Molecular detection of bacterial DNA in venereal-associated arthritis

OBJECTIVE

To evaluate the utility of polymerase chain reaction (PCR) amplification in detecting DNA from venereal-associated microorganisms in the synovial fluid of patients with inflammatory arthritis.

METHODS

Oligonucleotide primers were developed for nested PCR based on Chlamydia, Ureaplasma, and Neisseria DNA sequences. PCR products were detected by gel electrophoresis and dot-blot hybridization. Primers specific for the target bacterial DNA were used to search for bacterial DNA in 61 synovial fluid specimens from patients with inflammatory arthritis, including several clinically associated with venereal infection.

RESULTS

Five of the 61 synovial fluid specimens were positive for Neisseria gonorrhoeae DNA. Four of the 5 patients had clinical diagnoses of gonococcal arthritis; the other patient had an unexplained monarthritis. One specimen from a patient with a clinical diagnosis of gonococcal arthritis was negative for N gonorrhoeae. Three of the 61 specimens were positive for Chlamydia DNA. Two were derived from patients with clinical diagnoses of reactive arthritis or Reiter's syndrome, and 1 was from a patient with unexplained monarthritis. One of the 61 specimens was positive from Ureaplasma DNA; this sample was from a patient with a clinical diagnosis of Reiter's syndrome. In an additional patient with Reiter's syndrome, Ureaplasma DNA was also found in prostate biopsy tissue and a urine sample obtained after prostate massage (synovial fluid not available).

CONCLUSION

These data support the classification of these 3 venereal-associated arthritides as infectious processes, and suggest that PCR for bacterial DNA is a useful method for detecting infectious agents in synovial fluid.

Laboratory tests for rheumatic diseases. When are they useful?

Because negative tests often do not exclude a rheumatic disease and positive tests do not always diagnose it, judicious use of laboratory testing in patients with suspected rheumatic disease is essential. The final diagnosis must be made clinically. However, when the tests are used in conjunction with clinical manifestations, they may help differentiate the numerous rheumatic disorders, and they may also be of value in monitoring activity of the disease.

Detection of T cell receptors in early rheumatoid arthritis synovial tissue

Synovial tissue is rarely available from patients with early synovitis, with the exception of synovial biopsies. However, T cell populations early in the development of synovitis may be enriched in antigen-specific cells and critical to disease pathogenesis. To investigate the T cell repertoire in early synovitis, we utilized a PCR protocol for detection of T cell receptor (TCR) transcripts present in small amounts of synovial tissue. To expand the substrate for PCR, preamplification of cDNA was performed with a 3' constant region primer plus either a mixture of variable region primers or random hexanucleotides. Utilizing this method improved the sensitivity of detection. This technique is applied here to the analysis of TCR transcripts in synovial biopsies from individuals with early rheumatoid arthritis (RA) and non-RA synovitis. TCR alpha-chain transcripts were detectable in 5/5 RA and 4/4 non-RA specimens evaluated, with beta-chain transcripts detected in 4/5 early RA and 4/4 non-RA specimens evaluated. Confirmation of transcripts by sequencing of cloned PCR products verified the specificity of amplification. The most frequently expressed TCR V region families in early RA synovitis were V alpha 11, V alpha 14, V alpha 28, V beta 7, V beta 9 and V beta 17. Several of these V regions have previously been implicated in studies of chronic RA synovitis. J alpha and J beta region usage was similar to that seen in chronic RA, and conserved N region motifs were apparent. We conclude that it is possible to detect TCR transcripts in small synovial biopsies from individuals with early arthritis.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteoporosis and bone morbidity in cardiac transplant recipients

PURPOSE

To evaluate the incidence and etiology of osteopenia and pathologic fractures in cardiac transplant recipients.

PATIENTS

Thirty-one adult male cardiac transplant recipients and 14 adult men with congestive heart failure (CHF) awaiting cardiac transplantation.

METHODS

Assessment of indices of bone and mineral metabolism and of bone mineral density (BMD) by dual-energy x-ray absorptiometry.

RESULTS

BMD in the proximal femur was below normal in both groups compared to that in age-matched control subjects, whereas BMD in the lumbar spine was normal. There was no significant difference in BMD at any site between the two groups. No clinical parameter predicted BMD. In all patients, laboratory indices of bone mineral metabolism, except parathyroid hormone (PTH) levels, were normal and not statistically different between the two groups. CHF patients had a trend toward elevations of PTH, 1,25-dihydroxyvitamin D, and urinary calcium excretion compared to transplant patients. Eight of 31 transplant patients and 2 of 14 CHF patients had vertebral compression fractures (c2 = 11.8, p < 0.0006). Transplant recipients with fractures had twice as many rejection episodes as did transplant patients without fractures, but did not differ in cumulative dose of steroids. Two patients developed avascular necrosis of the femoral head following transplantation.

CONCLUSIONS

Cardiac transplant recipients and patients with CHF awaiting transplantation had decreased hip BMD, but normal spine BMD. Although immunosuppressive therapy did not appear to influence bone mass, loop diuretics prior to transplantation may have stimulated a mild secondary increase in PTH that could have differentially caused loss of bone density at the hip in both groups. Pulse corticosteroids used in treating rejection may have contributed to the increased incidence of vertebral fractures in transplant patients. These data suggest that severe CHF with its associated diuretic use and decreased activity are primary contributors to osteopenia in these patients.

Pulmonary alveolar hemorrhage in systemic lupus erythematosus

Pulmonary alveolar hemorrhage (PAH) is a rare and often fatal presenting feature of systemic lupus erythematosus (SLE). Reported mortality rates are extremely high, 70% to 90%. Death frequently occurs within the first several days of the hemorrhage. The hospital records of all inpatients with PAH and SLE between April 1986 and May 1991 at the Hospital of the University of Pennsylvania were reviewed. The complete resolution of PAH and the 75% survival rate found in this study is in marked contrast to previous reports. This experience suggests that patients with PAH and SLE may have a better prognosis than previously reported.

Gonococcal septic arthritis of the hip

We describe a patient with a Neisseria gonorrhoeae monoarthritis of the hip. Treatment with intravenous ceftriaxone, oral doxycycline, and repeated fluoroscopic needle aspirations resulted in a complete recovery of function without residual deficit. Gonococcal monoarthritis of the hip is rare. Gonococcal hip infections appear to respond well to antibiotics and drainage by arthrocentesis. This differs from hip infections caused by other bacteria where joint damage is common and where the recommended initial treatment is open surgical drainage.

Botanical lipids: potential role in modulation of immunologic responses and inflammatory reactions

Enrichment of cells with fatty acids of particular botanical lipids alters cell function in vitro (for example, suppression of human synovial cell and T lymphocyte proliferation) in a manner that suggests that administration of these botanical lipids may be a useful therapeutic strategy for patients with diseases characterized by disordered immune responses and chronic inflammation. Treatment of animal models with certain plant seed oils suppresses inflammation and joint tissue injury. Controlled trials in patients with rheumatoid arthritis are in an early stage, but offer encouragement. The mechanisms whereby these novel lipids influence host defense include alteration of arachidonic acid oxygenation products and direct effects on cells independent of fatty acid metabolism.

Systemic lupus erythematosus and the syndrome of inappropriate secretion of antidiuretic hormone

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) has been reported rarely in systemic lupus erythematosus (SLE) with central nervous system disease. Previous case reports linking SIADH with lupus have either not documented clearly that SLE was the sole cause of the problem, or have not demonstrated a correlation between indicators of lupus activity and the onset and resolution of antidiuretic hormone secretion. We describe a case in which SLE was the sole contributor to the initiation of SIADH and where other evidence of lupus activity correlated temporally with inappropriate antidiuretic hormone secretion.

Cocaine and its derivatives blunt neutrophil functions without influencing phosphorylation of a 47-kilodalton component of the reduced nicotinamide-adenine dinucleotide phosphate oxidase

Cocaine and its derivatives blunted responses of neutrophils (cell/cell aggregation, up-regulation of the receptor for C3bi (CR3, CD11b/CD18), generation of superoxide anion (O2-) and degranulation to various stimuli. The order of potency of these agents was the same as that for local anesthesia: tetracaine greater than bupivacaine greater than cocaine greater than lidocaine. Neutrophil aggregation elicited by the chemoattractant FMLP (10(-7) M) was inhibited by cocaine (10 mM) to 13.6 +/- 6% of control (p less than 0.002); the IC50 was approximately 4 mM. Cocaine and the other local anesthetics not only inhibited the upregulation of CR3 and O2- generation, but also blocked degranulation of cytochalasin B-treated cells. Cocaine (10 mM) reduced beta-glucuronidase and lysozyme secretion to 4.3 +/- 0.7 and 13 +/- 2.2% controls, respectively; its IC50 was 4 mM. Local anesthetics added after ligand/receptor engagement (FMLP) interrupted aggregation and halted generation of O2-. Moreover, local anesthetics rapidly inhibited aggregation, O2- generation, and degranulation elicited by PMA (1 microgram/ml) or the Ca ionophore A23187 (10 microM): the effects of cocaine could therefore not be attributed to unique actions at the FMLP receptor. Peak levels of intracellular Ca2+ ([Ca]i) at 5 to 10 s, and levels of [Ca]i 120 s after FMLP in Fura 2-loaded cells were significantly lower in cells treated with lidocaine, findings that could be explained by enhanced 45Ca2+ efflux from neutrophils. In cells loaded with bis(carboxyethyl)carboxyfluorescine (pH indicator) local anesthetics failed to affect the initial FMLP-induced (0 to 15 s) drop of pHi but inhibited the later (120 s) realkalinization of the cytosol (lidocaine, bupivacaine). Most remarkably, autoradiographs of SDS gels prepared from stimulated, 32P-labeled neutrophils treated with local anesthetics showed no difference from resting cells, either with respect to patterns of phosphorylation and dephosphorylation or their kinetics. Labeling of a 47-kDa protein, a component of the reduced nicotinamide-adenine dinucleotide phosphate-oxidase system, was unchanged. The effects of local anesthetics, which blunt neutrophil responses without affecting protein phosphorylation, suggest that protein phosphorylation is an insufficient signal for neutrophil activation. Inasmuch as cocaine and its derivatives affect cell functions at sites distal to activation of protein kinase C, these agents should prove useful in uncoupling protein phosphorylation from functional responses.

Cocaine and its derivatives blunt neutrophil functions without influencing phosphorylation of a 47-kilodalton component of the reduced nicotinamide-adenine dinucleotide phosphate oxidase

Cocaine and its derivatives blunted responses of neutrophils (cell/cell aggregation, up-regulation of the receptor for C3bi (CR3, CD11b/CD18), generation of superoxide anion (O2-) and degranulation to various stimuli. The order of potency of these agents was the same as that for local anesthesia: tetracaine greater than bupivacaine greater than cocaine greater than lidocaine. Neutrophil aggregation elicited by the chemoattractant FMLP (10(-7) M) was inhibited by cocaine (10 mM) to 13.6 +/- 6% of control (p less than 0.002); the IC50 was approximately 4 mM. Cocaine and the other local anesthetics not only inhibited the upregulation of CR3 and O2- generation, but also blocked degranulation of cytochalasin B-treated cells. Cocaine (10 mM) reduced beta-glucuronidase and lysozyme secretion to 4.3 +/- 0.7 and 13 +/- 2.2% controls, respectively; its IC50 was 4 mM. Local anesthetics added after ligand/receptor engagement (FMLP) interrupted aggregation and halted generation of O2-. Moreover, local anesthetics rapidly inhibited aggregation, O2- generation, and degranulation elicited by PMA (1 microgram/ml) or the Ca ionophore A23187 (10 microM): the effects of cocaine could therefore not be attributed to unique actions at the FMLP receptor. Peak levels of intracellular Ca2+ ([Ca]i) at 5 to 10 s, and levels of [Ca]i 120 s after FMLP in Fura 2-loaded cells were significantly lower in cells treated with lidocaine, findings that could be explained by enhanced 45Ca2+ efflux from neutrophils. In cells loaded with bis(carboxyethyl)carboxyfluorescine (pH indicator) local anesthetics failed to affect the initial FMLP-induced (0 to 15 s) drop of pHi but inhibited the later (120 s) realkalinization of the cytosol (lidocaine, bupivacaine). Most remarkably, autoradiographs of SDS gels prepared from stimulated, 32P-labeled neutrophils treated with local anesthetics showed no difference from resting cells, either with respect to patterns of phosphorylation and dephosphorylation or their kinetics. Labeling of a 47-kDa protein, a component of the reduced nicotinamide-adenine dinucleotide phosphate-oxidase system, was unchanged. The effects of local anesthetics, which blunt neutrophil responses without affecting protein phosphorylation, suggest that protein phosphorylation is an insufficient signal for neutrophil activation. Inasmuch as cocaine and its derivatives affect cell functions at sites distal to activation of protein kinase C, these agents should prove useful in uncoupling protein phosphorylation from functional responses.