Atrial arrhythmias--the dominating cardiac problem in three patients with HLA B27 associated rheumatic disorders

Three young patients with atrial arrhythmias as the probable consequence of an HLA B27 associated inflammatory disease process are described. They are presented as an expansion of the spectrum of cardiac manifestations that can be seen in patients with HLA B27 associated rheumatic disorders, and as possible evidence of myocardial involvement of this disease process.

The treatment of psoriatic arthritis and inflammatory spondylitis

NSAIDs still remain the initial therapeutic modality for psoriatic arthritis and inflammatory spondylitis. Disease-modifying antirheumatic drugs have only been proven to be useful in peripheral arthritis, without efficacy in axial inflammatory spondylitis. In recent years, the introduction of tumor necrosis alpha inhibitors into clinical practice has produced a substantial impact in both peripheral and axial disease, with improvement in pain, function, and quality of life. Factors such as cost-effectiveness and safety will need to be better characterized over time.

[Genetics in patients with psoriatic arthritis]

OBJECTIVES

HLA antigens were studied in 100 Hungarian patients suffered from psoriatic arthritis. Genetic markers for the development of different clinical pattern of the disease and skin disorder were identified.

METHODS

Determination of class I and class II antigens was performed by using microlymphocytotoxicity assay.

RESULTS

The frequency of HLA-Cw6, HLA-B16 (and its split B-39) and HLA-B27 antigens were significantly higher in psoriatic arthritis patients than in the Hungarian general population. No connection was found between HLA-DR4, DR7, B17 antigens and psoriatic arthritis. The patients were classified according to the subgroups proposed by Gladman. The comparisons between the clinical subgroups revealed a significant association of HLA-B27 with spondylitis (Gladman 4, 5, 6, 7). There was no association between HLA DR4 and polyarticular pattern of the disease (Gladman 3, 7). Psoriasis seemed to be significantly associated only with HLA-Cw6. There was a higher frequency of HLA-B38 in psoriatic arthritis patients with erythroderma.

An increase of blood squamous cell carcinoma antigen in Pseudomonas aeruginosa spondylitis

Squamous cell carcinoma antigen (SCCA) is traditionally engaged for detecting and following up malignancy from a squamous cell origin. We encountered an unusual increase of blood SCCA but no other cancer markers in a patient associated with an infective lumbar spondylitis due to Pseudomonas aeruginosa. An overshooting of Th1 expression, such as tumor necrosis factor alpha, bumped up by his uremia as a result of P. aeruginosa infection may hasten SCCA. Therefore, SCCA might additionally serve as a serological marker for infection besides squamous cell cancer, and its false-positive increase also highlights the appropriateness of tumor marker screening.

Inflammatory bowel disease-specific autoantibodies in HLA-B27-associated spondyloarthropathies: increased prevalence of ASCA and pANCA

AIMS

An association between inflammatory bowel disease (IBD) and spondyloarthropathies (SpA) has repeatedly been reported. The aim of the present study was to investigate whether serologic markers of IBD, e.g. antibodies against Saccharomyces cerevisiae (ASCA), antibodies against exocrine pancreas (PAB) and perinuclear antineutrophil cytoplasmic antibodies (pANCA) are present in HLA-B27-associated SpA.

METHODS

87 patients with HLA-B27-positive SpA and 145 controls were tested for ASCA, PAB and pANCA employing ELISA or indirect immunofluorescence, respectively. Antibody-positive patients were interviewed regarding IBD-related symptoms using a standardized questionnaire.

RESULTS/CONCLUSION

When compared to the controls, ASCA IgA but not ASCA IgG levels were significantly increased in patients with SpA, in particular in ankylosing spondylitis (AS) and undifferentiated SpA (uSpA). pANCA were found in increased frequency in patients with SpA whereas PAB were not detected. The existence of autoantibodies was not associated with gastrointestinal symptoms but sustains the presence of a pathophysiological link between bowel inflammation and SpA.

Uveitis as the initial clinical manifestation in patients with spondyloarthropathies

OBJECTIVE

To investigate the frequency and pattern of presentation of uveitis as the first clinical manifestation to prompt diagnostic evaluation in patients with spondyloarthropathies (SpA).

METHODS

Patients with uveitis were attended simultaneously by ophthalmologists and rheumatologists in our Uveitis Clinic between June 1997 and October 2000. An established clinical protocol based on the pattern of uveitis and the patient's symptoms was used to determine diagnosis. Evaluation included clinical history, ophthalmologic examination, hemogram, biochemistry, erythrocyte sedimentation rate, the fluorescent treponemal antibody absorption test, urinalysis, and chest radiograph. Additional studies were requested according to the protocol.

RESULTS

Data from 394 patients were recorded in our database. Seventy-two (18%) had some type of SpA; their mean age was 44.7 years (SD 15.7) and 51 (71.8%) were men. Forty-two patients (59%) of the SpA group had been previously diagnosed. In the 30 (41%) who were undiagnosed, uveitis was the first manifestation to prompt diagnostic evaluation. The most frequent clinical pattern was acute unilateral anterior uveitis. The 2 main keys to confirm the diagnosis of SpA were the presence of recurrent acute unilateral uveitis and low back or joint pain, in addition to the uveitis flare. HLA-B27 was found in 94% of patients.

CONCLUSION

In 41% of the patients diagnosed with SpA, uveitis was the first clinical sign, suggesting that collaboration between ophthalmologists and rheumatologists greatly aids the diagnosis and treatment of these patients. When this close collaboration is not possible, all patients with rheumatic complaints and recurrent acute unilateral uveitis should be referred to a rheumatologist.

Experimental immunity to the G1 domain of the proteoglycan versican induces spondylitis and sacroiliitis, of a kind seen in human spondylarthropathies

OBJECTIVE

Experimental immunity to the G1 domain of the cartilage proteoglycan (PG) aggrecan (AG1) leads to the development of spondylitis as well as polyarthritis in BALB/c mice. The PG versican contains a structurally similar G1 domain (VG1). This study was conducted to determine whether immunity to VG1 would elicit similar pathology in these mice.

METHODS

Recombinant natively folded VG1 and AG1 were prepared. BALB/c mice received either a series of 5 injections of human VG1 or AG1, or no protein. Polyarthritis was determined clinically, and spondylitis and sacroiliitis histologically. Immunohistochemistry of rat tissues was used to study the localization of versican. Enzyme-linked immunosorbent assays were employed to study humoral immunity to the recombinant proteins as well as to overlapping synthetic peptides covering all these human G1 domains and mouse homologs. Affinity-purified antibodies to human AG1 and VG1 were isolated from sera of hyperimmunized mice. T lymphocyte proliferation assays were performed using recombinant human proteins. T cell lines reactive with specific immunodominant T cell epitopes in human AG1 and VG1 were isolated. Synthetic peptides encoding sequences in these human proteins and in corresponding mouse proteins were used in these analyses. Guanidinium chloride extracts of mouse spines were also used in Western blots to study antibody cross-reactivity.

RESULTS

Immunity to recombinant VG1 did not result in clinical polyarthritis. There was, however, clear evidence that VG1, like AG1, could induce spondylitis in the lumbar spine and sacroiliitis. Accumulation of mononuclear cells was observed in spinal ligaments adjacent to the intervertebral disc, in the intervertebral disc, and in the sacroiliac joints, the same sites where versican is localized. In contrast to AG1-immunized mice, in which T cells reactive with human AG1 cross-reacted with mouse AG1, there was no evidence in VG1-immunized mice that T cell immunity to human VG1 was cross-reactive with a mouse synthetic peptide that contained the sequence corresponding to the single immunodominant T cell sequence recognized in human VG1. Antibodies to specific sequences in human VG1 did, however, cross-react with human AG1 and with corresponding peptide sequences in mouse versican and aggrecan and with mouse proteins containing VG1 and AG1, present in mouse spine extracts. Similarly, antibodies to human AG1 cross-reacted with human VG1 and with extracted mouse VG1 and AG1 and synthetic peptides containing mouse sequences that corresponded to the reactive human epitopes in AG1 and VG1.

CONCLUSION

These observations suggest that humoral immunity to human VG1 is involved in the induction of experimental spondylitis and sacroiliitis in BALB/c mice. This humoral immunity is cross-reactive with mouse versican and aggrecan but is not associated with polyarthritis, probably because of the lack of cross-reactive T cell immunity and the absence of detectable versican in articular cartilage limbs. Induction of polyarthritis by bovine or human aggrecan requires the involvement of immunity mediated by T lymphocytes that are cross-reactive to a mouse aggrecan epitope. Together these observations suggest that humoral immunity to versican as well as immunity to aggrecan may be of importance in the development of the spinal pathology characteristic of spondylarthropathies.

[Immunity in patients with active tuberculous spondylitis]

Immunological parameters were studied in 45 patients with active tuberculous spondylitis, admitted for surgical treatment, who were divided into 2 groups in accordance with the prevalence of exudative-necrotic, or productive components of inflammation in the vertebral bodies and paravertebral tissues. The patients with a predominantly exudative-necrotic component of inflammation exhibited a severe clinical course with frequent neurological disorders, large abscesses in the paravertebral tissues, inflammatory changes in the leukogram, enhanced specific T-lymphocytic activity in the PPD blast-transformation reaction, significant increases in the levels of tuberculosis antibodies and IgE, IL-2 and it soluble IL-2 receptor RR-alpha, an excessively high increase in the functional activity of neutrophilic granulocytes, and lower with IgG2. The degree of immunological disorders corresponds to the severity of a course of tuberculous spondylitis.

Novel approaches in the treatment of ankylosing spondylitis and other spondyloarthritides

The therapeutic options for patients suffering from severe forms of spondyloarthritis (SpA) have been rather limited in recent decades. There is now accumulating evidence that anti-TNF therapy is highly effective in SpA, especially in ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Based on the data recently published on what is now several hundred AS and PsA patients, this treatment seems to be even more effective than the same therapy in rheumatoid arthritis (RA). The anti-TNF-alpha agents currently available, infliximab (Remicade); Centocor), etanercept (Enbrel); Amgen) and adalimumab (Humira; Abbott), are approved for the treatment of RA in the US; infliximab and etanercept are approved in Europe. The situation in SpA is different to RA because there is an unmet medical need, especially in AS, since no therapies with disease-controlling antirheumatic drugs are available for severely affected patients, especially with spinal disease. Thus, TNF blockers might even be considered as first-line immunosuppressive agents in patients with active AS and PsA who are not sufficiently treated by non-steroidal anti-inflammatory drugs and sulfasalazine, if peripheral arthritis is present. For infliximab, a dosage of 5 mg/kg at intervals between 6 and 12 weeks was necessary to constantly suppress disease activity; this is also a major aim of long-term treatment. No dose-finding studies have yet been performed. The standard dose of etanercept is 25 mg s.c. twice-weekly. No studies on adalimumab (standard RA dose 20 - 40 mg s.c. every 2 weeks) have yet been conducted in SpA. The efficacy of etanercept was first demonstrated in PsA and etanercept is now approved for this indication. A double-blind study has also been performed in AS, with similarly clearcut efficacy. There is preliminary evidence that both agents do also work in other SpA such as undifferentiated SpA. Infliximab has recently been approved for short-term treatment of severe uncontrolled AS; the approval for etanercept is pending. Studies should be performed to document the long-term efficacy of this treatment. There is hope that ankylosis might be preventable but it remains to be shown whether patients benefit from long-term anti-TNF therapy and whether radiological progression and ankylosis can be stopped. Severe adverse events have remained rare. Complicated infections including tuberculosis have been reported. Tuberculosis can be mostly prevented if patients are checked for previous contact with tuberculosis. Currently, the benefits of anti-TNF therapy in AS seem to outweigh these shortcomings.

Management of Aspergillus osteomyelitis: report of failure of liposomal amphotericin B and response to voriconazole in an immunocompetent host and literature review

Presented here is a case of Aspergillus osteomyelitis in an immunocompetent patient that progressed despite surgery and prolonged treatment with liposomal amphotericin B; the report is followed by a review of the literature. The review of this case and 41 similar cases found an overall cure rate of 69%. The importance of surgery when amphotericin B is used as first-line therapy is indicated by a 14% cure rate when amphotericin B is used alone compared to 75% when combined with surgery. When therapy is failing or surgery is contraindicated, dose escalation using a lipid formulation was not effective. On review, the addition of another agent, in particular 5-fluorocytosine, appears to be more beneficial. The patient reported here responded rapidly to voriconazole, a promising new antifungal agent for Aspergillus infections.

The peptide repertoires of HLA-B27 subtypes differentially associated to spondyloarthropathy (B*2704 and B*2706) differ by specific changes at three anchor positions

HLA-B*2704 is strongly associated with ankylosing spondylitis. B*2706, which differs from B*2704 by two amino acid changes, is not associated with this disease. A systematic comparison of the B*2704- and B*2706-bound peptide repertoires was carried out to elucidate their overlap and differential features and to correlate them with disease susceptibility. Both subtypes shared about 90% of their peptide repertoires, consisting of peptides with Arg(2) and C-terminal aliphatic or Phe residues. B*2706 polymorphism influenced specificity at three anchor positions: it favored basic residues at P3 and POmega-2 and impaired binding of Tyr and Arg at POmega. Thus, the main structural feature of peptides differentially bound to B*2704 was the presence of C-terminal Tyr or Arg, together with a strong preference for aliphatic/aromatic P3 residues. This is the only known feature of B*2704 and B*2706 that correlates to their differential association with spondyloarthropathy. The concomitant presence of basic P3 and POmega-2 residues was observed only among peptides differentially bound to B*2706, suggesting that it impairs binding to B*2704. Similarity between peptide overlap and the degree of cross-reaction with alloreactive T lymphocytes suggested that the majority of shared ligands maintain unaltered antigenic features in the context of both subtypes.

Aspergillus spondylitis in immunocompetent patients

Four immunocompetent patients with neurological deficit underwent anterior decompression for Aspergillus osteomyelitis of the spine. All patients improved neurologically following anterior spinal decompression and antifungal therapy. This study emphasizes the importance of obtaining a tissue diagnosis as these unusual infections may mimic tuberculosis, which is more common.

Gorillas with spondyloarthropathies express an MHC class I molecule with only limited sequence similarity to HLA-B27 that binds peptides with arginine at P2

The human MHC class I gene, HLA-B27, is a strong risk factor for susceptibility to a group of disorders termed spondyloarthropathies (SpAs). HLA-B27-transgenic rodents develop SpAs, implicating HLA-B27 in the etiology of these disorders. Several nonhuman primates, including gorillas, develop signs of SpAs indistinguishable from clinical signs of humans with SpAs. To determine whether SpAs in gorillas have a similar HLA-B27-related etiology, we analyzed the MHC class I molecules expressed in four affected gorillas. Gogo-B01, isolated from three of the animals, has only limited similarity to HLA-B27 at the end of the alpha1 domain. It differs by several residues in the B pocket, including differences at positions 45 and 67. However, the molecular model of Gogo-B*0101 is consistent with a requirement for positively charged residues at the second amino acid of peptides bound by the MHC class I molecule. Indeed, the peptide binding motif and sequence of individual ligands eluted from Gogo-B*0101 demonstrate that, like HLA-B27, this gorilla MHC class I molecule binds peptides with arginine at the second amino acid position of peptides bound by the MHC class I molecule. Furthermore, live cell binding assays show that Gogo-B*0101 can bind HLA-B27 ligands. Therefore, although most gorillas that develop SpAs express an MHC class I molecule with striking differences to HLA-B27, this molecule binds peptides similar to those bound by HLA-B27.

Clinical, radiological, and laboratory findings in Lebanese spondylarthropathy patients according to HLA-B27 status

To evaluate clinical, radiologic, and laboratory features in Lebanese spondylarthropathy patients according to HLA-B27 status.

METHODS

We retrospectively compared demographic, clinical, radiologic, and severity data in 40 HLA-B27-positive and 58 HLA-B27-negative patients. All 98 patients met Amor's or European Spondylarthropathy Study Group criteria for spondylarthropathy, and 51.7% met New York modified criteria for ankylosing spondylitis.

RESULTS

Onset before 16 years of age, hip involvement, and an elevated mean erythrocyte sedimentation rate were significantly associated with the presence of the HLA-B27 (32.5 vs 13.8%, P=0.02; 45 vs 7.5%, P=0.001; and 47.7 vs 25.4, P=0.02; respectively). The two groups were comparable for age, sex ratio, prevalence and distribution of spondylarthropathy types, family history, sacroiliitis, bamboo spine, syndesmophytes, peripheral joint involvement, enthesopathies, extra-articular involvement, response to nonsteroidal anti-inflammatory drugs, and need for other medications.

CONCLUSION

In Lebanon, spondylarthropathy patients positive for HLA-B27 experience disease onset at an earlier age, are more likely to develop hip involvement, and have laboratory evidence of more severe inflammation than their HLA-B27-negative counterparts. None of the other clinical and radiologic parameters are modified by HLA-B27 status.

Clinical significance of abdominal scintigraphy using 99mTc-HMPAO-labelled leucocytes in patients with seronegative spondyloarthropathies

Abdominal scintigraphy shows silent gut inflammation in patients with spondyloarthropathies (Sp) without clinical evidence of gut inflammation. Abdominal scintigraphy images are different than those obtained in patients with ulcerative colitis or Crohn's disease and are not related to the anti-inflammatory drugs administered. The aim of this study was to examine the clinical associations of findings on abdominal scintigraphy in patients with Sp. A total of 204 Sp patients (European Spondylarthropathy Study Group 1991 criteria) and 54 non-Sp controls receiving non-steroidal anti-inflammatory drugs were studied. Abdominal scintigraphy images were obtained at 30 and 120 min after injection of technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO)-labelled leucocytes. 99mTc-HMPAO-labelled leucocyte scans were positive in 104 Sp patients (50.9%) and in six non-Sp controls (2.9%) (P<0.001; OR=8.32; 95% CI=3.23-22.67). Silent gut inflammation was not associated with any of the following: age of onset, duration of evolution, sex, family history of Sp or psoriasis, articular manifestations, extra-articular manifestations, radiological findings or HLA-B27 positivity. Positive abdominal scintigraphy was associated with active disease (P < 0.0001; OR=52.7; 95% CI=19-145.6) and an increase in the C-reactive protein (P < 0.005; OR = 3.4; 95% CI = 1.5-7.4). It is concluded that (a) abdominal scintigraphy using 99mTc-HMPAO-labelled leucocytes is of value in detecting the silent gut inflammation in Sp patients, and (b) silent gut inflammation is related to the clinical activity, but is not associated with any particular type of illness or with HLA-B27.

Anti-inflammatory and immunomodulatory therapies in spondyloarthropathies

Although the spondyloarthropathies constitute amongst the commonest chronic inflammatory joint disorders, there have been few therapeutic advances since the introduction of nonsteroidal anti-inflammatory agents. A number of disease-modifying therapies originally developed for rheumatoid arthritis have also been examined in this class of arthritides, although placebo-controlled studies are lacking. Despite the low interest from industry, there is the promise that emerging therapies, particularly bisphosphonates and tumor necrosis factor alpha antagonists may be efficacious. Significant impediments to the development of additional therapeutic agents include a limited understanding of immunopathological events operative in early disease, disease heterogeneity, the inability to detect structural damage with adequate sensitivity, and the high cost of treatment. However, the recent development of internationally standardized and validated clinical outcome assessment tools as well as sophisticated magnetic resonance imaging are rekindling interest in these disorders.

[The possible role of alpha 2-macroglobulin in regulating the immune components of the brain in tick-borne encephalitis]

In tick-borne encephalitis certain immunopathological reactions develop in the tissues of the central nervous system; alpha 2-macroglobulin may serve as the marker of the activity of these reactions. The dynamic study of liquor taken from 16 patients with the meningeal and focal forms of tick-borne encephalitis (TBE), 8 patients with severe craniocerebral traumas accompanied by meningitis and 10 patients with osteochondrosis was made. As revealed in this study, in TBE patients the level of alpha 2-macroglobulin increases 3.5-fold and remains stable during the acute period of the disease.

Differential Th1/Th2 cytokine patterns in chronic arthritis: interferon gamma is highly expressed in synovium of rheumatoid arthritis compared with seronegative spondyloarthropathies

OBJECTIVE

To investigate possible differences in Th1 and Th2 cytokine mRNA expression in the synovial tissue (ST) of patients with rheumatoid arthritis (RA) and seronegative spondyloarthropathies (SpA) with diagnostic and/or pathogenic interest.

METHODS

Eleven RA patients and 14 SpA patients (10 with undifferentiated spondyloarthropathy (USpA), two with ankylosing spondylitis (AS) and two with psoriatic arthritis (PsA)) were included. Th1 (interferon gamma, interleukin 2) and Th2 (interleukin 4, interleukin 5 and interleukin 10) cytokine mRNA levels from arthritic knee ST were quantified by using an optimised polymerase chain reaction method with a computerised analysis system. Protein levels of proinflammatory cytokines (interleukin 1, tumour necrosis factor alpha and interleukin 6) in synovial fluid were quantified with a specific ELISA test.

RESULTS

Th1 cytokines were detected in all of RA ST samples in contrast with 58% (interferon gamma) and 71% (interleukin 2) of SpA samples. Th2 cytokines were expressed in 90% of RA ST samples, but the findings in SpA were interleukin 10 in 90%, interleukin 4 in 60% and interleukin 5 in 40% of ST samples. However, when the mRNA levels of each cytokine were quantified and corrected for T cell mRNA levels, only interferon gamma levels were significantly higher in RA than in SpA (p<0.003). Thus, the Th1/Th2 cytokine ratio in RA was fivefold that of SpA. Synovial fluid interleukin 1beta concentrations were higher in RA than in SpA (p<0. 05); there were also higher synovial fluid levels of tumour necrosis factor alpha in RA than in SpA, but without statistical significance.

CONCLUSION

This study has detected both Th1 and Th2 cytokine gene expression in ST from RA and SpA patients. Synovium interferon gamma mRNA levels and SF interleukin 1beta protein levels were significantly higher in RA than in SpA, so reflecting the known proinflammatory activity of interferon gamma through macrophage activation. Thus, the Th1 (interferon gamma)/Th2 (interleukin 4) ratio is significantly higher in RA than in SpA ST. These data confirm previous studies on ST Th1/Th2 balance in RA and extend previous work in comparing ST RA with subgroups of SpA distinct of ReA.

Opportunities for immune modulation in the spondyloarthropathies with special reference to gut inflammation

The spondyloarthropathies (SpA) are a related group of disorders, characterized primarily by spondylitis, pauci-articular arthritis and enthesitis. The presence of subclinical gut inflammation in patients with SpA ranges from 25 to 75%, depending upon the type of SpA. Several data suggest that the association between gut inflammation and synovitis reflects an etiopathogenetic relationship, and that strategies which interfere with the gut inflammation may also modulate the synovitis. Here we review some standard as well as experimental drugs used in the treatment of patients with inflammatory bowel disease and discuss what is known about their effect on SpA-related locomotor manifestations. For the more experimental drugs, such as cytokines, anticytokines and anti-adhesion compounds, clinical trials in patients with SpA are still very scarce.

Quantitative analyses of sacroiliac biopsies in spondyloarthropathies: T cells and macrophages predominate in early and active sacroiliitis- cellularity correlates with the degree of enhancement detected by magnetic resonance imaging

OBJECTIVE

Sacroiliitis is a hallmark of the spondyloarthropathies (SpA). The degree of inflammation can be quantified by magnetic resonance imaging (MRI). The aim of this study was to further elucidate the pathogenesis of SpA by quantitative cellular analysis of immunostained sacroiliac biopsy specimens and to compare these findings with the degree of enhancement in the sacroiliac joints (SJ) as detected by dynamic MRI.

METHODS

The degree of acute sacroiliitis detected by MRI after intravenous administration of gadolinium-DTPA was quantitatively assessed by calculating the enhancement observed in the SJ and chronic changes were graded as described in 32 patients with ankylosing spondylitis (n=18), undifferentiated SpA (n=12) and psoriatic arthritis (n=2). Back pain was graded on a visual analogue scale (VAS, 0-10) and disease duration (DD) was assessed. Shortly after MRI, SJ of patients with VAS > 5 were biopsied guided by computed tomography. Immunohistological examination was performed using the APAAP technique; only whole sections > 3 mm were counted.

RESULTS

By MRI, chronic changes </= grade II were detected in nine patients (group I, DD 2.5 (SD 2.9) years) and > II in 13 patients (group II, DD 7.3 (SD 4.8) years), while enhancement < 70% was found in eight (group A, DD 5.6 (SD 3.3) years) and > 70% in 12 patients (group B, DD 4.7 (SD 5.8) years). The relative percentage of cartilage (78-93%), bone (7-18%) and proliferating connective tissue (1-4%) was comparable between the groups (range). There were more inflammatory cells in group I compared with group II (mean (SD) 26.7(20.1) versus 5.3 (5. 2), p=0.04) and group A compared with B (21.8 (17.3) versus 6.0 (5. 6), p=0.05) cells/10 mm(2)), T cells (10.9 (8.5)) being slightly more frequent than macrophages (9.6 (16.8/10 mm(2))). Clusters of proliferating fibroblasts were seen in three and new vessel formation in seven cases.

CONCLUSION

This study shows that T cells and macrophages are the most frequent cells in early and active sacroiliitis in SpA. The correlation of cellularity and MRI enhancement provides further evidence for the role of dynamic MRI to detect early sacroiliitis.

Misfolding of HLA-B27 as a result of its B pocket suggests a novel mechanism for its role in susceptibility to spondyloarthropathies

The MHC class I protein HLA-B27 is strongly associated with susceptibility to spondyloarthropathies and can cause arthritis when expressed in rats and mice, implying a direct role in disease pathogenesis. A prominent hypothesis to explain this role suggests that the unique peptide binding specificity of HLA-B27 confers an ability to present arthritogenic peptides. The B pocket, a region of the peptide binding groove that is an important determinant of allele-specific peptide binding, is thought to be critical for arthritogenicity. However, this hypothesis remains unproven. We show that in addition to its role in peptide selection, the B pocket causes a portion of the pool of assembling HLA-B27 heavy chains in the endoplasmic reticulum to misfold, resulting in their degradation in the cytosol. The misfolding phenotype is corrected by replacing the HLA-B27 B pocket with one from HLA-A2. Our results suggest an alternative to the arthritogenic peptide hypothesis. Misfolding and its consequences, rather than allele-specific peptide presentation, may underlie the strong link between the HLA-B27 B pocket and susceptibility to spondyloarthropathies.

Salmonella typhi spondylitis

We report on five patients with Salmonella typhi spondylitis who were immunologically normal and had no prodromal gastrointestinal illness. The diagnosis was confirmed on blood cultures, Widal test, and needle biopsy of the spine. Appropriate antibiotic treatment resulted in a favorable outcome.

Cytokines and the immunopathology of the spondyloarthropathies

In contrast to rheumatoid arthritis (RA), the triggering antigens are known in reactive arthritis (ReA) and Lyme arthritis. Thus, in these arthritides the antigen-specific T-cell response can be investigated in much detail and lessons possibly learned for other spondyloarthropathies (SpA) such as ankylosing spondylitis (AS) where T cells may well also play an important role in the pathogenesis. This article focusses on the immunopathology of the SpA, ReA, and AS with special reference to T cells and cytokines.

Studying patients with inflammatory back pain and arthritis of the lower limbs clinically and by magnetic resonance imaging: many, but not all patients with sacroiliitis have spondyloarthropathy

OBJECTIVE

Clinical and magnetic resonance imaging (MRI) data of 170 consecutive patients with inflammatory back pain (IBP) and/or oligoarthritis of the lower limbs were evaluated in a retrospective study. The aim was to determine the frequency of sacroiliitis and spondyloarthropathy (SpA) in this population, and to assess the significance of HLA B27 measurements for diagnosis in early disease.

METHODS

Pelvic X-rays were performed in all IBP patients and dynamic MRI of the sacroiliac joints in patients with IBP who had indefinite results on sacroiliac X-rays (n = 32).

RESULTS

European Spondyloarthropathy Study Group criteria for SpA were fulfilled by 106/170 patients (62.4%); eight additional patients had symptoms suggestive of SpA (4.7%). The most frequent SpA subset was undifferentiated SpA (uSpA), diagnosed in 46/106 patients (43.4%). Sacroiliitis was detected by MRI in 21/32 patients with IBP and unclear X-rays (65.6%). Of those, 14 were diagnosed as SpA and seven females with moderate unilateral sacroiliitis, but no features of SpA, also not on follow-up (at least 1 yr), were classified as undifferentiated sacroiliitis (US). Ten of the 14 SpA (71.4%) and none of the seven US patients were HLA B27 positive.

CONCLUSION

HLA B27 positivity in IBP patients with MRI-proven sacroiliitis positively predicts SpA. uSpA is a frequent SpA subset. There are HLA B27-negative non-SpA patients with moderate unilateral sacroiliitis whom we propose to be classified as US.

[The diagnostic significance of immunogenetic markers in vertebrogenic neurological syndromes]

A total of 116 patients presenting with different neurological syndromes of vertebral osteochondrosis were examined. More common in patients with reflex neurological manifestations of osteochondrosis compared with controls (n = 51) was a complete HLA phenotype (heterozygosity) determining better evolutional and biological resistance to injuring factors and ability to produce adequate adaptive and compensatory reactions. The diagnosing of incomplete phenotype in other groups indicated homozygosity of genes and suggested a high risk for development of the disorder. Criteria have been established for a relative risk of development of the disease for all six vertebrogenic neurological syndromes.

Evidence that HLA-B*2706 is not protective against spondyloarthropathy

OBJECTIVE

Studies in Southeast Asia showed that HLA-B*2704 is positively associated with spondyloarthropathy (SpA), while B*2706 does not occur in such patients. In view of the absence of an association between B*2706 and SpA it was suggested that B*2706 protects against the disease, while it is supposed that B*2704 presents pathogenetic peptides. We studied families in which both B*2704 and B*2706 occurred to see whether in B*2704/B*2706 heterozygotes the effect of one of the subtypes shows a preponderance over the other.

METHODS

Two families of mixed Chinese/Indonesian origin were studied. HLA-B27 subtyping was performed by polymerase chain reaction in combination with sequence specific oligonucleotide probes.

RESULTS

In one family, members with B*2704, B*2706, or both occurred. In the other family B*2704, B*2706, and B*2708 were present. In both families SpA was seen only in B*2704 positive members, while the B*2706 and B*2708 positive members were healthy, except some B*2704/B*2706 or B*2704/B2708 heterozygotes.

CONCLUSION

The pathogenic influence of B*2704 is thus dominant over the supposed protective influence of B*2706. It is probable that B*2704 can present pathogenetic peptides, while a protective influence of B*2706 does not exist. B*2708, which was until now described in only a few cases, behaved in this study as B*2706 and is probably not associated with SpA.

Inflammatory disease in HLA-B27 transgenic rats

A spontaneous inflammatory disease in rats transgenic for HLA-B27 resembles the B27-associated human spondyloarthropathies. Colitis and arthritis, the two most important features, require T cells, gut bacteria, and high expression of B27 in bone marrow-derived cells. Control rats with HLA-B7 remain healthy. Most rats with HLA-Cw6 (associated with psoriasis vulgaris) remain healthy; a minority develop mild and transient disease. Rats with a mutant B27 with a Cys67-->Ser substitution resemble wild-type B27 transgenics, but with a lower prevalence of arthritis. A similar phenotype is seen in B27 rats co-expressing a viral peptide that binds B27. Disease-prone LEW but not F344 B27 rats develop high serum IgA levels concurrent with disease progression. Colitis is associated with high interferon-gamma, arthritis with high interleukin-6. Disease is similar in B27 LEW, F344, and PVG rats, but the DA background is protective.

CONCLUSIONS

The spondyloarthropathy-like disease in rats is specific for HLA-B27 but does not require Cys67. Arthritis but not colitis is particularly sensitive to B27 peptide-binding specificity. Genetic background exerts a strong influence, but some phenotypic differences exist between permissive strains that do not influence disease susceptibility. The data favor a role for B27 peptide presentation in arthritis, but other mechanisms to explain the role of B27 have not been excluded.

Two color analysis of HLA-B27 antigen by flow cytometer--a comparative study by conventional microlymphocytotoxicity, DNA genotyping polymerase chain reaction and flow cytometric measurement

For evaluation of specificity and sensitivity of flowcytometric determination of HLA-B27 antigen, we determined the HLA-B27 on lymphocytes using HLA-B27 monoclonal antibody by flow cytometer. Data were compared to those by conventional Terasaki microlymphocytoxicity test and DNA genotyping Polymerase Chain Reaction (PCR) method. One hundred and ninety four patients with various forms of arthritis were included in this study. Forty one of them were HLA-B27 positive, confirmed by three methods concomitantly with complete accordance. None of serological B27 negative, B7 CREG positive cells were found to be flowcytometric fluorescence positive. Furthermore, there was no significant difference of B27 intensity between different B27 DNA subtypes, nor was there any difference between primary ankylosing spondylitis (AS) and other secondary spondylitis patients as measured by mean channel of fluorescence. It is suggested that flowcytometric measurement of HLA-B27 antigen is a rapid and reliable method for HLA-B27 determination.

Nuclear factor-kappa B activity in T cells from patients with rheumatic diseases: a preliminary report

OBJECTIVE

The NF-kappa B/Rel family of transcription factors regulates the expression of many genes involved in the immune or inflammatory response at the transcriptional level. The aim of this study was to determine whether distinctive patterns of NF-kappa B activation are seen in different forms of joint disease.

METHODS

The DNA binding activity of these nucleoproteins was examined in purified synovial and peripheral T cells from patients with various chronic rheumatic diseases (12: four with rheumatoid arthritis; five with spondyloarthropathies; and three with osteoarthritis).

RESULTS

Electrophoretic mobility shift assays disclosed two specific complexes bound to a NF-kappa B specific 32P-labelled oligonucleotide in nucleoproteins extracted from purified T cells isolated from synovial fluid and peripheral blood of patients with rheumatoid arthritis. The complexes consisted of p50/p50 homodimers and p50/p65 heterodimers. Increased NF-kappa B binding to DNA in synovial T cells was observed relative to peripheral T cells. In non-rheumatoid arthritis, binding of NF-kappa B in synovial T cells was exclusively mediated by p50/p50 homodimers.

CONCLUSION

Overall, the results suggest that NF-kappa B may play a central part in the activation of infiltrating T cells in chronic rheumatoid arthritis. The activation of this nuclear factor is qualitatively different in rheumatoid synovial T cells to that in other forms of non-rheumatoid arthritis (for example, osteoarthritis, spondyloarthropathies).

HLA-B27 and the seronegative spondyloarthropathies

In the 25 years since the initial reports of the association of HLA-B27 with ankylosing spondylitis (AS) and subsequently with Reiter's syndrome, psoriatic spondylitis, and the spondylitis of inflammatory bowel disease, the association of HLA-B27 with the seronegative spondyloarthropathies has remained one of the best examples of a disease association with a hereditary marker. HLA-B27 has been recognized as representative of a spectrum of diseases, ranging from the majority of HLA-B27-positive individuals who have no disease at all, through those with isolated eye or skin involvement, to those with critical eye, heart, and peripheral joint compromise of full-blown AS. Yet HLA polymorphism has evolved in response to environmental stresses, and even the presence of HLA-B27 itself appears to confer advantages in certain infectious diseases, such as acquired immune deficiency syndrome (AIDS). This article will review what is currently known about HLA-B27 and disease, especially in the seronegative spondyloarthropathies. The structure-function relationship of HLA-B27 will be presented, including differences between the B27 subtypes both in their ethnic variation and possible disease implications. The disease spectrum conferred by the presence of HLA-B27 will also be discussed, and the theories of how HLA-B27 contributes to the pathogenesis of the spondyloarthropathies will be considered.

Contrasting cytokine profiles in the synovium of different forms of juvenile rheumatoid arthritis and juvenile spondyloarthropathy: prominence of interleukin 4 in restricted disease

OBJECTIVE

To determine the pattern of expression of Type 1 and Type 2 cytokines in synovial tissues and fluids (SF) of patients with different forms of juvenile rheumatoid arthritis (JRA) and juvenile spondyloarthropathy (JSpA), and to contrast these with findings in adult patients with RA.

METHODS

Sixty-three SF mononuclear cell preparations and synovial tissue samples from 50 patients with JRA or JSpA and 7 synovial tissues from patients with adult onset RA were analyzed by reverse transcription polymerase chain reaction for the presence or absence of interleukin 2 (IL-2), tumor necrosis factor-beta (TNF-beta), interferon-gamma (IFN-gamma), and IL-10 and IL-4 mRNA.

RESULTS

IL-4 mRNA was identified significantly more often in the synovial compartment of patients with pauciarticular onset disease (JRA or JSpA) compared with polyarticular onset JRA (58 vs 14%; p < 0.01) or RA (29%). Similarly, IL-4 mRNA was detected more often in those with a persistently pauciarticular disease course compared to those with a polyarticular course (68 vs 30%; p < 0.01). Furthermore, the combination of IL-4 and IL-10 mRNA was found more frequently in nonerosive compared with erosive disease (38 vs 15%; p < 0.05). IL-2 and TNF-beta mRNA were found in all groups. IFN-gamma mRNA was detected in 33% of those with systemic onset JRA compared with 85% of other types of JRA (p < 0.01).

CONCLUSION

This study provides further evidence of immunopathological differences between chronic forms of arthritis with childhood onset, and highlights similarities with and differences from adult RA. Our findings suggest that IL-4, possibly in combination with IL-10, has an antiinflammatory or disease restricting role.

Tuberculous spondylitis as a cause of inflammatory spinal pain: a report of 4 cases

Patients are said to have inflammatory spinal pain if they fulfill at presentation 4 of the following 5 criteria: duration of spinal discomfort for at least 3 months, spinal morning stiffness, age less than 40, insidious onset of symptoms, and no relief from pain with rest, but improvement with exercise. Inflammatory spinal pain is typical of the spondylarthropathies. Only in a minority of the cases it is found in other rheumatic disorders such as rheumatoid arthritis, fibromyalgia or infectious spondyilitis. Tuberculous spondylitis is rarely mentioned as a possible cause of inflammatory spinal pain. We describe 4 patients with tuberculous spondylitis seen over a 3-year period who met the clinical criteria for inflammatory spinal pain at presentation. We conclude that inflammatory spinal pain may be a presenting feature, albeit rare, of tuberculous spondylitis. Awareness of this finding should help facilitate the proper diagnosis and the institution of appropriate therapy.

Routine molecular genotyping of HLA-B27 in spondyloarthropathies overcomes the obstacles of serological typing and reveals an increased B *2702 frequency in ankylosing spondylitis

OBJECTIVE

To evaluate the reproducibility and reliability of polymerase chain reaction (PCR) in HLA-B27 typing compared to the conventionally used microlymphocytotoxicity test (MLCT). To determine the HLA-B27 subtype frequencies (B*2701-B*2709) in patients with HLA-B27 associated disease and healthy persons using sequence specific oligonucleotides (SSO).

METHODS

398 consecutive patients were HLA-B27 typed by MLCT and PCR. Subtyping by SSO was performed in 142 patients with HLA-B27 associated disease [ankylosing spondylitis (AS) n = 38, reactive arthritis 44, undifferentiated spondyloarthropathy (uSpA) 45, psoriatic arthritis 15] and 125 healthy HLA-B27 controls.

RESULTS

MLCT identified 61 HLA-B27 positive patients (15.3%); PCR identified 78 positive patients (19.6%). MLCT gave false negative results for 8 patients (2.0%) and false positives for a further 7 (1.8%). Only subtypes B*2702 and B*2705 were present in patients and controls. Overall frequencies of B*2702 in patients and controls were 14.1 and 9.6%, respectively. The B*2702 frequency was significantly (pcorr. < 0.04) higher in AS (23.7%) and lower in uSpA (6.7%) patients.

CONCLUSION

HLA-B27 typing by PCR is reliable and reproducible and therefore recommended for routine typing. It overcomes the obstacles of serological typing, i.e., equivocal results and cross-reactivity. In addition, subtype frequencies (B*2702 and B*2705) are equally distributed among patients and controls, although subtype B*2702 seems to be more frequent in AS and less so in uSpA.

The seronegative spondyloarthropathies

The four seronegative spondyloarthropathies can be divided into two main groups by their pattern of sacroiliitis and spondylitis (Table 1). The axial skeletal changes of ankylosing spondylitis and enteropathic arthropathy are often indistinguishable, as are those of psoriatic arthritis and Reiter's syndrome. Early proximal appendicular joint involvement in ankylosing spondylitis is a poor prognostic sign except in women where peripheral arthritis is more common, but has a more benign course. Peripheral joint destruction in enteropathic arthropathy is rare because treatment of the bowel disease also treats the arthritis. Distal appendicular involvement is characteristic of psoriatic arthritis and Reiter's syndrome. Proliferative erosions and enthesitis, periostitis, and normal mineralization aid in differentiating psoriatic arthritis and Reiter's syndrome from rheumatoid arthritis. The distribution of arthritis also differs from that seen in classic rheumatoid arthritis, with asymmetry and involvement of the distal interphalangeal joints more common in psoriatic disease and Reiter's syndrome.

Psoriatic spondyloarthropathy with secondary amyloidosis

We report an HLA-B27 positive patient with severe psoriatic spondyloarthropathy who developed secondary reactive amyloidosis. The clinical course was characterized by progressive renal failure with nephrotic syndrome and cardiac dysfunction. He died suddenly and autopsy revealed diffuse amyloid deposits in the heart, kidneys, and many other organs. Amyloid deposits were present in the cardiac conduction system including the sinoatrial and atrioventricular nodes, myocardial interstitium, and intramyocardial small blood vessels. The severe AA amyloid deposit in the heart with involvement of conduction system is unusual, and has not been described in patients with psoriasis or psoriatic arthritis.

Immunity to the G1 globular domain of the cartilage proteoglycan aggrecan can induce inflammatory erosive polyarthritis and spondylitis in BALB/c mice but immunity to G1 is inhibited by covalently bound keratan sulfate in vitro and in vivo

Earlier work from this laboratory showed that the human proteoglycan aggrecan from fetal cartilages can induce a CD4+ T cell-dependent inflammatory polyarthritis in BALB/c mice when injected after removal of chondroitin sulfate chains. Adult keratan sulfate (KS)-rich aggrecan does not possess this property. We found that two CD4+ T cell hybridomas (TH5 and TH14) isolated from arthritic mice recognize bovine calf aggrecan and the purified G1 domain of this molecule, which also contains a portion of the interglobular domain to which KS is bound. These hybridoma responses to G1 are enhanced by partial removal of KS by the endoglycosidase keratanase or by cyanogen bromide cleavage of core protein. KS removal results in increased cellular uptake by antigen-present cells in vitro. After removal of KS by keratanase, G1 alone can induce a severe erosive polyarthritis and spondylitis in BALB/c mice identifying it as an arthritogenic domain of aggrecan. The presence of KS prevents induction of arthritis presumably as a result of an impaired immune response as observed in vitro. These observations not only identify the arthritogenic properties of G1 but they also point to the importance of glycosylation and proteolysis in determining the arthritogenicity of aggrecan and fragments thereof.

Seronegative spondyloarthropathies and HLA-B27 subtyes: a study in Asian Indians

In this study, 60 HLA-B27+ve SSA patients and 17 healthy controls belonging to North India were analyzed to ascertain heterogeneity of the B27 molecule in this population. ID-IEF and PCR-SSOP technologies were used to analyze polymorphism in exon 2 and 3 of the HLA-B27 gene. Four different subtypes were encountered: B*2702,04,05 and 07. Other subtypes of B27 viz B*2701,03,06 and 08 were not encountered. B*2704 (common oriental subtype) and B*2705 (common Caucasian subtype) were the most common subtypes in the control and patient groups. B*2707 was less frequently encountered in both groups and B*2702 was found in only one AAU patient. B*2704 was the predominant subtype in the AS group (70.8%) compared to its frequency of 47% in healthy controls (RR = 2.73) while in the undiff SpA group, B*2705 occurred most frequently (73.1%, RR = 3.05). B27 subtypes segregated differently in males and females. 12 of the 17 male AS patients carried B*2704 as compared to 1 of 8 healthy males (X2 = 3.9, P < 0.05). On the other hand, in the undiff SpA, B*2705 was significantly raised in female patients (100%) as compared to healthy females (22.2%, X2 = 4.9, P < 0.05). Subtype distribution is indicative of racial admixture in the Asian Indian population.

HLA-B27 and bacteria

Most HLA-B27 positive individuals live without noticing the risk factor they carry. Only when certain bacteria come into play, usually in the form of intestinal or genital infection, some of the HLA-B27 positive individuals will develop a reactive disease. Such an association is so well established that it has formed a basis to study the relation of autoimmune reactions to microbial infections. Early epidemiological investigations have been followed by studies on immunological cross-reactivity and recently by studies on presentation of bacterial peptides by the HLA-B27 molecule. This introductory review briefly summarizes the evolution of the research, the goal of which still remains to clarify the etiopathogenetic mechanisms of HLA-B27 associated diseases.

HLA-B27 binding of peptide from its own sequence and similar peptides from bacteria: implications for spondyloarthropathies

The spondyloarthropathies are associated by an unknown mechanism with HLA-B27 and certain bacteria. HLA-B27 shares sequence with proteins from enteric bacteria. The B*2705 sequence contains a nonapeptide, LRRYLENGK, predicted to bind in the binding cleft of B27. Some nonapeptides from enteric organisms that share sequence with this nonapeptide of B27 also bind B27. These observations suggest an unappreciated mechanism for autoimmunity that may operate in the B27-associated spondyloarthropathies involving peptides bound to and derived from histocompatibility alleles.