Close Association of Streptococcus sanguis Uncommon Serotypes with Behcet's Disease

Behçet’s Disease: A Review

Behçet’s disease (BD) is a multi-system inflammatory disorder dominated clinically by recurrent oral and genital ulceration, uveitis, and erythema nodosum. Behçet’s disease runs a chronic course, with unpredictable exacerbations and remissions whose frequency and severity may diminish with time. Behçet’s disease typically arises in young adults, although childhood-onset BD has also been reported. The disease can affect both genders and has a worldwide distribution, although it is more prevalent in countries of the ancient Silk Route. The cause of BD remains unknown, although an autoimmune reaction triggered by an infectious agent in a genetically predisposed individual has been suggested. The treatment of BD is symptomatic and empirical, but generally specific to the clinical features of each patient. The majority of affected individuals do not have life-threatening disease, although mortality can be associated with vascular-thrombotic and neurological disease.

Tonsillectomy to Effectively Treat a Patient with Behçet's Disease

Behçet's disease (BD) is a polysymptomatic and recurrent systemic vasculitis with a chronic course and unknown cause. We herein report a 27-year-old woman who had suffered from a recurrent fever and tonsillitis for nearly ten years with BD for who tonsillectomy was effective.

A New Diagnostic Way for Behcet's Disease: Skin Prick with Self-Saliva

Behcet's disease (BD) is a mysterious multisystemic disorder characterized by recurrent involvement of mucocutaneous (including recurrent aphthous stomatitis; RAS), ocular, intestinal, vascular, and/or nervous system organs. Previously, the positivity of "pathergy test", which is one of the diagnostic examinations, was reported to be related to the possession of HLA-B51 gene in BD patients, even though the positivity is low and different from the countries. Here, instead of the ordinal pathergy test, we would like to propose the prick with self-saliva as a new diagnostic way for patients with RAS of BD based on the genetic intrinsic factors including HLA-B51 and extrinsic triggering factors. BD patients are considered to acquire the hypersensitivity against oral streptococci through the innate immune mechanism in the oral cavity. Bes-1 gene and 65 kD of heat shock protein (HSP-65) derived from oral S. sanguinis are supposed to play important roles as extrinsic factors in BD pathogenesis. Although the prick positivity was not related to the possession of HLA-B51 gene, the method is suggested to be a significant way for BD diagnosis. The results also suggest that BD symptoms are due to the vascular immune responses by monocytes expressed oral streptococcal agents of the patients.

The role of an uncommon type of oral streptococcus sanguis in the etiology of behcet's disease

The relationships of Behcet's disease (BD) with oral diseases and the prevalence of an uncommon type of oralStreptococcus sanguis (Str. sanguis) in the oral cavity were investigated in a case-control study. BD patients were compared to patient controls (collagen disease) and healthy controls.An interview questionnaire survey of BD and oral diseases showed that during the pre-onset, onset, and post-onset periods, the incidences of tonsillitis and dental caries, or the history of dental treatment, were greater in BD cases. Typological analysis showed a higher prevalence of an uncommon type ofStr. sanguis, differing from the common type, among BD cases compared to control groups. These results, showing a higher incidence of tonsillitis and dental caries during the presymptomatic period, a greater frequency of dental treatments during the symptomatic period, and the presence of an uncommon type ofStr. sanguis, indicate thatStr. sanguis of an uncommon type is related to increased risk of BD, and the possibility of a causal role is suggested.

Behçet's disease (Adamantiades-Behçet's disease)

Adamantiades-Behçet's disease (ABD) is characterized by starting with oral aphthous ulceration and developing of the systemic involvements. The pathogenesis of ABD is closely correlated with the genetic factors and the triggering factors which acquire delayed-type hypersensitivity reaction against oral streptococci mediated by IL-12 cytokine family. HLA-B51 is associated in more than 60% of the patients and its restricted CD8+ T cell response is clearly correlated with the target tissues. Bes-1 gene encoded partial S. sanguinis genome which is highly homologous with retinal protein, and 65 kD heat shock protein (Hsp-65) released from streptococci is playing an important role with human Hsp-60 in the pathogenesis of ABD. Although Hsp-65/60 has homologies with the respective T cell epitope, it stimulates peripheral blood mononuclear cells (PBMCs) from ABD patients. On the other hand, some peptides of Hsp-65 were found to reduce IL-8 and IL-12 production from PBMCs of ABD patients in active stage.

Neutrophil and lymphocyte responses to oralStreptococcusin Adamantiades-Behçet's disease

Immune reactions against microorganisms play an important pathogenic role in Adamantiades-Behçet's disease. We had previously obtained Streptococcus sanguinis (strain BD113-20), isolated from the oral cavity of patients with Adamantiades-Behçet's syndrome. To investigate the pathogenesis of this isolate, we examined neutrophil reactions and levels of cytokine production by lymphocytes after stimulation with the strain. The reactions of neutrophils were examined by chemiluminescence assay using whole blood. The amounts of interferon gamma (IFN-gamma) and interleukin (IL)-4, IL-8, IL-10 and IL-12, produced by peripheral blood mononuclear cells, were measured by ELISA. Strain BD113-20 activated neutrophils from Adamantiades-Behçet's patients and healthy volunteers, and, in addition it increased the IFN-gamma production by lymphocytes. Lymphocytes from Adamantiades-Behçet's patients showed a dominant T helper-1 immune response. Results indicated that both bacterial stimulation and host hypersensitivity might be involved in the symptoms and pathogenesis of Adamantiades-Behçet's disease.

Oral tolerization with peptide 336-351 linked to cholera toxin B subunit in preventing relapses of uveitis in Behcet's disease

Behcet's disease (BD) specific peptide (p336-351) was identified within the human 60 kD heat shock protein (HSP60). Oral p336-351 induced uveitis in rats which was prevented by oral tolerization with the peptide linked to recombinant cholera toxin B subunit (CTB). This strategy was adopted in a phase I/II clinical trial by oral administration of p336-351-CTB, 3 times weekly, followed by gradual withdrawal of all immunosuppressive drugs used to control the disease in 8 patients with BD. The patients were monitored by clinical and ophthalmological examination, as well as extensive immunological investigations. Oral administration of p336-351-CTB had no adverse effect and withdrawal of the immunosuppressive drugs showed no relapse of uveitis in 5 of 8 patients or 5 of 6 selected patients who were free of disease activity prior to initiating the tolerization regimen. After tolerization was discontinued, 3 of 5 patients remained free of relapsing uveitis for 10-18 months after cessation of all treatment. Control of uveitis and extra-ocular manifestations of BD was associated with a lack of peptide-specific CD4+ T cell proliferation, a decrease in expression of TH1 type cells (CCR5, CXCR3), IFN-gamma and TNF-alpha production, CCR7+ T cells and costimulatory molecules (CD40 and CD28), as compared with an increase in these parameters in patients in whom uveitis had relapsed. The efficacy of oral peptide-CTB tolerization will need to be confirmed in a phase III trial, but this novel strategy in humans might be applicable generally to autoimmune diseases in which specific antigens have been identified.

Periodontal Findings and Systemic Antibody Responses to Oral Microorganisms in Behçet's Disease

BACKGROUND

Behçet's disease is a multisystem disorder of unknown etiology, affecting predominantly the oral mucosa, skin, and eyes. Recurrent and painful episodes of oral ulcerations interfere with regular oral hygiene leading to rapid bacterial plaque accumulation. The aims of this study were to evaluate the periodontal status of patients with Behçet's disease and determine serum antibody responses to selected oral microorganisms, including major periodontopathogens in these patients.

METHODS

Thirty-three patients with Behçet's disease and 15 healthy subjects were included in the study. Plaque, sulcular bleeding, periodontal index scores, probing depths, and total number of teeth were recorded. Serum IgG antibody levels to a panel of 13 oral microorganisms were determined.

RESULTS

Significantly higher values for each of the clinical measures were observed in patients with Behçet's disease compared to healthy subjects (P <0.0001). Antibody levels to selected members of plaque, including Actinomyces viscosus, Streptococcus mutans, Streptococcus sanguis, Streptococcus oralis, Eikenella corrodens, Campylobacter rectus, and Prevotella intermedia were significantly lower in patients with Behçet's disease than in controls (P <0.001-0.05). In contrast, these patients exhibited significantly elevated antibody levels to Actinobacillus actinomycetemcomitans Y4 compared to controls (P <0.01).

CONCLUSIONS

Our data indicate that the patients with Behçet's disease generally exhibit clinical findings of established periodontal disease. Decreased antibody responses to early colonizers of both supra- and subgingival plaque were observed along with the elevation in antibody levels to A. actinomycetemcomitans. These results suggest that the bacterial plaque ecology and/or immune responses to these microorganisms may be affected in Behçet's disease which could lead to changes in the expression of periodontal disease.

Proliferative response of CD8+ gamma delta+ T cells to Streptococcus sanguis in patients with Behçet's disease

To analyze the pathogenesis of Behçet's disease (BD), we investigated the immune response of peripheral blood T cell subsets from patients with BD to Streptococcus sanguis (S. sanguis) strain KTH-I, a bacteria suggested to be associated with the etiology of BD. Cultured peripheral blood mononuclear cells (PBMC) of patients with BD activated by lyophilized whole bacterium of S. sanguis were assayed by two-color flow cytometry using monoclonal antibodies (mAbs) specific for gamma delta+ T cell receptor, CD4 or CD8 molecules. The lymphostimulatory activity of S. sanguis to either gamma delta+ CD4-CD8-, gamma delta+ CD4-CD8+, gamma delta-CD4+CD8-, or gamma delta-CD4-CD8+ T cells was evaluated. The absolute number of gamma delta+ T cells from patients with BD (n = 8) as well as from healthy controls (n = 7) significantly increased after stimulation with S. sanguis, whereas gamma delta- T cells from both groups showed no response to S. sanguis. The absolute number of gamma delta+ CD8+ T cells from patients with BD significantly increased after stimulation with S. sanguis compared with healthy controls (p < 0.05). Peripheral gamma delta+ CD8+ T cells from patients with BD showed a significantly higher proliferative response to S. sanguis compared with healthy controls.

Cloning and sequencing of BeS-1 gene encoding the immunogenic antigen of Streptococcus sanguis KTH-1 isolated from the patients with Behçet's disease

In order to analyze the immunopathologic mechanisms of Behçet's disease, the gene (bes-1) encoding a streptococcal antigen correlated with the disease was cloned and sequenced, and protein produced by this clone was identified by Western immunoblotting using serum antibody from the patient. Cellular DNA of Streptococcus (S.) sanguis serotype KTH-1 (uncommon serotype 1, strain 113-20) from the patient was extracted and digested with EcoRI. The digested fragments were cloned into the cloning vector lambda gt11, and then the resulting DNA library was immunoscreened using the patient's serum antibody to serotype KTH-1. The immunopositive clone of the 1.5 kbp fragment was subcloned into pUC 118 plasmid (pU8BeS1-1) and sequenced. The sequence showed that the 3'-terminal half side region of this insert contained 962bp of open-reading frame (ORF) discontinued at the EcoRI restriction site, and the stop codon was not found. The nucleotide sequence of the remaining additional 3'-terminal region of this gene encoding whole BES-1 was determined by genome walking. The whole ORF of bes-1 consisted of 849 amino acid residues with a calculated molecular mass of 95 kDa. The residues in a portion of the amino acid sequence showed a 60% correspondence to those of the human intraocular peptide Brn-3b.

IgA protease produced by Streptococcus sanguis and antibody production against IgA protease in patients with Behçet's disease

The production of IgA protease in twelve strains of Streptococcus sanguis isolated from patients with Behcet's disease (BD) was examined. Protease activity was detected in 10 out of 12 strains. The protease was purified from one representative strain, S. sanguis 113-20, by employing Rotofor and DEAE-Sephacel chromatography. The molecular mass of the purified protease was approximately 100 kDa, and it cleaved the proline-threonine site of the IgA. Both IgG and IgA titers against the cells (113-20) and the purified IgA protease in the sera of BD patients and healthy controls, 36 each, were assayed. The IgG titers against the cells and protease were not significant in the BD patients or controls, but the IgA titers against the cells and protease in the BD patients were significantly higher than those of the controls. These data indicate that the BD patients are infected with IgA protease-producing S. sanguis strains, which cause an increase of IgA titer against these organisms and IgA protease antigen. Since the organisms can proliferate in BD patients for a long period of time (years), it seems that IgA antibodies cannot effectively eliminate the organisms.

The role of heat shock protein, microbial and autoimmune agents in the aetiology of Behçet's disease

Investigation of the aetiology of Behçet's disease (BD) has focused predominantly on herpes simplex virus immunopathology, autoimmunity to oral mucosa or cross-reactive microbial antigens, and streptococcal infection. These aetiological factors might have a common denominator in microbial heat shock protein (HSP) which shows significant homology with the human mitochondrial HSP. Indeed, the uncommon serotypes of Streptococcus sanguis found in BD cross-react with the 65 kD HSP which also shares antigenicity with an oral mucosal antigen. T cell epitope mapping has identified 4 peptides derived from the sequence of the 65 kD HSP which stimulate specifically TCR gamma delta + lymphocytes from patients with BD. These peptides (111-125, 154-172, 219-233 and 311-325) show significant homology with the corresponding peptides derived from the human 60 kD HSP. The specific proliferative response of TCR gamma delta + lymphocytes elicited by the 4 peptides can be used as a laboratory test for the diagnosis of BD. The pathogenic significance of these peptides has been established by inducing uveitis in rats.

Induction of lymphocytes cytotoxic to oral epithelial cells by Streptococcus mitis superantigen

The preparation of a superantigenic fraction F-2 from the culture supernatant of Streptococcus mitis 108, a fresh isolate from human tooth surfaces, was reported previously. Now, to determine the possible pathogenic role of the superantigen in oral mucosal diseases, we examined the cytotoxic effects of human peripheral blood T-cells activated with F-2 on human oral epithelial cells. T-cells activated with F-2 were cytotoxic to the human squamous carcinoma HO-1-N-1 cells derived from the oral mucosa, similar to those activated with Staphylococcus aureus enterotoxin B (SEB). This cytotoxic effect was increased in a dose-dependent manner by the addition of the respective stimulant, F-2 or SEB, to the cytotoxic assay system. F-2 endowed mainly CD8+ T-cells with cytotoxic activity. Pretreatment with human interferon gamma increased the sensitivity of the HO-1-N-1 cells to the cytotoxic effects of F-2-activated T-cells. The F-2-activated T-cells were also cytotoxic to human keratinocytes derived from gingiva. There was no correlation between the degree of cytotoxicity and the levels of tumor necrosis factor alpha in co-cultures of F-2-activated T-cells and HO-1-N-1 cells. A double-chamber plate experiment revealed no cytotoxic effects when the F-2-activated T-cells were separated from the HO-1-N-1 cells. Supernatants of the co-cultures of target and effector cells were not cytotoxic to HO-1-N-1 cells. These findings suggest that the cytotoxic effects of the F-2-activated T-cells on HO-1-N-1 cells were mediated not by soluble factors but by the direct interaction between the activated T-cells and the target cells. The cytotoxicity of the F-2-activated T-cells against HO-1-N-1 cells was markedly inhibited by monoclonal antibodies (MAbs) against CD11a and CD54, but was only slightly inhibited by MAbs against human leukocyte antigen (HLA)-DR and CD2. Thus, the interaction between lymphocyte-function-associated antigen-1 (LFA-1) and intercellular adhesion molecule-1 (ICAM-1) was crucial for the F-2-dependent T-cell-mediated cytotoxicity against oral epithelial cells, while HLA-DR and CD2 molecules are not necessarily involved in the cytotoxicity observed.

Characterization of Streptococcus sanguis isolated from patients with Behçet's disease

The DNA homology and cell wall sugar constituents of eight Streptococcus sanguis(-like) strains, three isolated from the patients with Behçet's disease (BD114-23, BD113-20, BD118-1), two from patients with Kawasaki disease (MCLS-1, MCLS-2), and three type and reference strains of ATCC (ATCC10556T: S. sanguis, ATCC10557: S. oralis, and ATCC10558T: S. gordonii) were analyzed. Strains BD114-23 and BD118-1 showed high DNA homology to ATCC10556T, and their cell wall constituents were identical. Conversely, BD113-20, MCLS-1, MCLS-2, and ATCC10557 showed little DNA homology to ATCC10556T and ATCC10558T, but showed approximately 50 to 60% homology to each other. The cell wall constituents of BD113-20, MCLS-1, MCLS-2, and ATCC10557, however, were somewhat different, indicating that some of the clinical isolates have different characters from those of the three ATCC strains.

Bactericidal action of tachyplesin I against oral streptococci

Tachyplesin I, a polycationic antimicrobial peptide isolated from hemocytes of horseshoe crabs, kills bacteria by disrupting the membrane potential of the cytoplasmic membrane. The present study shows that, among 36 oral streptococcal strains, 12 of 21 Streptococcus sanguis, 3 Streptococcus mutans, 9 Streptococcus salivarius and 3 Streptococcus milleri strains were susceptible to tachyplesin I, whereas 9 S. sanguis strains were resistant. Interestingly, these resistant strains include the clinical isolates from both Kawasaki disease and Behçet patients. According to the time-kill study, tachyplesin I inhibited irreversibly the growth of S. sanguis, S. mutans and S. salivarius strains within 20 min and an S. milleri strain within 80 min. Although it has been suggested that Escherichia coli cultured in rich media were more susceptible to tachyplesin I, the present results show that only 3 S. milleri strains were more sensitized to tachyplesin I in a glucose-supplemented medium, and other tested strains were not. Similarly, only 4 strains were more resistant to tachyplesin I in saline than these were in a rich medium.

Demonstration of antigen-specific immune response against Streptococcus sanguis

The genetic control of Streptococcus sanguis antigen response was studied. Mice sensitized with inactivated S. sanguis organisms antigen-injected at the base of the tail developed footpad swelling. Those with an I-Ak,q,r region of H-2 showed a strong footpad response, whereas those with an I-Ab,d,s region showed a weak response to S. sanguis cell wall antigen. Footpad response was mediated by CD4+,8- T cells by using in vitro monoclonal antibody treatment. Similar evidence of genetic control was obtained with an in vitro T cell proliferation assay. However, quantitation of antibodies against S. sanguis showed that antibody production was not controlled by H-2. These results indicated that both in vivo footpad swelling and in vitro T cell proliferation responses were functions of helper (CD3+,4+,8-) T cells and controlled by the I-A region of H-2.

Antibody response to oral streptococci in Behçet's disease

The serum antibody titers against oral streptococci were studied by enzyme-linked immunosorbent assay (ELISA) both in patients with Behçet's disease (BD) and control groups. The patients with BD showed significantly higher antibody titers to S. sanguis strains 113-20, 114-23, and 118-1 which were isolated from patients with BD, in comparison with control groups. Also, the reactions of high-titered sera to the crude cell wall and soluble (or membrane) fractions of the 113-20 strain were observed by western blot test. The sera of the patients with BD demonstrated strong bands of approximately 36 kDa, 82 kDa, and 87 kDa in the crude cell wall fractions, and many bands of 80 kDa to 150 kDa in the membrane fractions, indicating that these proteins are the ones leading the high antibody titers to this bacterium in the sera of patients with BD.

Streptococcal-related antigens stimulate production of IL6 and interferon-gamma by T cells from patients with Behcet's disease

Greater attention has been recently paid to the role of certain strains of streptococcus as an etiologic agent of Behçet's disease, in which T cell abnormalities are considered to be involved. We therefore examined whether T cells from patients with Behçet's disease might to be stimulated by Streptococcus sanguis-related antigen (RRE KTH-1 antigens). T cells from 17 patients with Behcet's disease, but not those from 13 healthy individuals or from 13 patients with other rheumatic diseases, were stimulated to produce greater amounts of interleukin 6 (IL6) by addition of RRE KTH-1 antigens [stimulation index: 3.96 +/- 0.56 and 1.35 +/- 0.28 or 1.83 +/- 0.43 (mean +/- SEM), respectively]. The IL6 production by T cells required the presence of either fresh or paraformaldehyde-fixed monocytes. The enhancement of T cell IL6 production was not related to the presence of HLA-B51, which has been shown to be frequently associated with Behçet's disease. These results indicate that T cells from patients with Behçet's disease are stimulated by streptococcal antigens to produce IL6 through T cell-monocyte interactions in which binding of the antigens to monocytes, but not necessarily processing of the antigens by monocytes, is involved. Moreover, RRE KTH-1 antigens as well as Escherichia coli-derived antigens also enhanced the production of interferon-gamma by T cells from patients with Behçet's disease. The data thus suggest that T cell hypersensitivity to several bacterial antigens may play a central role in the pathogenesis of Behçet's disease.

Platelet aggregation induced by uncommon serotypes of Streptococcus sanguis isolated from patients with Behçet's disease

Uncommon serotypes were tested for their ability to induce aggregation in platelet-rich plasma. Both uncommon and common serotypes induced platelet aggregation in rabbit platelet-rich plasma, but serotonin release was higher with the uncommon serotypes. Aggregation at ATP release varied between uncommon and common serotypes. With human platelet-rich plasma, only uncommon serotypes showed aggregation. Differences in serotype selectivity and the rate of aggregation were noted among platelet donors. About half of the patients with Behçet's disease and 30% of health controls showed platelet aggregation. Plasma from non-responder patients with Behçet's disease inhibited aggregation of healthy responder platelets within 20 min. Thus selective binding of uncommon serotypes of Strep. sanguis to platelets might cause the vasculitis in Behçet's disease.