Systemic lupus erythematosus in Europe at the change of the millennium: lessons from the "Euro-Lupus Project"

The "Euro-Lupus Cohort" is composed by 1000 patients with systemic lupus erythematosus (SLE) that have been followed prospectively since 1991. These patients have been gathered by a European consortium--the "Euro-Lupus Project Group". This consortium was originated as part of the network promoted by the "European Working Party on SLE", a working group created in 1990 in order to promote research in Europe on the different problems related to this disease. The "Euro-Lupus Cohort" provides an updated information on the SLE morbidity and mortality characteristics in the present decade as well as defines several clinical and immunological prognostic factors.

Reproduction and gynaecological manifestations in women with primary Sjögren's syndrome: a case-control study

BACKGROUND

The impact of primary Sjögren's syndrome (pSS) on reproduction and gynaecological manifestations has seldom been explored.

AIM OF STUDY

Assess gynaecological aspects, gynaecological interventions, and use of contraceptives in a population of pSS-patients versus controls.

METHODS

In a case-control study, 58 pSS-patients and 157 controls answered a self-administered questionnaire, covering demographic data, reproductive events, gynaecological problems, and gynaecological interventions.

RESULTS

Significantly more patients than controls reported episodes of amenorrhoea lasting for more than 3 months, and more patients suffered from menorrhagia/metrorrhagia compared with controls (54.5% versus 35.7%; p = 0.012). Complaints of vaginal dryness were common among the patients (52.9% versus 28.3%; p = 0.005). Endometriosis was reported to occur more frequently in the patients (8.5% versus 2.1%; p = 0.03), and 6.3% of pSS-patients reported having undergone surgical intervention for endometriosis versus 0.7% of the controls (p = 0.009). Positive information about surgery for endometriosis correlated with the presence of the autoantibodies anti-SSA (r = 0.322; p = 0.008) and anti-SSB (r = 0.313; p = 0.01). Among the pSS-patients, 5.9% had chosen not to have children due to the disease, but there was no indication of reduced fertility as judged by the number of pregnancies.

CONCLUSION

Patients with pSS reported more gynaecological problems than controls, including vaginal sicca symptoms, endometriosis, several episodes of amenorrhoea, and menorrhagia/metrorrhagia.

Lessons from the "Euro-Lupus Cohort"

The "Euro-Lupus Cohort" is composed by 1,000 patients with systemic lupus erythematosus (SLE) that have been followed prospectively since 1991. These patients have been gathered by a European consortium - the "Euro-Lupus Project Group". This consortium was originated as part of the network promoted by the "European Working Party on SLE", a working group created in 1990 in order to promote research in Europe on the different problems related to this disease. The "Euro-Lupus Cohort" provides an updated information on the SLE morbidity and mortality characteristics in the present decade as well as defines several clinical and immunological prognostic factors.

Associations of MHC class II alleles in Norwegian primary Sjögren's syndrome patients: implications for development of autoantibodies to the Ro52 autoantigen

Sjögren's syndrome (SS) is a chronic autoimmune disease characterized by dryness of the eyes and mouth. Currently, the highly polymorphic major histocompatibility complex (MHC) genes are the best documented genetic risk factor for the development of autoimmune disease. We examined the MHC class II alleles DRB1, DRB3, DRB4, DRB5, DQA1 and DQB1 in a group of Norwegian pSS patients and compared with a group of healthy controls. Because a number of studies have shown that some of the MHC class II alleles are not associated with the disease as a whole, but rather to the development of autoantibodies, anti-Ro52 autoantibodies in serum were measured and compared to MHC class II allele status. A clear association with pSS was detected for the DRB1*0301 and DRB3*0101 alleles, but these alleles were more closely associated with the presence of anti-Ro52 autoantibodies than with pSS itself. Moreover, the DQA1*0501 and DQB1*0201 alleles were only associated with the presence of anti-Ro52 autoantibodies. This study shows that the production of anti-Ro52 autoantibodies in pSS is associated with the DRB1*0301, DRB3*0101, DQA1*0501 and DQB1*0201 alleles which are in strong linkage disequilibrium.

Total mortality is increased in rheumatoid arthritis. A 17-year prospective study

The purpose of this study was to determine the total and cause-specific mortality in rheumatoid arthritis (RA) patients compared to a control population in northern Norway. One hundred and eighty-seven patients with RA and 930 population controls matched for age, gender and municipality were followed until death or for a maximum of 17 years. The total mortality in RA patients was twice that of their controls (MRR = 2.0, 95% CI = 1.6-2.5). Patients possessing serum rheumatoid factors did not have a higher relative mortality than the seronegative patients. There was no statistically significant increased mortality from cancer or cardiovascular diseases. Indications for a higher death rate in RA patients than in controls were found for infection and sudden death.

HLA markers and clinical characteristics in Caucasians with primary Sjögren's syndrome

OBJECTIVE

To explore the association between HLA genotypes and clinical and immunological characteristics in Caucasians with primary Sjögren's syndrome (pSS).

METHODS

HLA genotyping for DRB1, DQA1 and DQB1 was carried out in 62 single case patients with pSS and 64 healthy controls. The specific amino acid residues at DQA1 position 34 (DQalpha-34Q) and DQB1 position 26 (DQbeta-26L) in addition to the DQ-DI (AA59-AA69) motif were deterrmined. Subsequently, the relative contribution of individual HLA markers to clinical and immunologic characteristics of pSS was assessed by group comparisons.

RESULTS

No significant associations were seen between HLA markers and histopathological or clinical features of pSS. Significant positive associations with HLA Class II markers were restricted to the formation of different autoantibodies. Formation of an anti-Ro/SSA and anti-La/SSB autoantibody response was positively associated with DRB1*03, DQB1*02 and DRB1*03/DRB1*15-DQB1*02/DQB1*0602 heterozygosity. Patients positive for anti-La/SSB also showed a strong positive anti-La/SSB association with DQA1*0501. Considering the contribution of individual DQA1 and DQB1 amino acids and sequence motifs to the formation of anti-Ro/SSA and anti-La/SSB autoantibodies, a dose dependent positive influence was detected for DQalpha-34Q and DQbeta-26L. For DQbeta-DI, the largest difference between patients and controls was seen for the presence of a single copy of this motif after selecting patients with either anti-Ro/SSA or anti-La/SSB autoantibodies.

CONCLUSION

The association of HLA Class II markers with pSS may concern the anti-Ro/La response rather than the disease itself. The strongest contributors to the formation of an anti-Ro/La response included components of the DRB1*03-DQB1*02-DQA1*0501 haplotype also encompassing the transethnically-associated DQbeta-DI motif. In addition, the dose dependent contribution of DQalpha-34Q and DQbeta-26L argue for a recessive contribution of HLA-DQ to the formation of an anti-Ro/La response. Given the prominent associations with DRB1*03 and the complex dose dependent interactions at HLA-DQ, a joint contribution of HLA-DR and DQ is likely to be relevant for the formation of anti-Ro/La autoantibodies in patients with pSS.

Clinical utility of diagnostic tests for rheumatoid factor

OBJECTIVE

To investigate and compare the accuracy and usefulness of diagnostic tests for rheumatoid factor (RF).

METHODS

In a cross-sectional study sera derived from patients admitted to the Section of Rheumatology were tested for presence of RF using either nephelometry or the Waaler test. Diagnostic sensitivity and predictive values of the tests were calculated and compared. The accuracy of the tests was compared using receiver-operating characteristics (ROC) methodology.

RESULTS

Good agreement was found between the tests (kappa approximately 0.7). At cut-off 19 IU/mL nephelometry showed the highest sensitivity (82.4%) and specificity (95.9%) for rheumatoid arthritis (RA). In comparison, the Waaler test had a sensitivity of 60.3% and specificity of 95.9% at cut-off titer 128. The tests showed nearly equal performance characteristics when predicting SS.

CONCLUSION

Although both tests exhibit good performance characteristics, nephelometry has a higher accuracy when predicting RA and SS. The common practice of using both tests for detection of RF is not recommended.

Current concepts on diagnosis, autoantibodies and therapy in Sjögren's syndrome

Sjögren's syndrome is a chronic autoimmune and rheumatic disorder. Most patients have mild to moderate complaints and this may explain the great discrepancy in prevalence found in population studies compared to studies performed in the clinic. However, there is no straightforward and simple diagnostic test for Sjögren's syndrome, although several classification criteria have been designed. Initiatives have been taken to propose a new set of classification criteria in a joint effort by research groups in Europe and USA. A large number of autoantibodies have been reported in Sjögren's syndrome where, in some cases, the antibodies are correlated with the extent and severity of disease. The finding of serum autoantibodies directed against the muscarinic M3 receptor is an important advance in understanding the pathogenesis of not only the impaired glandular function but also associated features of autonomic dysfunction in some patients. The treatment of primary Sjögren's syndrome is still mainly symptomatic.

Anti-cardiolipin autoantibodies and pulmonary embolism. A case for a common cause

A patient with primary Sjögren's syndrome developed pulmonary embolism following infection with influenza A virus. IgM anti-cardiolipin autoantibodies (aCL) evolved two weeks after hospitalisation, synchronously with antibodies against influenza A. IgG aCL developed three weeks after hospitalization, peaked during the recovery period, and gradually declined to undetectable levels 12 months after admission. Antibodies against beta2 glycoprotein I were not detected. Our results assign a high likelihood to the hypothesis that influenza A virus caused the patient's thromboembolic disease as well as development of aCL. aCL may have contributed to tissue pathology by forming immune-complexes with cardiolipin and rheumatoid factor.

Fine mapping of the SLEB2 locus involved in susceptibility to systemic lupus erythematosus

We have previously reported linkage of systemic lupus erythematosus to chromosome 2q37 in multicase families from Iceland and Sweden. This locus (SLEB2) was identified by linkage to the markers D2S125 and D2S140. In the present study we have analyzed additional microsatellite markers and SNPs covering a region of 30 cM around D2S125 in an extended set of Nordic families (Icelandic, Swedish, and Norwegian). Two-point linkage analysis in these families gave a maximum lod score at the position of markers D2S2585 and D2S2985 (Z = 4.51, PIC = 0.65), by applying a "model-free" pseudo-marker linkage analysis. Based on multipoint linkage analysis in the Nordic families, the most likely location of the SLEB2 locus is estimated to be in the interval between D2S125 and the position of markers D2S2585 and D2S2985, with a peak multipoint lod score of Z = 6.03, assuming a dominant pseudo-marker model. Linkage disequilibrium (LD) analysis was performed using the data from the multicase families and 89 single-case families of Swedish origin, using the same set of markers. The LD analysis showed evidence for association in the single-case and multicase families with locus GAAT3C11 (P < 0.0003), and weak evidence for association was obtained for several markers located telomeric to D2S125 in the multicase families. Thirteen Mexican families were analyzed separately and found not to have linkage to this region. Our results support the presence of the SLEB2 locus at 2q37.

[Myalgia and high sedimentation rate in adults]

The polymyalgic syndrome may be the presenting clinical feature for several diseases such as polymyalgia rheumatica, temporal arteritis, malignancy, rheumatoid arthritis, virus infections, connective tissue diseases, and myositis. In this review we present the various diagnostic options seen from a rheumatological point of view, with emphasis on polymyalgia rheumatica, temporal arteritis and the paraneoplastic syndrome. We are of the opinion that polymyalgia rheumatica is overdiagnosed in general practice, and steroid treatment may delay diagnosis and treatment of other differential diagnosis presenting as the polymyalgic syndrome. Several recently published Norwegian epidemiological studies offer new information on various aspects of the polymyalgic syndrome, which will be discussed.

Fas and Fas ligand gene polymorphisms in primary Sjögren's syndrome

OBJECTIVE

To screen for polymorphisms in the apoptosis regulating Fas and Fas ligand (FasL) genes in patients with primary Sjögren's syndrome (SS), and to explore associations with susceptibility to the disease.

METHODS

Polymorphisms in Fas and FasL of 70 patients with primary SS and 72 controls were determined by polymerase chain reaction combined with the restriction enzyme fingerprinting single strand conformation polymorphism technique, verified by automatic sequencing and natural or amplification created restriction site tests.

RESULTS

Polymorphisms were found in both Fas and FasL, but only some of the Fas polymorphisms were found in statistically significant differences between patients and controls. Patients displayed a higher frequency of the G/G genotype at position -671 than the controls, and the -671 G allele frequency for primary SS was increased compared to controls. A higher frequency of the C allele at position IVS2nt176 and IVS5nt82 was also found. Of note, the nucleotide variants in intron 2 and intron 5 were associated.

CONCLUSION

We describe the positions and frequencies of several polymorphisms in the genes encoding Fas and FasL in patients with primary SS. None caused any amino acid change. Three Fas alleles, of which one is located in the promoter area, showed significant although modest differences between patients and controls.

Monozygotic twins with primary Sjögren's syndrome

Sjögren's syndrome (SS) is a chronic autoimmune disease mainly characterized by dry mouth and dry eyes due to an inflammatory process in the exocrine glands. We describe a pair of Caucasian monozygotic twin sisters and their mother, all having primary SS. The twins had very similar clinical presentation and almost identical serological data, and histological examination of lower labial salivary glands gave a focus score of 3 in both twins. We also present their family medical history, which shows aggregation of immunological disorders among family members, although the twins and their mother were the only individuals with primary SS.

Evaluation of diagnostic tests for antinuclear antibodies in rheumatological practice

To investigate and compare the accuracy and usefulness of diagnostic tests for antinuclear antibodies (ANA) a cross-sectional study of sera derived from patients admitted to the Department of Rheumatology was tested for the presence of ANA using either indirect immunofluorescence on HEp-2 cells, indirect immunoperoxidase techniques on HEp-2 cells and mouse kidney, or two commercial enzyme-linked immunosorbent assays (ELISA). The diagnostic sensitivity and predictive values of the tests were calculated and compared. The accuracy of tests was compared using receiver-operating characteristics (ROC) methodology. All ANA-positive sera were further analysed for the presence of antibodies against extractable nuclear antigens (anti-ENA) and anti-DNA. A moderate to good agreement was found between tests, with kappa ranging from 0.469 to 0.659. Highest sensitivity for systemic lupus erythematosus (SLE; 93.3%) and primary Sjögren's syndrome (SS; 70%) was found using immunofluorescence on HEp-2 cells. Immunofluorescence on HEp-2 cells performed statistically better than the other tests in predicting SLE but not SS. All tests except mouse kidney showed good and comparable performance in detecting sera with anti-ENA and anti-DNA. At the given cut-off values indirect immunofluorescence on HEp-2 cells performed best. All assays except mouse kidney showed performance characteristics sufficient for use in routine analysis of ANA.

A longitudinal study of human cytomegalovirus serology and viruria fails to detect active viral infection in 20 systemic lupus erythematosus patients

In this study, we investigated whether active human cytomegalovirus infection could be detected in 20 systemic lupus erythematosus (SLE) patients over a one-year observation period by polymerase chain reaction on serial urine specimens and by monitoring of IgG and IgM HCMV-specific antibody profiles in serial serum samples. Of 788 urine samples analysed for the presence of human cytomegalovirus DNA, only 2 specimens (0.25%) collected from two different patients contained genuine human cytomegalovirus sequences as determined by polymerase chain reaction and subsequent sequencing of the PCR products. These two patients had one positive sample out of 36 samples or 40 samples, respectively. Nineteen of the patients (95%) possessed IgG antibodies against human cytomegalovirus, while 9 (45%) produced IgM antibodies. However, none of the patients showed signs of an active virus infection as judged by the stable anti-HCMV IgG or IgM antibody levels during the observation period, nor was any correlation between disease activity and HCMV serology/viruria observed. Of single serum samples of 26 age- and sex-matched blood donors, 21 (81%) were HCMV IgG positive and 1 (3.8%) was IgM seropositive. In conclusion, our data fail to establish an active human cytomegalovirus infection in SLE patients.

Renal involvement in primary Sjögren's syndrome

Renal involvement was evaluated in 62 patients with primary Sjögren's syndrome, classified according to criteria proposed by The European Classification Criteria Group. Urine concentration capacity was tested using intranasal 1-desamino-8-D-arginine-vasopressin. For patients with urine pH>5.5 without metabolic acidosis (n=28), an acidification test with ammonium chloride was performed. Urinary citrate, albumin, NAG, ALP and beta2-microglobulin were measured and creatinine clearance was calculated. Maximum urine concentration capacity and creatinine clearance were reduced in 13 (21%). Albumin excretion was >30 microg/min in only one patient (1.6%). Seven patients (11.3%) had complete or incomplete distal renal tubular acidosis (dRTA), four had reduced creatinine clearance and five had reduced maximum urine concentration capacity. The ratio of citrate/creatinine in spot urine was below the 2.5 percentile in all patients with complete or incomplete dRTA. The prevalence of dRTA was lower than in previous studies. There were also few patients with signs of glomerular disease (1.6%). The use of citrate:creatinine ratio in spot urine can be a helpful method in identifying patients with complete or incomplete dRTA.

[Rheumatological manifestations in HIV infections]

BACKGROUND

The recognised clinical spectrum of disease associated with HIV infection is rapidly expanding and now includes a variety of rheumatological manifestations.

MATERIAL AND METHODS

In this review of the literature of the last 15 years, we present the most common rheumatic manifestations described in association with HIV infection.

RESULTS

Manifestations include a wide array of articular syndromes and autoimmune manifestations such as Reiter's syndrome, psoriatic arthritis, HIV associated arthritis and septic arthritis. Autoimmune diseases associated with HIV infection include a Sjögren-like syndrome, myopathies and systemic vasculitis.

INTERPRETATION

Rheumatological manifestations of HIV infection may present earlier than clinical signs of the infection itself. Steroid and cytostatic treatment of rheumatic diseases may worsen the HIV disease.

[Heredity and immunology in Sjogren's syndrome]

BACKGROUND

Over the next 3-5 years, the rapid progress in genomic research will enable the discovery of many genes associated with the more common diseases. An example of such a common disease is the rheumatic disorder Sjögren's syndrome, an autoimmune disease. A more precise genetic explanation of the mechanism leading to Sjögren's syndrome remains to be given.

MATERIAL AND METHODS

One way of investigating the disease related genes in such complex polygenic diseases is to perform linkage studies in families with two or more affected. Another possibility is to conduct association studies on trios (parents and affected child), case control studies, or other experimental designs. In association studies one is testing if an allele is significantly elevated among patients compared to controls, while in linkage analyses one finds subchromosomal regions that are significantly more often inherited by patients than by healthy family members.

RESULTS

The most well defined genetic association in Sjögren's syndrome is currently related to different HLA alleles and their association with anti-Ro/SSA and anti-La/SSB autoantibodies. Additional genetic studies focusing on non-HLA regions are under way.

INTERPRETATION

Increased genetic knowledge would allow optimisation of the diagnostic criteria as well as development of new and more effective treatment for Sjögren's syndrome, which causes substantial suffering for a large group of patients.

[Symptoms in women with Sjogren's syndrome]

More knowledge about symptom experience is needed for diagnosing Sjögren's disease at an early stage of disease development. We have performed a qualitative study based on group interview with eight women with Sjögren's disease. The women presented with several different symptoms. They all described weariness, fatigue, sicca symptoms, various pains, hypersensitivity and organ manifestations in the same manner. Some of the symptoms had a dramatic impact on their life activities. The study revealed new descriptions of previously known symptoms and descriptions of previously unfamiliar symptoms. The results of the study may supplement the existing criteria of Sjögren's disease and provide new hypotheses about pathogenetic mechanisms related to chest pain, abdominal pain and facial pain in patients with Sjögren's disease.

Complement activation in patients with systemic lupus erythematosus without nephritis

OBJECTIVE

To study the association between disease activity and complement activation prospectively in patients with systemic lupus erythematosus (SLE).

PATIENTS AND METHODS

Twenty-one SLE patients were examined monthly for 1 yr. Disease activity, autoantibodies, conventional complement tests and the following complement activation products were investigated: C1rs-C1inh complexes, C4bc, Bb, C3a, C3bc, C5a and the terminal SC5b-9 complement complex (TCC).

RESULTS

Modest variation in disease activity was noted. None of the patients had nephritis. Flare was observed at 27 visits. Four patients had anti-C1q antibodies in conjunction with modestly low C1q concentrations. The complement parameters were rather constant during the observation period. Slightly to moderately decreased C4 (0.05-0.10 g/l) was found in 10 patients and severely decreased C4 (<0.05 g/l) in seven patients. Decreased C4 was not associated with increased complement activation. Complement activation products were either normal or slightly elevated. TCC was the only activation product correlating significantly with score for disease activity at flare. None of the variables tested predicted flares.

CONCLUSION

Complement tests are of limited importance in routine examination of SLE without nephritis, although TCC is suggested to be one of the most sensitive markers for disease activity.

The influence of age on disease manifestations and serological characteristics in primary Sjögren's syndrome

We have studied the influences of age on clinical manifestations and serological abnormalities in primary Sjögren's syndrome (pSS). The 67 patients included were diagnosed according to the preliminary European classification criteria for pSS, and disease manifestations were assessed according to a newly developed quantitative and qualitative classification model. We found that the age at diagnosis correlated to the presence of autoantibodies anti-SSA/SSB (r=-0.31, <0.02), rheumatoid factor (RF) (r=-0.33, p<0.01) and serum levels of IgG (r=-0.27, p<0.05). Young patients diagnosed before 45 years of age had the highest positivity of the autoantibodies anti-SSA/SSB (62.5%), RF (62.5%) and high levels of s-IgG (68.8%), while the corresponding values for old patients diagnosed after 60 years of age were anti-SSA/SSB: 20.8%, RF: 20.8%, and high s-IgG: 29.2%. None of these parameters correlated to age at onset nor disease duration. By applying a model for evaluating disease manifestations, no correlation between the global index nor the indices for subgroups of disease manifestations was found to age at onset, age at diagnosis, nor disease duration. We conclude that there is a significant influence of age on serological abnormalities in pSS, but not on disease manifestations.

Rheumatoid factors in primary Sjögren's syndrome (pSS) use diverse VH region genes, the majority of which show no evidence of somatic hypermutation

Rheumatoid factor (RF) is the most common autoantibody found in patients with Sjögren's syndrome (SS). To study the genetic origin and the mechanisms acting behind its generation we have characterized and sequenced the immunoglobulin VH genes used by 10 IgM RF MoAbs derived from peripheral blood of six female patients with pSS. We compared the structure of the RF immunoglobulin VH genes with those obtained previously from rheumatoid arthritis (RA) patients and healthy immunized donors (HID). VH1 and VH4 were each used by four RF clones, one clone was encoded by VH3 family gene and one by VH2 family gene. This distribution frequency was different from that observed in RA, where VH3 was the dominant family, followed by VH1. Eight different germ-line (GL) genes encoded the clones and all of these genes were seen previously in RA and/or HID RF. Five clones rearranged to JH6, four rearranged to JH4 and one to JH5, in contrast to RF from RA and HID, where JH4 was most frequently used. D segment use and CDR3 structure were diverse. Interestingly, three out of four VH4 clones used the GL gene DP-79 that was seen frequently in RA RF. The degree of somatic mutation in the pSS RF was very much lower than seen in RA and HID RF. All the pSS RF clones except three were in or very close to GL configuration. This indicates that there is little role for somatic hypermutation and a germinal centre reaction in the generation of RF from peripheral blood in pSS.

Seasonal variations in activity of systemic lupus erythematosus in a subarctic region

Photosensitivity is one of the major clinical features of Systemic Lupus Erythematosus (SLE), and is considered to be implicated in the disease pathogenesis. We studied seasonal variations of SLE disease activity at latitude 70 degrees North where there is no sunlight in the winter time, in contrast to 24 h daily sunlight in the summer (midnight sun). The associations between the level of plasma melatonin in June and December with disease manifestations were also studied. Twenty-one SLE patients were examined each month for 1 y, and disease activity was assessed by laboratory parameters as well as clinical disease activity parameters SLEDAI and doctor's global assessment. Melatonin levels were quantified by a RIA-assay. There was no significant change of clinical measures or laboratory parameters of disease activity from one month to the next during the one year, except photosensitive rashes. January was the only month without SLE-flares or arthritis, in contrast to rest of the year. The levels of plasma melatonin were highest in December for seven patients and highest in June for one patient (P < 0.005). Plasma melatonin levels did not correlate with measures of clinical disease activity. At a latitude of 70 degrees North there were no major seasonal variations in SLE disease activity during the one year. There was an accumulation of photosensitivity in the summer months, but no indications of worsening of the disease in the winter months. In contrast to the rest of the year, there was no flare in January which had only 5.6 h of sunshine. The level of p-melatonin did not correlate with measures of disease activity.

BK and JC viruses in patients with systemic lupus erythematosus: prevalent and persistent BK viruria, sequence stability of the viral regulatory regions, and nondetectable viremia

A role for polyomaviruses in the pathogenesis of systemic lupus erythematosus (SLE) has been suggested. BK virus (BKV) and JC virus (JCV) were demonstrated in single urine specimens from 7 (16%) of 44 and 5 (11%) of 44 patients with SLE and 0/88 and 18 (21%) of 88 matched healthy controls, respectively. During a 1-year follow-up study, episodes of polyomaviruria were detected in 16 (80%) of 20 patients, BKV in 13, and JCV in 3 patients. A group of 12 (60%) of 20 patients demonstrated persistent or recurrent polyomaviruria, BKV viruria (n=9), or JCV viruria (n=3) in 180 (70%) of 256 specimens. Polyomaviruria was not significantly associated with immunosuppressive therapy. The BKV and JCV isolates revealed predominantly stable archetypal regulatory regions over 3 years, indicating viral persistence rather than reinfection as a cause for urinary shedding. The demonstration of nondetectable viremia and stable archetypal BKV and JCV noncoding control regions during persistent viruria argue against the urinary tract as a focus for the creation of rearranged regulatory region variants.

Neural compressive symptoms appearing during steroid treatment in a patient with intracranial lipoma

Intracranial lipoma is a rare condition, and it is usually asymptomatic. We describe a 67 year old woman who developed blurred vision, diplopia, left sided oculomotor palsy, and ipsilateral ptosis during steroid treatment for giant cell arteritis. These symptoms were considered to be associated with aggressive giant cell arteritis, and the steroid dose was raised. Surprisingly, the symptoms increased, and further examination revealed an intracranial lipoma situated in the Meckel's cave. During tapering of the steroids her symptoms gradually improved. This is the first report demonstrating that steroids may induce hypertrophy of the fat tissue in the intracranial lipoma, causing compression of the cranial nerves passing through the cavernous sinus thereby mimicking the ocular symptoms sometimes associated with aggressive giant cell arteritis.

The prevalence of hyperprolactinemia in patients with primary Sjögren's syndrome

OBJECTIVE

To assess the prevalence of hyperprolactinemia in 55 patients with primary Sjögren's syndrome (SS), and its clinical significance.

METHODS

Concentrations of serum prolactin (PRL) were determined in 55 consecutive patients with primary SS and 110 controls by a fluoroimmunometric assay in a prospective case-control design.

RESULTS

The 55 patients with primary SS had higher serum PRL than 110 matching controls (271.5 vs 205.9 mIU/l; p < 0.02), and this difference was most evident in patients diagnosed before the age of 45 years (374.8 vs 245.5 mIU/l; p < 0.05), a patient population characterized by active immunological disease. Serum PRL did not correlate to disease duration, serum immunoglobulin, autoantibodies, or focus score in biopsies from minor salivary glands, but did correlate to score for internal organ disease (r = 0.33, p < 0.05). Two patients were diagnosed as having primary SS 12 years after hyperprolactinemia was first detected, and both patients had aggressive primary SS as indicated by extraglandular manifestations. One of the patients developed primary SS after being treated with bromocriptine, an inhibitor of PRL synthesis, for 12 years.

CONCLUSION

Patients with primary SS have moderately increased levels of serum PRL, especially evident in patients diagnosed at a young age with active immunological disease. Serum PRL is correlated to index for internal organ disease, and primary SS may be preceded by hyperprolactinemia for many years.

Morbidity and mortality in systemic lupus erythematosus during a 5-year period. A multicenter prospective study of 1,000 patients. European Working Party on Systemic Lupus Erythematosus

In the present study we assessed the frequency and characteristics of the main causes of morbidity and mortality in SLE during a 5-year period and analyzed the prognostic significance for morbidity and mortality of the main immunologic parameters used in clinical practice. We started in 1990 a multicenter study of 1,000 patients from 7 European countries. All had medical histories documented and underwent medical interview and routine general physical examination when entered in the study, and all were followed prospectively by the same physicians during the ensuing 5 years (1990-1995). Four hundred thirteen patients (41.3%) presented 1 or more episodes of arthritis, 264 (26.4%) had malar rash, 222 (22.2%) active nephropathy, 139 (13.9%) fever, 136 (13.6%) neurologic involvement, 132 (13.2%) Raynaud phenomenon, 129 (12.9%) serositis (pleuritis and/or pericarditis), 95 (9.5%) thrombocytopenia, and 72 (7.2%) thrombosis. Two hundred seventy patients (27%) presented infections, 113 (11.3%) hypertension, 75 (7.5%) osteoporosis, and 59 (5.9%) cytopenia due to immunosuppressive agents. Sixteen patients (1.6%) developed malignancies, with the most frequent primary localizations the uterus and the breast. Several immunologic parameters (anti-dsDNA or antiphospholipid antibodies) were found to have a predictive value for the development of SLE manifestations during the period of the study. Forty-five patients (4.5%) died; the most frequent causes of death were divided similarly among active SLE (28.9%), infections (28.9%), and thromboses (26.7%). A survival probability of 95% at 5 years was found. A lower survival probability (92%) was detected in those patients who presented at the beginning of the study with nephropathy.

Reliability and sensitivity of diagnostic tests for primary Sjögren's syndrome

OBJECTIVE

To investigate whether diagnostic tests for primary Sjögren's syndrome (pSS) are reproducible when repeated after one year (reliability). To evaluate whether the sensitivity of the diagnostic tests increases with repeated testing.

METHODS

A structured interview investigating the subjective sensation of dry eyes and dry mouth, and the diagnostic tests Schirmer I, unstimulated whole saliva collection (UWSC), serological tests for antinuclear antibodies (ANA), for anti-Ro/SSA and anti-La/SSB antibodies as well as Waaler's test for rheumatoid factor, were performed twice with a one year interval in 66 patients with pSS. Reliability was given as the percentage of positive tests remaining positive at the second examination, while sensitivity was given as the percentage of patients with positive tests.

RESULTS

Highest reliability was obtained for the sensation of dry mouth (98.2%) and sensation of dry eyes (96.4%), and anti-SSA/SSB antibodies (93.3%). Lowest reliability was obtained for rheumatoid factor at cutoff titer 1:32 (70.6%) and positive Schirmer I in one eye (77.4%). The reliability for ANA was 80% at cutoff titer 1:32, and increased to 93.3% at cutoff titer 1:128. UWSC had a reliability of 84.2%. The pooled sensitivity for all the tests increased significantly (p < 0.05) compared to the examination, which had the lowest sensitivity.

CONCLUSION

The diagnostic tests for pSS are generally highly reliable when performed twice with a one year interval. The gain in sensitivity by repeating the tests is limited, being most marked for Schirmer I.

Detection of anti-Ro/SSA and anti-La/SSB autoantibody-producing cells in salivary glands from patients with Sjögren's syndrome

OBJECTIVE

To investigate and identify the presence of cells producing anti-Ro/SSA and anti-La/SSB autoantibodies in salivary glands from patients with Sjögren's syndrome (SS).

METHODS

Submucosal salivary gland biopsy samples from 10 SS patients (8 with and 2 without circulating Ro and La autoantibodies) and 14 control subjects were evaluated. Frozen tissue sections were immunostained by an avidin-biotin complex technique, using biotinylated recombinant Ro and La proteins as detection reagents. Autoantibody levels in SS patient sera were analyzed by enzyme-linked immunosorbent assay.

RESULTS

Cells producing autoantibodies to the Ro 52-kd, Ro 60-kd, and La proteins were recorded in 8, 6, and 7 of the 10 SS patient biopsy samples, respectively. Samples from the 2 SS patients without circulating Ro and La autoantibodies were negative for these autoantibody-producing cells, as were all control biopsy samples. A strong positive correlation between the presence of autoantibodies in sera and the presence of autoantibody-producing cells in glandular biopsy tissues was evident. The number of autoantibody-producing cells and the serum autoantibody levels were also correlated (r(s)=0.94, P < 0.0001).

CONCLUSION

Using a novel technique, we have demonstrated the presence of Ro and La autoantibody-producing cells in salivary gland biopsy tissues from patients with SS. These findings indicate that anti-Ro/ SSA and anti-La/SSB autoantibodies are produced and are present at sites of inflammation and indicate their potential involvement in the autoimmune exocrinopathy of this disease.

[Sjögren's syndrome. New diagnostic aspects]

European criteria for classification of Sjögren's syndrome have recently been developed and evaluated. We report the clinical and laboratory findings in 96 patients with primary Sjögren's syndrome who have been classified according to these new criteria. In our patient population the latency from appearance of the first symptom to diagnosis was 11 years. In addition to sicca symptoms in mucous membranes, the dominant symptoms were periodic fatigue (92%), arthralgia (82%), hoarse voice (71%), dry cough (54%) and diarrhoea (51%). Antibodies to the nuclear antigens SSA and SSB were found in respectively 22.2% and 15.6% of the patients. Two out of ten patients with both anti-SSA and anti-SSB antibodies gave birth to a child with heart block.

Experimental expression in mice and spontaneous expression in human SLE of polyomavirus T-antigen. A molecular basis for induction of antibodies to DNA and eukaryotic transcription factors

We have previously demonstrated that experimental expression of the polyomavirus transcription factor T-antigen has the potential to induce anti-DNA antibodies in mice. Two sets of independent evidences are presented here that demonstrate a biological relevance for this model. First, we describe results demonstrating that mice inoculated with T-antigen-expressing plasmids produced antibodies, not only to T-antigen and DNA, but also to the DNA-binding eukaryotic transcription factors TATA-binding protein (TBP), and to the cAMP-response-element-binding protein (CREB). Secondly, we investigated whether polyomavirus reactivation occurs in SLE patients, and whether antibodies to T-antigen, DNA, and to TBP and CREB are linked to such events. Both within and among these SLE patients, frequent polyomavirus reactivations were observed that could not be explained by certain rearrangements of the noncoding control regions, nor by corticosteroid treatment. Linked to these events, antibodies to T-antigen, DNA, TBP, and CREB were detected, identical to what we observed in mice. Antibodies recognizing double-stranded DNA were confined to patients with frequent polyomavirus reactivations. The results described here indicate that cognate interaction of B cells recognizing DNA or DNA-associated proteins and T cells recognizing T antigen had taken place as a consequence of complex formation between T ag and DNA in vivo in the context of polyomavirus reactivations.

[Development of standards by the Norwegian Society of Rheumatology. Control of disease modifying drugs]

Rheumatoid arthritis is a serious disease associated with increased morbidity and mortality, and requires adequate routines for therapy and follow-up examination. This article presents the work of the Norwegian Society for Rheumatology to improve the quality of the therapeutic assessment of patients with rheumatoid arthritis in Norway. The process of reaching an agreement involved a large number of rheumatologists. The final meeting included a variety of activities, plenary lectures, workshops, group discussions and opinion polls. A literature search through Medline was provided continuously. Agreement was achieved on a programme for monitoring therapy with disease-modifying antirheumatic drugs, which was to comprise visits to the physician and laboratory tests. This programme was later voted on and affirmed by the Annual Meeting of the Norwegian Society for Rheumatology. Proposals were issued regarding endpoint measures to assess progression of the disease. These proposals can be expected to improve the quality of treatment and management of patients with rheumatoid arthritis, both in primary health care and in the specialized rheumatological health service.

[Consumer participation in the shaping of clinical quality assurance. A handling-oriented study of patient satisfaction]

Health care in a department of rheumatology was evaluated by interviewing 15 patients by a person not associated with the department. The patients' evaluation of the health care was then further evaluated by 264 former patients and the staff. There was a considerable mismatch between the patients' and staff's rating of the problems. The patients' feedback was then used systematically to choose between alternative methods of organising and providing the health care, and the effect of this was then re-evaluated by the patients.

Effects of calprotectin in avridine-induced arthritis

Plasma levels of calprotectin correlate with disease activity and clinical assessments of arthritis in various rheumatic diseases, and high levels have been demonstrated in the synovial fluid of patients with rheumatoid arthritis. However, the role of calprotectin in rheumatic inflammation is unclear. The purpose of the present study was to investigate potential intra-articular effects of calprotectin. Calprotectin was injected into joints of healthy male Lewis rats and into joints of rats in the latency period before onset of avridine-induced arthritis. In addition, a group of animals had IgG antibodies to rat calprotectin injected into joints before onset of avridine-induced arthritis. Injection of 0.2 or 10 micrograms calprotectin into the ankles of healthy male Lewis rats resulted in histologically minor and reversible inflammatory changes, but without any circulating antibodies to calprotectin. Furthermore, animals with 40 micrograms calprotectin injected into ankles before the expected onset of avridine-induced arthritis had lower scores for cellular infiltration than were seen in control joints. This difference did not quite reach statistical significance in the two-sided test used. However, the induced arthritis increased in joints injected with IgG antibodies to calprotectin. These findings may indicate that increased local concentrations of calprotectin are partially protective against avridine-induced arthritis. In contrast, reduced local concentrations appear to exacerbate the severity of arthritis. Calprotectin may thus be involved in the regulation of inflammatory processes in joints.

A prospective evaluation of antithyroid antibody prevalence in 100 patients with rheumatoid arthritis

The prevalence of thyroid antibodies in 100 patients with rheumatoid arthritis in Northern Norway was studied. The serological data were compared with those from a major population survey in the same area. Compared to the prevalence in the normal population, the present study demonstrates that patients with rheumatoid arthritis have a higher prevalence of antibodies to both thyroid microsomal antigen and thyroglobulin.

[Polymyalgia rheumatica and temporal arteritis. New aspects of diagnosis, treatment, prognosis and risk of cancer]

The incidence of polymyalgia rheumatica and temporal arteritis is increasing, mainly in elderly people. The risk of cancer during a lifetime is high in patients with positive biopsy of the temporal artery, but polymyalgia rheumatica and temporal arteritis are not to be considered as paraneoplastic syndromes. Temporal arteritis can appear in patients under treatment for polymyalgia rheumatica, and polymyalgia rheumatica can be accompanied by arthritis. Various new aspects of diagnoses and treatment are discussed.

[Early diagnosis of systemic lupus erythematosus. A challenge for clinicians of different specialties]

This paper presents some of the results from a ten year prospective study (Eurolupus) analyzing the main clinical and immunological manifestations in 1,000 patients with systemic lupus erythematosus (SLE). The time lag from the first symptoms to diagnosis was much longer in patients from Norway compared with patients from Europe in general (6.6 years versus two years respectively). In order to improve the early diagnosis of SLE, the authors focus on early clinical symptoms and signs.

Measurement of plasma calprotectin as an indicator of arthritis and disease activity in patients with inflammatory rheumatic diseases

OBJECTIVE

To investigate if the plasma level of the granulocyte protein calprotectin is a useful indicator of severity of arthritis in patients with inflammatory rheumatic diseases, and to analyze which factors contribute to the raised plasma calprotectin levels.

METHODS

Plasma calprotectin levels were measured by ELISA: In a cross sectional study of 154 patients with various inflammatory rheumatic diseases, calprotectin levels were correlated with laboratory and clinical variables.

RESULTS

The plasma levels of calprotectin and C-reactive protein (CRP) correlated significantly with the clinical evaluation of swollen joints (r = 0.51, p < or = 0.01 and r = 0.29, p < or = 0.01, respectively). Calprotectin levels, but not CRP levels or erythrocyte sedimentation rate, were significantly lower in patients with no swollen joints than in patients with one or more swollen joints (2613.6 micrograms/l vs 6287.0 micrograms/l, p < 0.001). A significant correlation between calprotectin and number of neutrophils was demonstrated (r = 0.43, p < or = 0.01), indicating that circulating neutrophils contribute to plasma calprotectin levels.

CONCLUSION

The plasma calprotectin level may be a useful indicator of arthritis in inflammatory rheumatic diseases.

Cancer in association with polymyalgia rheumatica and temporal arteritis

In our prospective controlled study, a total of 185 patients with polymyalgia rheumatica (PMR) and temporal arteritis (TA) diagnosed during 1978-83 and their 925 matched controls were cross checked with the data files at the Cancer Registry of Norway at the end of 1987. Malignancy was registered in 27 patients (14.6%) and 131 controls (14.2%) between 1953 and the end of 1987. Malignancy was registered in 16 (24.6%) of the patients with biopsy demonstrating arteritis temporalis. The hazard rate for developing malignancy after diagnosis for the whole patient population was not significantly different from the controls. The hazard rate for developing malignancy in patients with positive biopsy, however, was 2.35 times higher than in the controls (p = 0.036) and 4.40 times higher than the rest of the patient population (p = 0.007) (Cox proportional hazards model). The general long interval between diagnosis of PMR and/or TA and registration of malignancy (mean 6.5 years) is not consistent with a paraneoplastic mechanism.

Calprotectin in patients with systemic lupus erythematosus: relation to clinical and laboratory parameters of disease activity

Calprotectin (L1) is a granulocyte and monocyte cytosolic protein released during activation of these cells. The plasma level of L1 has been shown to be a good marker of disease activity in rheumatoid arthritis. In this cross-sectional study of 100 patients with systemic lupus erythematosus (SLE), the serum level of L1 was found to be higher in patients than in matched controls (3661 micrograms/l versus 1051 micrograms/l; P < 0.001). The serum level of L1 was the only laboratory parameter with significant association to the disease activity index SLEDAI (r = 0.28; P < 0.01). Furthermore, the serum level of L1 was significantly higher in SLE patients with anti-DNA antibodies compared to patients without anti-DNA antibodies (4501 micrograms/l versus 3279 micrograms/l; P = 0.01). SLE patients with arthritis had higher serum levels of L1 than patients without arthritis (7652 micrograms/l versus 2811 micrograms/l; P < 0.01), indicating that the serum level of L1 also reflects arthritis activity in SLE.

Lack of specific binding of anticardiolipin antibodies to intact platelets

The aims of this study were to investigate whether anticardiolipin antibodies (aCL) bind to intact (resting or activated) platelets in vitro. Suspensions of resting, activated (with a mixture of thrombin and collagen) and freeze-thawed platelets from healthy subjects were incubated with either affinity-purified aCL or pooled normal human immunoglobulin G (IgG). Platelet-bound IgG was measured by flow cytometric analysis of platelets incubated with a fluorescein-conjugated polyclonal goat anti-human IgG. There was no significant binding of IgG aCL to intact resting or activated platelets, while significant specific binding to freeze-thawed platelets was demonstrated. These results question the theory that aCL bind/activate intact platelets in vivo.

Short term effects of intravenous pulses of cyclophosphamide in the treatment of connective tissue disease crisis

A predominantly outpatient regimen of low dose intravenous cyclophosphamide was used to treat patients with serious progressive connective tissue diseases. Fifty five patients were treated with a total of 211 intravenous pulses of cyclophosphamide. Forty five patients had previously shown no response to a variety of other treatments. Low dose intravenous cyclophosphamide (500 mg) was given in 179 pulses and repeated pulses were given in most patients at weekly intervals for one to three weeks to induce disease remission. A good response was noted in 37 of 55 (67%) patients assessed four weeks after the pulses. Only 20 patients needed more than one such course of three pulses of intravenous cyclophosphamide during the observation period. The non-responders were characterised by longstanding disease and irreversible histological findings in renal and muscle biopsy samples. Patients with vasculitis, notably Wegener's granulomatosis, showed the most immediate response, and in most patients the amount of corticosteroids required was markedly reduced. In some patients steroids were completely stopped during the follow up period. The most striking observation of this effective but more conservative regimen was the low incidence of major side effects such as neutropenia and infections. It is concluded that low dose pulses of intravenous cyclophosphamide are well tolerated and are an effective treatment for patients with aggressive connective tissue diseases.

Calprotectin in patients with rheumatoid arthritis: relation to clinical and laboratory variables of disease activity

Calprotectin (L1) is a major granulocyte and monocyte protein which is released during activation of these cells. The plasma level of L1 is thought to reflect disease activity in rheumatoid arthritis (RA). In our cross sectional study of 70 patients with RA, L1 had significant correlations with erythrocyte sedimentation rate (r = 0.50), C-reactive protein (r = 0.58), orosomucoid (r = 0.62), platelet count (r = 0.42), leukocyte count (r = 0.33) and IgM rheumatoid factor (r = 0.32); and with the following clinical variables: number of swollen joints (r = 0.24), grip strength (r = -0.22), PIP joint circumferences (r = 0.33) and a combined global assessment score (r = 0.24). L1 was higher in seropositive (median 14,861 micrograms/l) than seronegative patients (median 10,487 micrograms/l) (p less than 0.03).

[Systemic lupus erythematosus and pregnancy]

In patients with systemic lupus erythematosus in remission pregnancy has a good prognosis for mother and foetus. Pregnancy does not have a negative effect on systemic lupus erythematosus in remission, either in the short or the long term. Immuno-regulatory drugs should not be withdrawn before or after start of pregnancy, and flares during pregnancy can be treated with steroids and/or azathioprine. The risk of flare is very high in the puerperium, and can be prevented by steroids. All patients are at high risk of losing the foetus, particularly patients with antiphospholipid antibodies. Patients at high risk should be given low doses of aspirin (80 mg daily) from the first day of pregnancy. Neonatal lupus and congenital heart block are rare, and are associated with the presence of anti-SSA and anti-SSB antibodies in the maternal blood.