Predicting outcome at the knee in juvenile rheumatoid arthritis

This study was undertaken to correlate long-term severe radiographic changes with clinical profiles in an attempt to identify a group of patients at risk. Knee radiographs of 100 juvenile rheumatoid arthritis (JRA) patients with 1-20 years of follow-up studies were reviewed for changes leading to severe disability. Eighteen children had evidence of destructive changes an average of 4.3 years after onset of JRA. 23 patients had reactive changes superimposed on destructive changes seen 9.7 years after onset of disease. 92% of the children with reactive and destructive knee changes had radiographic evidence of significant JRA at another joint. Polyarticular disease with significant JRA involvement of another joint seems to indicate a group of children at higher risk for destructive and reactive changes at the knee.

Connective tissue activation. XXXIII. Biologically active cleavage products of CTAP-III from human platelets

Evidence for three new isoforms of CTAP-III from human platelets is presented; two NH2-terminal cleavage products were identified, CTAP-III (des 1-13) and CTAP-III (des 1-15). CTAP-III (des 1-13) has a pI of 8.6 and is a relatively stable proteolytic cleavage product that retains the capacity to stimulate [14C]GAG synthesis in human synovial cell cultures. CTAP-III (des 1-15) appears to be an elastase or chymotrypsin cleavage product and identical to NAP-2, an entity thought to have neutrophil activating properties.

Factor VIII related antigen and childhood rheumatic diseases

Factor VIII related antigen (FVIIIRAg) levels were measured in the plasma of 63 children with rheumatic diseases and 20 controls. High levels were found in patients with systemic juvenile arthritis, systemic lupus erythematosus, dermatomyositis and systemic forms of vasculitis. The amount of circulating FVIIIRAg seemed to be independent of values for erythrocyte sedimentation rate, C-reactive protein and fibrinogen, implying that it was not just another acute phase reactant. Rather, a high level of circulating FVIIIRAg most likely reflects the presence of vascular endothelial injury, and this test may be useful in monitoring disease activity in children with rheumatic diseases in which vasculitis is present.

Late effects of JRA on the hip

Osseous changes at the hips were seen in the radiographs of 36 children with long-standing juvenile rheumatoid arthritis (JRA) and no significant steroid therapy. Seven boys and one girl had progressive primary inflammatory destruction of the hip with erosive arthritis and progressive joint space narrowing. Twenty-one girls and seven boys revealed adaptive developmental changes in the growing skeleton without erosion. Both courses resulted in secondary osteoarthritis and functional disability. Early recognition of adaptive, developmental changes may identify a group of children who may benefit from orthopedic intervention to maintain concentric, congruent reduction at the hip.

Prognostic factors in the uveitis of juvenile rheumatoid arthritis

Risk factors for significant visual loss were investigated in 51 patients with iridocyclitis associated with juvenile rheumatoid arthritis (JRA). Average follow-up was 12.7 years. Of 89 eyes with uveitis, 22% had visual loss to 20/200 or worse, 46% had cataracts, 30% had band keratopathy, and 27% had glaucoma. Severity of visual loss and complications correlated with the degree of inflammation found on initial ocular examination. Of 58 eyes that were initially normal or had signs of mild inflammation (cells, flare, keratitic precipitates), 3% had final vision of 20/200 or worse, 28% had cataracts, 5% had band keratopathy, and 17% had glaucoma. Of 31 eyes with posterior synechiae on initial examination, 58% had final vision of 20/200 or worse, 81% had cataracts, 77% had band keratopathy, and 45% had glaucoma. When arthritis clearly preceded uveitis, 6% of patients had a poor visual outcome compared to 67% of patients whose initial manifestation of JRA was uveitis. Systemic corticosteroid administration used primarily for arthritis correlated with cataract formation.

Anabolic and catabolic responses of human articular cells to growth factors

The responsiveness of human synovial cells and chondrocytes to L-ascorbate, CTAP Ib, III, IV and V was assessed by assays which measured DNA and glycosaminoglycan synthesis and plasminogen activator formation. Differences in behavior were noted between synovial and cartilage derived cells and between normal and OA chondrocytes.

Juvenile dermatomyositis: histological findings and pathogenetic hypothesis for the associated skin changes

Skin biopsies from patients with scleroderma and juvenile dermatomyositis (DM) share many histologic features. Characteristics common to both diseases are particularly evident in the dermal microvasculature and include endothelial swelling and concentric thickening of the vascular basement membrane. Biopsies performed on 3 patients with the severe vasculitic form of juvenile DM showed these changes as well as dropout of vessels and linear deposition of collagen. The latter findings, seen late in the course of the disease, are indistinguishable from those of advanced scleroderma. A hypothesis is presented which attempts to relate these histological findings to a common underlying pathophysiologic mechanism.

Autoimmunity to articular collagen in patients with osteoarticular syndromes

We studied the occurrence of autoimmunity to articular antigens in 39 patients with noninflammatory osteoarticular syndromes and 60 controls. Cell mediated immunity (CMI) was measured by assaying for leukocyte inhibitory factor (LIF) in supernates of mononuclear leukocytes cultured with native human collagen (types I, II, or III) or proteoglycan monomer. After stimulation with type II collagen, but not other antigens, 27/39 patients and 13/60 controls had positive LIF assays (p less than 0.001). In controls, but not in patients, CMI was associated with positivity for the HLA antigen DR4. No patient had antibodies to native type II collagen. These findings may reflect normal responses to articular injury or suggest that CMI contributes to the pathogenesis of osteoarticular syndromes. But they also emphasize that peripheral blood reactivity is not a certain reflection of synovial immunopathology.

Changes in the cervical spine in juvenile rheumatoid arthritis

One hundred and twenty-one patients with juvenile rheumatoid arthritis were studied clinically and roentgenographically for evidence of disease of the cervical spine. None of the fifty-seven patients with pauciarticular-onset juvenile rheumatoid arthritis had cervical symptoms or signs, and only one had minor roentgenographic changes of disease in the cervical spine. In contrast, clinical stiffness and roentgenographic changes in the cervical spine occurred commonly in the fifty-one patients with polyarticular-onset disease and in the thirteen patients with systemic-onset disease. Despite extensive roentgenographic involvement of the cervical spine, however, pain in the neck was not a common complaint. Neither severe pain in the neck nor torticollis, occurring either separately or concomitantly, is frequently found in patients with juvenile rheumatoid arthritis, and its presence may suggest an intercurrent problem such as a fracture or infection. As patients with juvenile rheumatoid arthritis rarely have disease in the cervical spine alone, the patient should be carefully examined for involvement of multiple joints.

Immune induction of human monocyte plasminogen activator. Characteristics of an assay for cell-mediated immunity

We characterized immunologic induction of monocyte plasminogen activator (PA) to determine whether assay for PA induction reliably detected cell-mediated immunity (CMI). Mononuclear leukocytes (MNL) were incubated in teflon-lined culture tubes for 1-4 days in the presence or absence of phytohemagglutinin-P (PHA), concanavalin A (Con A) or Candida antigen. PA activity of the monocytes in those suspensions was then measured using a micro fibrin plate assay. Monocytes in stimulated MNL had more PA activity than monocytes in unstimulated MNL. Maximal differences between stimulated and unstimulated cells were seen after 2 days of culture. Dose-response studies demonstrated that PA induction occurred at submitogenic concentrations of stimuli. Peak induction was seen using suboptimally mitogenic concentrations of PHA, Con A and Candida antigen. PA induction in response to Candida stimulation corresponded with skin test results. More than 90% of healthy adults tested had positive assays to all stimuli. LPS, in picogram concentrations, induced PA activity in the absence of lymphocytes, but such induction was prevented by polymyxin B. Supernates from activated MNL also induced PA in purified monocytes. This indirect assay of PA induction was less sensitive than direct assay of the MNL. A standard indirect assay for leukocyte inhibitory factor (LIF) was also less sensitive than the direct PA induction assay. The direct PA induction assay is sensitive and convenient and requires small volumes of blood. It may prove valuable in in vitro analysis of cell-mediated immunity in health and disease.

HLA-DR and MT associations with the clinical and serologic manifestations of pauciarticular onset juvenile rheumatoid arthritis

Significant HLA-DR and MT associations were observed with certain clinical and serologic manifestations of pauciarticular onset juvenile rheumatoid arthritis (PO-JRA). An increase in the MTI frequency was found in 56 children with PO-JRA in comparison to 95 normal controls. This association was limited to children with a younger age of onset (less than 6 years) and a persistent pauciarticular course. An increase in HLA-DRW8 and a decrease in DR4 were associated with a younger age of onset and antinuclear antibody (ANA) seropositivity. In addition, an increased frequency of DR5 was seen in ANA positive children. All of these HLA-DR and MT associations were independent of coassociating Ia specificities.

Connective tissue activating peptide III. Induction of synthesis and secretion of plasminogen activator by synovial fibroblasts

Connective tissue activating peptide III (CTAP-III) is a platelet factor that induces, in cultured connective tissue cells, activities observed in chronic inflammation. In this study we measured plasminogen activator secretion by synovial fibroblasts after stimulation by CTAP-III. Increased plasminogen activator secretion was observed 24-48 hours after stimulation. Induction was prevented by dexamethasone (10(-9)-10(-7) M), cycloheximide (1 microgram/ml) and, variably, by actinomycin D (0.3 microgram/ml), but not by cytosine arabinoside (10(-4)M). This is the first evidence that CTAP-III induces degradative as well as proliferative activity by connective tissue cells.

Mucha-Habermann disease in children -- the association with rheumatic diseases

Two children are described who developed Mucha-Habermann disease as infants. One boy had juvenile rheumatoid arthritis that ran a progressive course over 10 years, although his skin disease responded to a low dose of corticosteroids. One girl had polyarthritis associated with onset of her rash but both resolved over several years without treatment. She has since developed scleroderma followed by a reappearance of her skin lesions.

Characteristics of fibrinolytic enzyme release from human monocytes

We have investigated further two patterns of neutral protease secretion previously described in cultured human monocytes. Freshly isolated or cultured monocytes were plated onto 125I-fibrin either with or without adherent immune complexes. Fibrinolysis was quantified in the presence or absence of added plasminogen. Freshly isolated monocytes cultured on plain fibrin produced fibrinolysis primarily through secretion of plasminogen activator (PA), while contact with adherent complexes induced the release of plasminogen-independent fibrinolytic enzymes. In vitro differentiation of monocytes led to altered enzyme release. PA secretion rose six-fold over the first 3 days of culture, then decreased. Plasminogen-independent enzyme release fell 70% after 24 hr of culture then declined no further. Whereas adherent complexes inhibited secretion of PA in freshly isolated cells, such complexes stimulated PA activity after 3 or more days of culture. PA secretion from freshly isolated monocytes was inhibited by cycloheximide, indicating a requirement for protein synthesis, and by cytochalasin B. PA secretion was also reduced by the local anaesthetics ethanol, octanol, or lidocaine, but was enhanced by propranolol. The reduced PA activity of freshly isolated monocytes cultured on adherent immune complexes was partially reversed by ethanol or propranolol, but not by cytochalasin B. The plasminogen-independent fibrinolytic activity or monocytes on adherent complexes was enhanced by cytochalasin B, but unaffected by cychloheximide suggesting that the enzymes were granule-associated. This secretion was reduced by preincubation with 8-Br-cAMP and methyl isobutyl xanthine and by the local anaesthetics examined.

The clinical progression of apparent juvenile rheumatoid arthritis to systemic lupus erythematosus

Ten patients with juvenile rheumatoid arthritis (JRA) developed clinical manifestations of systemic lupus erythematosus (SLE) in 2 1/2 to 21 yr. At onset there was little to distinguish these patients from other children with JRA. Chronic arthritis developed in all and was not different from that seen in JRA. Onset of SLE followed a flare of arthritis in 8 patients, development of serositis in 5, and fever and rash in 5. LE cells and elevated DNA-binding were found in all patients, and glomerulonephritis was demonstrated in the 6 patients on whom renal biopsies were done. This group of patients may represent an important diagnostic subset of children with JRA or SLE.

Loss of Fc receptor activity after culture of human monocytes on surface-bound immune complexes. Mediation by cyclic nucleotides

Human monocytes cultured on surface-bound immune complexes exhibited a loss of ability to form rosettes with IgG-sensitized sheep erythrocytes (EA). This loss was not a result of inhibition of Fc receptors by solubilized complexes nor of release of soluble factors by the cells. Loss of EA rosetting was not prevented by culture of monocytes at 4 degrees C, or by treatment with colchicine, cytochalasin B, or local anethetic agents. These results suggested that the loss was not secondary to capping or interiorization of Fc receptors. The results of other studies indicated that the Fc receptors were not damaged by lysosomal enzymes or oxygen radicals. Maintenance of EA rosetting ability of monocytes cultured on surface-bound immune complexes was seen after a 3-h preincubation of the cells in 100 mM 2-deoxy-D-glucose (2dG). A similar preincubation in ATP or in 8-bromoadenosine 3':5'-cyclic monophosphoric acid plus the phosphodiesterase inhibitor methyl isobutyl xanthine led to a partial loss of EA rosetting of cells on plain fibrin and to a partial reversal of the effects of 2dG seen with cells on complexes. We conclude that EA rosetting of monocytes cultured on surface-bound immune complexes is reduced by cyclic nucleotide-mediated effects on Fc receptor number or function.

Neutral protease secretion by human monocytes. Effect of surface-bound immune complexes

The effect of surface-bound immune complexes on the secretion of neutral proteases by human peripheral monocytes was examined. Monocytes cultured on 125I-fibrin secreted plasminogen activator in a continuous fashion. Monocytes incubated on 125I-fibrin with surface-bound immune complexes displayed a burst of plasminogen-independent fibrinolytic activity, whereas no release of plasminogen activator was observed through 21 h. The plasminogen-independent fibrinolytic enzymes were derived from monocytes and not from lymphocytes or contaminating polymorphonuclear neutrophils. The effects of various protease inhibitors on the secretion of plasminogen-dependent and independent enzymes were determined. Chymostatin selectively inhibited the monocyte-derived plasminogen activators. Similar effects of chymostatin were observed on human urokinase in the absence of cells. The predominant protease producing plasminogen-independent fibrinolysis exhibited responses to inhibitors characteristic of leukocyte elastase. When monocytes were cultured on 125I-fibrin with adherent immune complexes approximately equal to 40% of the solubilized radioactivity represented deiodination and not proteolysis. It was concluded that culture of human monocytes on surface-bound immune complexes stimulates the secretion of plasminogen-independent fibrinolytic proteases, primarily elastase, and of deiodinating enzymes. Under these conditions, plasminogen activator secretion is inhibited. Neutral proteases secreted from newly recruited monocytes may contribute to tissue injury in human diseases characterized by the presence of adherent immune complexes.