed genetic diversity among strains, two main clusters were identified. Cluster I comprised significantly more pathogenic and invasive isolates, while cluster II grouped the majority of nonpathogenic, noninvasive isolates. These data indicate that most of the invasive Campylobacter strains could be differentiated from noninvasive isolates by RAPD analysis and PCR using specific primers that amplify a fragment of the iam locus.

Failure To detect muramic acid in normal rat tissues but detection in cerebrospinal fluids from patients with Pneumococcal meningitis

Muramic acid serves as a marker for the presence of bacterial cell wall debris in mammalian tissues. There have been a number of controversial and sometimes conflicting results on assessing the levels of muramic acid in health and disease. The present report is the first to use the state-of-the art technique, gas chromatography-tandem mass spectrometry, to identify and quantify the levels of muramic acid in tissues. Muramic acid was not found in normal rat brain or spleen. However, when tissues were spiked with muramic acid, it was readily identified. The detection limit was <1 ng of muramic acid/100 mg (wet weight) of tissue. The levels of muramic acid reported in diseased human spleen and spleen of arthritic rats, previously injected with bacterial cell walls, were 100- to 1,000-fold higher. In the present study, muramic acid was also readily detected in the cerebrospinal fluid of patients with pneumococcal meningitis (6.8 to 3,900 ng of muramic acid/ml of cerebrospinal fluid). In summary, there can be an enormous difference in the levels of muramic acid found in different mammalian tissues and body fluids in health and disease. This report could have great impact in future studies assessing the role of bacterial cell wall remnants in the pathogenesis of certain human inflammatory diseases.

Vasculitis as the basis of cutaneous lesions in Reiter's disease

The cutaneous lesions of Reiter's disease (RD) and pustular psoriasis (PP) are said to be histologically similar and often indistinguishable. We encountered three cases of RD in which biopsy specimens of lesions clinically compatible with keratoderma blenorrhagicum showed a pustular psoriasiform tissue reaction in conjunction with a subjacent superficial leukocytoclastic vasculitis (LCV). In an attempt to ascertain if these changes were distinctive and unique to cutaneous RD, the incidence of such changes in lesions of PP was examined using light microscopy and immunohistochemistry. The role of chlamydial infection in the pathogenesis of the observed vascular changes also was explored by assessing for the presence or absence of vascular deposition of chlamydial antigen in cutaneous RD compared with that in a control group that included cases of LCV and PP. In addition to conventional light microscopic analysis, immunoperoxidase studies to identify immunoglobulin deposition were performed on formalin-fixed, paraffin-embedded tissue from two of three patients with RD and on skin biopsy specimens from 11 patients with PP. Direct immunofluorescence (DIF) studies with antibodies to immunoglobulin (Ig)G, IgM, IgA, C3, and chlamydial antigens were performed on frozen tissue from one patient with RD, two patients with PP, three patients with LCV, one patient with nonspecific dermatitis, and one patient with Behçet's disease, who had a high antichlamydia antibody titer. All three specimens of RD showed a pustular psoriasiform diathesis in conjunction with a subjacent superficial LCV that was of maximal intensity in the dermal papillae capillaries. Through an immunoperoxidase technique performed on formalin-fixed tissue, the RD cases for which tissue was available for study demonstrated Ig deposition in injured blood vessels; using the same technique one of 11 PP biopsy specimens showed vascular Ig deposition in concert with LCV. This patient's biopsy was from a lesion of drug-induced LCV. None of the other specimens showed either light microscopic or immunohistochemical evidence of vasculitis. In the one specimen of RD studied by DIF, vascular deposition of IgG, IgM, C3, chlamydia heat shock protein 60 (CHSP60), and chlamydia-specific lipopolysaccharide (LPS) was observed. In the two specimens of PP studied, vascular deposition of C3, fibrin, CHSP 60, and chlamydia-specific LPS was not observed. Two specimens of LCV and the one specimen of dermatitis with concomitant nonspecific vascular injury showed vascular Ig and C3 deposition; in contrast, no vascular deposition of CHSP 60 or chlamydia-specific LPS was observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Rheumatic manifestations of Campylobacter jejuni and C. fetus infections in adults

Reports of the rheumatic manifestations of Campylobacter jejuni and C. fetus infections in adults are reviewed in order to determine the most common presentations and which individuals are at risk for rheumatic disease. Relevant English-language articles were identified through a Medline search and from bibliographies of identified articles. 105 articles were reviewed in detail. 29 cases of reactive arthritis or Reiter's syndrome following Campylobacter jejuni enteritis were identified. The knee is the most commonly involved joint and an average of 3.2 joints were involved in affected persons. HL-A B27 positive patients are more frequently affected and have higher erythrocyte sedimentation rates than HL-A B27 negative patients. Eight cases of septic arthritis and 4 cases of osteomyelitis caused by C. fetus or C. jejuni were identified, and these cases generally occurred in compromised hosts or in diseased joints.

Reactive arthritis associated with Clostridium difficile pseudomembranous colitis

Reactive arthritis is associated with several gastrointestinal pathogens, particularly Shigella, Salmonella, Campylobacter, and Yersinia. Another, less well recognized bowel infection leading to reactive arthritis is pseudomembranous colitis, caused by Clostridium difficile. An illustrative case is presented, and the clinical features and characteristics of all reported patients with this association are reviewed. The pathogenesis of the reactive arthritis seems to be related to an immunological response in joints and other tissues against bacterial antigens, which gain access to the systemic circulation through increased intestinal permeability. Therapy with nonspecific antiinflammatory drugs, anticlostridial agents, or a combination of the above is effective. Despite the possibility of persistent articular involvement after gastrointestinal symptoms have subsided, the long-term prognosis seems to be excellent.

MHC restriction of synovial fluid lymphocyte responses to the triggering organism in reactive arthritis. Absence of a class I-restricted response

Synovial fluid mononuclear cells (SFMC) from patients with reactive arthritis (ReA) show marked proliferative responses to preparations of the organism triggering the arthritis. Initial studies with MHC-specific MoAbs have indicated that a significant element of these proliferative responses is mediated by class II MHC-restricted CD4+ T cells. It is imperative to establish the presence or absence of a class I-restricted response, for two reasons. Firstly, the association of ReA with the MHC class I molecule, HLA B27, raises the possibility of there being a B27-restricted response to the triggering organism. Secondly, a number of the organisms associated with ReA are intracellular pathogens, whose antigens might be expected to be presented by class I MHC molecules. In an effort to identify a class I MHC-restricted pathogen-specific response in the SFMC of ReA patients, we have assessed the proliferative responses of SFMC depleted of CD4+ T cells. Responses were grossly diminished by CD4+ T cell depletion. We also investigated Chlamydia-specific cytotoxicity in the SFMC of patients with sexually acquired ReA in a system using productive chlamydial infection to produce both targets and effectors. Significant antigen specific cytotoxicity was not seen. These experiments do not provide evidence to support the existence of pathogen-specific responses by CD8+, class I-restricted synovial fluid T cells in ReA.

Rheumatic symptoms following an outbreak of campylobacter enteritis: a five year follow up

Eighty six of 106 (81%) guests attending a party were followed up after an outbreak of Campylobacter jejuni enterocolitis. Acute diarrhoeal illness was reported in 35 subjects (33%), of whom seven showed acute rheumatic symptoms either alone or with other symptoms of infection with C jejuni. The antibody response to C jejuni corresponded well with the intensity of the disease. In the early phase of the gastrointestinal disease the patients with acute rheumatic symptoms displayed significantly higher IgM antibody levels in serum samples than the other patients in this study. Levels of antibodies to C jejuni were increased in serum samples from 31 patients (29%) without symptoms of infection with C jejuni. At a follow up after five and a half years, four of these patients suffered from chronic rheumatic disorders. One HLA-B27 positive woman developed reactive arthritis with a relapse seven years later. The remaining 20 subjects (19%) remained healthy and their antibody tests and stool cultures were negative for C jejuni. It is concluded that C jejuni enterocolitis is significantly associated with rheumatic symptoms in the early phase and may also cause chronic rheumatic disorders.

Treatment of non-steroidal anti-inflammatory drug induced enteropathy

Non-steroidal anti-inflammatory drug induced small intestinal inflammation may have an adverse effect on the joints of patients with rheumatoid arthritis. We therefore assessed small intestinal and joint inflammation in patients with rheumatoid arthritis before and after three to nine months' treatment with sulphasalazine (n = 40) and other second line drugs (n = 20), while keeping the dosage of non-steroidal anti-inflammatory drug at the same level. Sulphasalazine significantly decreased the mean (SD) faecal excretion of 111indium labelled leucocytes from 2.39 (2.22)% to 1.33 (1.13)% (normal less than 1%, p less than 0.01) and improved the joint inflammation as assessed by a variety of parameters. There was no significant correlation between the effects of sulphasalazine treatment on the intestine and the joints. Treatment with other second line drugs had no significant effect on the faecal excretion of 111indium (1.58 (1.04)% and 1.86 (1.51)%, respectively) but improved joint inflammation significantly. The lack of correlation between the intestinal and joint inflammation and their response to treatment suggests that the two are not causally related.

Waterborne Campylobacter jejuni epidemic in a Finnish hospital for rheumatic diseases

A waterborne Campylobacter jejuni outbreak in the Rheumatism Foundation Hospital in Heinola, Finland, in November-December 1986 is described. 32 patients and 62 members of the staff developed gastrointestinal symptoms. C. jejuni heat-stable serotype 45 was isolated from the faeces of 32 enteritis patients and from none of the controls. No other enteropathogens were found. Positive serological responses to C. jejuni acid extract antigen were detected by enzyme immunoassay in 34% of the symptomatic hospital patients, in 40% of the symptomatic staff members, and in 10% of the controls. The clinical course of the illness was mostly mild and self-limited. No striking progress in the arthritis symptoms of the patients was found after the outbreak. The hospital has its own water supply. C. jejuni of the same serotype as the epidemic strain was isolated from the water of the pipeline system. After a careful examination some aged components of the waterworks were found to be responsible for leaks that resulted in the contamination of the water.

Intestinal permeability, non-steroidal anti-inflammatory drug enteropathy and inflammatory bowel disease: an overview

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Seronegative spondarthritides

We have attempted to review the epidemiology of a group of diseases collectively termed the seronegative spondarthritides. In discussing environmental influences on these diseases we have reviewed shared aetiological hypotheses and how these have been, and may be, manipulated to influence disease development. The socioeconomic impact of disease has been discussed, together with some of the strategies we might adopt to prevent further disability and handicap. Recent developments, particularly in the laboratory, promise imminent advances in the aetiopathogenesis of this group of chronic inflammatory disorders.

Histopathology of intestinal inflammation related to reactive arthritis

This study has identified a group of patients with inflammatory chronic, or relapsing acute arthritis who even in the absence of gastrointestinal symptoms have histological evidence of ileocolitis. At colonoscopy simultaneous biopsies of the terminal ileum and colon were taken from 108 patients with reactive arthritis (n = 55) or ankylosing spondylitis (n = 53), 47 patients with other rheumatic diseases and 19 control patients suffering from colonic polyps, adenocarcinoma, or chronic constipation. All control patients and all but one patient with rheumatoid arthritis, juvenile chronic arthritis, systemic lupus erythematosus, lumbar back ache, and psoriatic arthritis did not have histological evidence of acute or chronic inflammatory bowel disease. In contrast, in 30 of 35 (56.6%) patients with ankylosing spondylitis, and in 37 of 55 (67%) patients with reactive arthritis, regardless of HLA B27 phenotype, there was histological evidence of inflammatory bowel disease with features either of acute enterocolitis, or early Crohn's disease. Only 18 of 67 (27%) of the patients with histological gut inflammation, however, had intestinal symptoms.

Reactive arthritis

Although sometimes used to refer to any sterile arthritis occurring in association with infection, the term 'reactive arthritis' is better reserved for arthritis following sexually acquired nonspecific urethritis or enteric infections with organisms such as Shigella, Salmonella, Yersinia and Campylobacter, because these arthropathies are unified by a number of shared clinical characteristics and an association with HLA B27. This review suggests that these arthropathies may also share a common pathogenic pathway, triggered by an ' arthritogenic factor' common to the diverse microbes which cause the disease and modified by genetic factors other than HLA B27. Although uncommon, reactive arthritis is important because it could provide the key to understanding the other seronegative arthropathies and mechanisms basic to chronic inflammatory synovitis.

Acute erosive reactive arthritis associated with Campylobacter jejuni-induced colitis

A case of acute erosive, reactive arthritis following Campylobacter jejuni-induced ulcerative colitis is presented. This is the 12th such case reported in the literature and the first in which destructive lesions of periarticular bone are demonstrated. A review of the literature suggests that reactive arthritis associated with C. jejuni infection is similar to that following other invasive types of bacterial diarrhea and is often associated with HLA-B27 lymphocyte antigen.

Campylobacter jejuni enteritis and reactive arthritis

A further case of reactive arthritis following Campylobacter jejuni enteritis is reported. The interim results of a small prospective study are discussed. It may be desirable to do serological studies for campylobacter infection in the investigation of mono- or polyarthritis of acute onset.

Yersinia arthritis: a clinical, immunological, and family study of 2 cases

We describe 2 patients who presented with yersinia arthritis within a period of 5 months in Leicester. Both were HLA B27 positive. Arthritis followed 2 to 3 weeks after pneumonia, abdominal pain, dysuria, and evidence of hepatic involvement in the first case, and dysuria and conjunctivitis in the second. Immunological studies showed the presence of IgM, IgG, and IgA antibodies at a significant level against Yersinia enterocolitica serotype O:3 in serum and synovial fluid, and immune complexes in the serum of the first case and synovial fluid of both. Arthropathy resolved after 16 weeks in the first case and 12 weeks in the second, the latter requiring systemic corticosteroids. Family studies revealed psoriatic spondylarthritis in the brother, and bilateral sacroiliitis in the mother of the second case. Both were HLA B27 positive. These are the fourth and fifth reported cases of yersinia arthritis in Britain. We believe the condition is probably underdiagnosed and that yersiniosis should be considered as a possibility in otherwise unexplained arthritis.

Epidemiology of campylobacter enteritis

Campylobacter jejuni/coli (CJC) was isolated from 386 patients (6.9%) of 5571 with a history of acute diarrhoea between December 1977 and June 1980. In the same study population Salmonella was found in 4.1%, Shigella in 1.7% and Yersinia enterocolitica in 2.1%. Only 5 (0.25%) of 2000 health controls had CJC in their stools. 53% of the patients had acquired their infection in Sweden. The peak incidence for CJC was from July to September. More than 50% of the patients were between 16-35 years. Within 1 month of the acute enteritis 80% had negative stool cultures for CJC. In general, campylobacter enteritis is not a severe disease and only 11% were admitted to hospital. The most common signs were high fever in 35%, frequent watery diarrhoea in 37%, colics or abdominal pains in 84%, and fresh blood in stools in 12%. Antibiotic treatment was given in 13% and was erythromycin in 56% and doxycycline in 26% of these patients. If chemotherapy was given and the strain was sensitive, no relapse occurred within 2 weeks of the treatment. The antibiograms for 435 strains showed that the aminoglycosides, erythromycin, doxycycline, chloramphenicol and nalidixic acid were the most effective drugs. This study implies that CJC is a common cause of bacterial diarrhoea also in patients with domestic enteritis.

Reactive arthritis

Reactive arthritis is a rare complication of certain infections. The similar features and HLA associations with the seronegative arthropathies have raised the possibility that the latter may be forms of reactive arthritis. This review describes the clinical and epidemiological features, and the recent advances in our understanding of the underlying pathogenesis of reactive arthritis.

Campylobacter Enteritis

Campylobacter jejuni (previously called "related vibrio") has recently become recognized as an important cause of acute diarrhoeal disease in many countries. As with other intestinal pathogens, the clinical picture of C. jejuni infection varies from symptomless excretion to severe disease. The incubation period averages two to five days. Fever, abdominal pain and bloody diarrhoea are the usual symptoms of campylobacter enteritis. Although it is normally a self-limiting disease, complications such as cholecystitis, peritonitis, septicaemia and meningitis occasionally arise. The small intestine is thought to be the main site of infection, but the colon is also regularly involved. The disease might be more accurately described as an enterocolitis. Campylobacters, like salmonellae and yersiniae, are thought to be pathogenic by virtue of their invasive ability. Chemotherapy is usually effective. Erythromycin is commonly used for patients ill enough to require specific treatment. Although the infection can be transmitted from person to person, it is mainly a zoonosis with many possible routes of infection. Poultry is a potential source of infection, dogs may also transmit the disease and there have been major outbreaks of campylobacter enteritis from the consumption of untreated or inadequately treated milk and water. Further epidemiological work is hampered by the lack of suitable typing techniques.

Yersinia enterocolitica biotype I. Diarrhoea and episodes of HLA B27 related ocular and rheumatic inflammatory disease in South-East England

Yersinia enterocolitica biotype I were isolated from faeces of 16% of 56 consecutive patients with diarrhoea or gastrointestinal symptoms and 2.8% of 109 healthy controls (p less than 0.01). Similar Yersinia biotypes were isolated from 4% of samples from 86 rheumatoid arthritis patients and 4.5% of samples from 140 ankylosing spondylitis patients examined regularly over an 8-month period. These results suggest that Yersinia enterocolitica biotype I are regular but infrequent inhabitants of the human gastrointestinal tract in south-east England. The increased isolation rate of these microorganisms from patients with enteric disease and from patients with exacerbations of HLA B27-related arthritic and ocular inflammatory disease justifies further investigations.

Clinical and serological studies in patients with Campylobacter fetus ssp. jejuni infection: I. Clinical findings

Stool samples from 775 patients with diarrhoea referred to a hospital over an 18-month period were cultured for Campylobacter fetus ssp. jejuni, and in 55 patients (7.1%), infections were identified. In addition, one asymptomatic patient had a positive stool sample and serological evidence of a current infection. The patients were aged between 11 and 76 years, the majority being in the age group 15 to 39 years. The symptoms included diarrhoea (in almost 100%), fever (in 80%) and abdominal tenderness (in 35%). Almost half the patients vomited. The total leucocyte count was usually normal, but half the patients showed increased numbers of juvenile neutrophils. Eosinopenia and high serum C-reactive protein were frequently seen in the acute phase of the illness. Complications included haematemesis, pancreatic affection, carditis, reactive arthritis, urticaria, and transient malabsorption in one patient who had had a previous Billroth II operation. Invasive disease was occasionally suggested by clinical manifestations of extensive mesenteric lymphadenitis, septicaemia and focal bone necrosis.

Immune complexes in early arthritis. L Detection of immune complexes before rheumatoid arthritis is definite

Fifty-three patients with early arthritis were studied longitudinally for up to 3 years. During this time, 24 developed sufficient features for definite rheumatoid arthritis (RA) to be diagnosed. The other (arthralgia patients) differed from the RA patients as, in the majority, C-reactive protein and ESR were normal and anti-nuclear antibodies or rheumatoid factors were rarely found. Moreover, in time their signs and symptoms improved or disappeared. Circulating immune complexes were detected in both groups of patients by the platelet aggregation test whereas complexes detected by abnormal Clq-binding activity were found mainly in the RA patients. Platelet-aggregating complexes were usually present in the first samples studied and disappeared in the arthralgia patients with recovery from their symptoms. In the RA patients, Clq-binding complexes appeared simultaneously or later than platelet-aggregating complexes but both tests were positive several months before RA could be diagnosed. These results suggest that immune complexes are one of the first immunological abnormalities to appear in patients with arthritis. Although the constituent antigen and antibody of complexes detected by either test are unknown, their possible nature is discussed.

Reactive arthritis associated with campylobacter enteritis

Campylobacter enteritis is a known aetiological factor in reactive arthritis. We surveyed patients in the Harrow Health District known to have had campylobacter enteritis for manifestations of arthritis. Acute attacks of arthritis occurred in 8 of 33 adults admitted with enteritis. None were identified in patients under 16 or in those diagnosed in the community.

Ocular inflammation in Reiter's syndrome associated with Campylobacter jejuni enteritis

An 18-year-old woman developed acute polyarthritis one week and bilateral, acute, mucopurulent conjunctivitis and sterile pyuria two weeks after onset of Campylobacter jejuni enteritis. The conjunctivitis resolved spontaneously in one week and the arthritis in two months. The patient had HLA-B27 antigen. Campylobacter organisms may lead to Reiter's syndrome in a patient with HLA-B27 antigen.