Outcome of active disease in ankylosing spondylitis: a prospective study

BACKGROUND

People with ankylosing spondylitis (AS) typically experience episodic exacerbations, but the extent to which they subsequently experience a sustained reduction in disease markers below recognized thresholds for active disease is unclear.

OBJECTIVE

To investigate changes in, and associations between, disease markers over 18 months in people with active AS.

METHODS

Within a cohort of 89 participants with AS, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores of 4 or higher were used to identify those with active disease. Standard assessment tools were used to monitor participants prospectively at four consecutive six-monthly intervals. Participants received standard treatments but none received anti-tumor necrosis factor-alpha (TNFalpha) medication during the study.

RESULTS

The median age of the cohort was 50 years (inter-quartile range [IQR] 38.5-55.5), the median age of disease onset was 25 years (IQR 18-33) and the median disease duration was 18 years (IQR 13-27). Forty-seven (53%) participants had a BASDAI score of 4 or higher on the first assessment, of whom 45 (51%) scored 4 or higher on all subsequent assessments. Furthermore, 38 (43%) and 16 (18%) participants scored BASDAI 5 or 6, respectively, or higher, throughout. BASDAI scores correlated strongly with Bath Ankylosing Spondylitis Functional Index (BASFI) scores. Compared with 19 (21%) participants whose BASDAI scores were consistently below 4 throughout, participants with persistently high BASDAI scores showed higher scores for anxiety and depression, and some evidence of functional deterioration during the study period.

CONCLUSIONS

In this cohort, disease markers in most people with active AS were sustained above the standard threshold for active disease. This has important implications for planning care pathways and for optimal utilization of anti-TNFalpha treatment.

Disease and psychological status in ankylosing spondylitis

OBJECTIVES

Psychological factors may be important in the assessment and management of ankylosing spondylitis (AS). Our primary objective was to describe associations between disease and psychological status in AS, using AS-specific assessment tools and questionnaires. Our secondary objectives were to identify patient subgroups based on such associations and to determine the stability of the measures over time.

METHODS

A total of 110 patients were assessed at 6-monthly intervals up to four times using tools to measure disease [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and the Bath Ankylosing Spondylitis Metrology Index (BASMI)], psychological [Hospital Anxiety and Depression Questionnaire (HADS), Health Locus of Control-Form C Questionnaire (HLC-C)] and generic health [Short form (SF)-36] status.

RESULTS

Eighty-nine participants completed all four assessments. Throughout the study, BASDAI, BASFI and BASMI scores correlated significantly with anxiety, depression, internality and health status, but not with levels of belief in chance or powerful others. Clinically anxious or depressed subgroups had significantly worse BASDAI and BASFI, but not BASMI, scores. BASMI scores were the least closely linked to psychological status. Mean scores for disease, psychological and health status were clinically stable over the 18 months period.

CONCLUSIONS

Disease status scores in AS correlated significantly with anxiety, depression, internality and health status. Interpretation of AS disease scores should take an account of psychological status and the choice of measures used. These findings have important potential applications in AS management and monitoring, including the identification of patients for biological therapies.

Factors influencing the beliefs of patients with rheumatoid arthritis regarding disease-modifying medication

OBJECTIVE

To investigate factors influencing the beliefs of patients with rheumatoid arthritis (RA) regarding disease-modifying medication.

METHOD

Twenty-nine patients with RA either starting a disease-modifying anti-rheumatic drug (DMARD) for the first time or changing DMARD were recruited. Semi-structured interviews, activity diaries and focus groups were conducted over 9 months. A coding framework was developed and data analysed using the constant comparative method to identify key themes.

RESULTS

DMARDs were perceived as central to the management of RA but strong concerns were expressed about potential long-term effects. Beliefs about DMARDs were informed by material from a wide range of sources. Judgements of efficacy were influenced by symptom relief, occurrence of side-effects and perception of alternative treatment options. Perception, reporting and tolerance of side-effects differed widely between individuals. The emotional impact of starting and being withdrawn from medication appeared stronger in people with more experience of DMARD use.

CONCLUSIONS

Patients have complex and evolving belief systems relating to DMARDs. Understanding these systems will facilitate the provision of appropriate information and effective support not only in decision-making about treatment but also in relation to discontinuing treatment.

Health problems following Campylobacter jejuni enteritis in a Lancashire population

OBJECTIVES

Campylobacter jejuni enteritis can lead to musculoskeletal, neuropathic or other health sequelae. We investigated the coexistence, seasonal occurrence, strain-type associations and impact on work capacity of different health problems following C. jejuni enteritis in a Lancashire population during 1999 and 2001.

METHODS

A semistructured questionnaire was used to characterize health problems that occurred in the community after laboratory-confirmed episodes of C. jejuni enteritis. The questionnaire was posted to all adults in the Preston and Chorley area who developed C. jejuni enteritis in 1999 or 2001. All Campylobacter isolates from this population were serotyped.

RESULTS

Several types of sequelae occurred consistently in both years, including the coexistence of musculoskeletal and neuropathic problems. There was no evidence of C. jejuni strain-type associations or seasonal preponderance for any type of sequela. The overall health impact of C. jejuni enteritis, as measured by workdays lost, was high in this population.

CONCLUSIONS

A variety of health problems occur consistently following C. jejuni enteritis and substantially increase morbidity due to campylobacteriosis in the community.

Characterization of an isogenic mutant of Streptococcus pyogenes Manfredo lacking the ability to make streptococcal acid glycoprotein

An isogenic mutant of Streptococcus pyogenes Manfredo that lacks the ability to make streptococcal acid glycoprotein (SAGP) has been constructed by inserting a deletion in the sagp gene using the method of allelic exchange. An assay of cell extracts (CE) prepared from the wild-type and mutant Manfredo strains for the enzyme arginine deiminase (AD) showed that significant activity was present in wild-type CE but none could be detected in mutant CE. These findings confirm our earlier conclusion that SAGP has AD activity (B. A. Degnan, J. M. Palmer, T. Robson, C. E. D. Jones, M. Fischer, M. Glanville, G. D. Mellor, A. G. Diamond, M. A. Kehoe, and J. A. Goodacre, Infect. Immun. 66:3050-3058, 1998). Wild-type CE but not mutant CE potently inhibited human peripheral blood mononuclear cell proliferation in response to phytohemagglutinin, and this inhibition was overcome by the addition of L-arginine to proliferation assay mixtures. Invasion assays showed that the isogenic mutant organisms lacking SAGP, and thus AD activity, were between three and five times less able to enter epithelial cells (Hep-2C and A549) than were the wild-type streptococci. Both wild-type and mutant S. pyogenes bacteria were extremely sensitive to low pH. However, L-arginine (1 mM or above) significantly increased the viability of the wild type but not the isogenic mutant organisms under acidic conditions. The difference in acid susceptibility between wild-type and mutant bacteria may explain the reduced capacity of the isogenic mutant bacteria to invade and survive intracellularly.

Inhibition of human peripheral blood mononuclear cell proliferation by Streptococcus pyogenes cell extract is associated with arginine deiminase activity

Streptococcus pyogenes (group A Streptococcus) cell extracts (CE) have a remarkably powerful and dose-dependent inhibitory effect on antigen, superantigen, or mitogen-stimulated human peripheral blood mononuclear cell (PBMC) proliferation in vitro. Purification of the inhibitory component present in S. pyogenes type M5 (Manfredo strain) CE by anion-exchange chromatography followed by gel filtration chromatography showed that the inhibitor had an approximate native molecular mass of 100 kDa. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of purified inhibitory fractions followed by silver staining gave a single band with an approximate molecular mass of 47 kDa, indicating that the inhibitor is composed of two identical subunits. NH2-terminal sequencing of the protein revealed that it was identical to the previously characterized streptococcal acid glycoprotein (SAGP); this protein possesses between 31.5 and 39.0% amino acid identity with arginine deiminase (AD) from Mycoplasma hominis, Mycoplasma arginini, Pseudomonas putida, and Pseudomonas aeruginosa. AD enzyme activity was present in unfractionated CE prepared from a range of streptococcal strains, and partially purified inhibitory fractions of Manfredo CE also had high levels of activity. The inhibitory effect of Manfredo CE was overcome by the addition of L-arginine to proliferation assays in which human PBMC were stimulated with phytohemagglutinin. We conclude that SAGP, or its homolog, possesses AD activity and that the potent inhibition of proliferation of human T cells by streptococcal CE is due to activity of this enzyme.

Cryptic T-cell epitopes and their role in the pathogenesis of autoimmune diseases

Immune recognition of self-proteins features prominently in the early pathogenesis of autoimmune rheumatic diseases such as rheumatoid arthritis (RA), Sjögren's syndrome (SS), systemic lupus erythematosus (SLE) and systemic sclerosis. The mechanisms which provide lymphocytes with access to such autoantigens are therefore fundamental in creating the opportunity for autoimmune responses to develop. It has long been thought that the tissue or cellular location of some self-proteins may determine that they are normally 'hidden' from immune recognition, thereby reducing their potential for autoantigenicity. Recently, this concept has been extended to apply even to different epitopes within the same protein. Many studies, encompassing a wide variety of antigens, have shown that some epitopes are not presented for recognition by T lymphocytes unless they are produced in unusually large concentrations or unless they are freed from the configuration of their native antigen. Epitopes for which this phenomenon occurs are described as cryptic. There is increasing interest in the possibility that crypticity may be an important characteristic of epitopes which are recognized by T lymphocytes in autoimmune pathogenesis. The evidence which has led to this theory and its significance are reviewed.

Streptococcus pyogenes type 5 M protein is an antigen, not a superantigen, for human T cells

M proteins are coiled-coil dimers expressed on group A streptococcal cell surfaces. They have an important role in host antistreptococcal immunity and in poststreptococcal autoimmune sequelae. Controversy has arisen regarding whether type 5 M proteins are superantigenic for human T cells. To investigate this, we have produced and tested M5 in the form of two novel recombinant proteins. We found no evidence of superantigenicity using either recombinant whole M5 protein (rM5) or recombinant pep M5 protein (rpepM5) to activate peripheral blood mononuclear cells (PBMC) from healthy adult volunteers. Short-term, rM5-specific T-cell lines from different subjects were uniformly self-APC restricted and showed no consistent pattern of TCR V beta usage. A synthetic peptide of M5 residues 217-237 was found to contain epitope(s) recognized by some rM5-specific human T cells. PBMC responses to rM5 and rpepM5 in 3- and 7-day proliferation assays were characteristic of antigenic rather than superantigenic stimulation. We conclude that type 5 M protein activates human T cells as a conventional antigen.

Analysis of human T cell responses to group A streptococci using fractionated Streptococcus pyogenes proteins

Cell extract and spent culture supernatant proteins from Streptococcus pyogenes Manfredo strain (type M5) were each separated to give 22 narrow range molecular weight fractions by blot-elution from SDS-polyacrylamide gels. Eluted samples and unfractionated proteins were screened for T cell stimulatory activity using human peripheral blood mononuclear cells (PBMC) from healthy adults in proliferation assays. Responses were measured in 4- and 7d cultures. Responses to a wide range of cell extract proteins were revealed by fractionation, the degree of response to each fraction varying between donors. Unfractionated culture supernatant proteins elicited proliferative responses by PBMC from all individuals examined. Responses to culture supernatant fractions containing 25-33 kDa proteins could be attributed to known superantigens. Furthermore, samples from culture supernatants containing higher molecular weight fractions (> 45 kDa) elicited responses in 50% of donors in 7d cultures, suggesting that these fractions contained common recall antigens. The efficacy of using electroeluted samples to identify T lymphocyte stimulatory proteins was confirmed by demonstrating that a known superantigen of S. pyogenes Manfredo strain, streptococcal pyrogenic exotoxin C (SPEC), could be fractionated successfully using this method and its activity recovered. Our results show that human T cell responses to group A streptococci involve a remarkably wide range of both cell-associated and released streptococcal proteins.

Limitations of flow cytometry in the analysis of CD1a/HLADR+ human oral mucosal Langerhans cells

Suspensions of human oral epithelial cells were stained with antibodies to CD1a and HLADR conjugated with fluorochromes and analysed by flow cytometry with the aim of purifying double-labelled Langerhans cells, a population comprising approximately 2% of the cell total. Whole suspensions had high levels of autofluorescence and a wide range of forward and right angle scatter properties. The mean percentage of CD1a/HLADR+ cells was 2.1%, though the double-labelled cells did not form a discrete group and the percentages of positive cells using control antibodies were similar. Density gradient centrifugation prior to flow cytometry did not facilitate Langerhans cell identification within the suspension. The results indicate flow cytometric analysis of minority cell populations (such as Langerhans cells) within oral epithelium is limited by the autofluorescence of physically heterogeneous keratinocytes, and emphasize the importance of controls in studies of oral epithelium which use this method.

Group A streptococcal antigens and superantigens in the pathogenesis of autoimmune arthritis

Evidence from repeated clinical observations and from a variety of experimental approaches implicates group A streptococci in the pathogenesis of the autoimmune arthritides. Several streptococcal antigens and superantigens have now been characterized and their properties suggest that they may be involved in the mechanisms which underlie these diseases, although other antigens and superantigens yet to be discovered may also be involved. The association between group A streptococcal infection and autoimmune arthritis offers a useful model for providing a long-elusive understanding of the role of bacterial infection in the pathogenesis of autoimmune disease.

Bacterial superantigens in autoimmune arthritis

Discoveries of the biological properties of bacterial superantigens have given rise to much speculation about their possible role in the pathogenesis of autoimmune diseases. There is an increasing body of data to support these speculations. This field of research has the potential to provide a long-elusive understanding of the mechanisms which underlie microbial involvement in the pathogenesis of autoimmune polyarthritides.

Purified human oral mucosal Langerhans cells function as accessory cells in vitro

Oral mucosal Langerhans cells (OMLC) may have an important role in the induction of immune responses to oral pathogens. In this study, anti-HLA-DR antibody-coated immunomagnetic beads were used to purify OMLC from suspensions of normal human buccal epithelium and the capacity of the purified cells to function as accessory cells (AC) was investigated. Electron microscopy was used to show that the purified cells possessed all recognized ultrastructural features previously described in epidermal Langerhans cells. Using T lymphocyte proliferation assays in hanging drop microcultures, it was found that purified OMLC could function as AC for responses to concanavalin A by autologous T cells. Purification of OMLC from small biopsies of oral mucosa has enabled us to show that OMLC, like epidermal Langerhans cells, can function as AC in vitro.

Human cartilage aggrecan CS1 region contains cryptic T-cell recognition sites

Cartilage proteoglycan aggregates (PG) are candidate T-cell autoantigens in the pathogenesis of rheumatoid arthritis (RA). We have investigated the possibility that responses to class II-restricted T-cell recognition sites in human cartilage aggrecan (core protein) may depend upon whether these sites are available as free peptide antigens or as part of intact monomers. Analysis of mouse T-cell responses to intact or deglycosylated monomers, purified from human articular cartilage, and to synthetic peptides of the chondroitin sulphate (CS) attachment region homologous repeat sequence showed that recognition of T-cell epitopes in the CS1 region was strongly dependent upon the form of antigen used. The results show that the CS1 region contains cryptic T-cell recognition sites and raise the possibility that fragments of PG, released through the action of extracellular proteases in inflamed joints, may be capable of activating T cells with specificities for epitopes which are not made available following processing of intact PG. T cells with specificities for cryptic epitopes in PG may play a role in the pathogenesis of RA.

Inflammation activates self hsp60-specific T cells

Injection of incomplete Freund's adjuvant (IFA) into the footpads of BALB/c mice induced an acute inflammation. Draining popliteal lymph nodes showed major histocompatibility complex (MHC) class II-restricted proliferation when challenged in vitro with recombinant Mycobacterium bovis 65-kDa heat shock protein (hsp65). alpha beta T cell receptor-positive, CD4+, hsp65-specific T cell lines and clones were generated from these lymph nodes, and 87% of clones responded to a beta galactosidase fusion protein containing residues 238-573 of human hsp60. Seventy percent of these hsp60-responsive clones also responded to a synthetic peptide corresponding to residues 412-423 of the mouse hsp60. This peptide also induced significant responses in IFA-primed lymph node cells but not in lymphoid cells from unimmunized mice. These results demonstrate that T cells specific for epitopes in self hsp60 are activated during inflammatory responses induced in the absence of exogenous bacterial hsp65. The findings of this study may provide a basis for understanding the often reported isolation of mycobacterial hsp65-responsive T cells from inflammatory sites of arthritis patients, and the protective effects of preimmunization with hsp65 in experimental models of arthritis.

Mapping T-cell epitopes in group A streptococcal type 5 M protein

Group A streptococcal cell surface M proteins elicit highly protective, serotype-specific opsonic antibodies and many serotypes also elicit host cross-reactive antibodies, which may contribute to the pathogenesis of poststreptococcal autoimmune disease. To date, studies aimed at designing safe (non-host-cross-reactive, defined-epitope) M vaccines have focused almost exclusively on antibody epitopes. Here we identify T-cell epitopes recognized by T cells from BALB/c, C57BL/6, and CBA/Ca mice immunized with purified, recombinant serotype 5 M protein (rM5). The responses of rM5-specific, major histocompatibility complex class II-restricted, T-cell clones to synthetic peptides representing most of the M5 sequence identified at least 13 distinct T-cell recognition sites, including sites recognized by more than one major histocompatibility complex haplotype of mice. Although none of these sites appeared to be strongly immunodominant, an N-terminal peptide, sM5[1-35], was recognized by lymph node T cells of rM5-immunized mice and by a larger proportion of rM5-specific T-cell clones than any other individual peptide. The fine specificity of these clones was mapped with subpeptides to a single site at or overlapping the sequence ELENHDL at residues 21 to 27, which is in close proximity to previously mapped protective antibody epitopes. Other T-cell recognition sites are distributed throughout the M protein and include several in the highly conserved C-terminal region of the molecule. One of these C-terminal sites, located within residues 300 to 319, was recognized by a significant proportion of T-cell clones from two strains of mice. Helper T-cell epitopes located in the C-terminal region of M5 are likely to be widely conserved between different M serotypes and could be particularly useful in designing multivalent, defined-epitope M vaccines.

Patients with ankylosing spondylitis show individual patterns of variation in disease activity

Disease activity was monitored sequentially over 1 year in 22 patients with ankylosing spondylitis (AS) attending regularly the local NASS group. Assessments, using standard methods, were made at monthly intervals by the same observer. There was marked heterogeneity such that each patient's profile of disease activity was virtually unique. All patients experienced at least one exacerbation and most underwent exacerbations and remissions, reminiscent of the experience of many patients with rheumatoid arthritis. In most instances no reason for changes in disease activity could be discerned clinically. These observations raise the possibility that the natural history of disease in AS may be different for each individual patient, which, if true, would have important implications for the design of studies to test the efficacy of therapy and for approaches to investigating pathogenic mechanisms in patients with AS.

Comparative analysis of murine T lymphocyte responses to cartilage proteoglycans

Cartilage proteoglycans are large molecules consisting of several sub-regions each of which comprises homologous repeating subunits. Comparisons of murine primed popliteal lymph node responses to human cartilage proteoglycans in BALB and B10 congenic mice showed that the major histocompatibility complex (MHC) influences T cell responsiveness to this antigen. H-2k and H-2d were higher responders than H-2b. Responses were MHC class II-restricted, and human cartilage proteoglycans were cross-reactive with mouse cartilage proteoglycans for a BALB/c T cell line. The proportion of proteoglycan-specific T lymphocytes in BALB/c primed popliteal lymph nodes was about 45% lower in females than males. These results show that in mice both MHC haplotype and sex can determine T lymphocyte responsiveness to cartilage proteoglycans. If the same mechanisms apply in humans they could be important in determining the HLA-DR haplotype associations and the predilection of rheumatoid arthritis for females.

Phosphorylation and activation of hormone-sensitive lipase in isolated macrophages

Hormone-sensitive lipase (HSL) is responsible for the neutral cholesterol ester hydrolase activity in macrophages. Incubation of intact WEHI macrophages or mouse peritoneal macrophages leads to phosphorylation of HSL, which is increased by incubation with either dibutyryl cyclic AMP and 3-isobutyl-1-methylxanthine or okadaic acid. Correspondingly, these agents also activate neutral cholesterol ester hydrolase activity in intact WEHI cells. Regulation of mobilisation of esterified cholesterol in macrophages may be of antiatherogenic value, which this model system now allows us to investigate further.

The frequency of mouse spleen dendritic cells which present alloantigens or ovalbumin to primed T lymphocytes is equal

We have used limiting dilution analysis to compare the frequency of dendritic cells (DC) which present endogenous alloantigens with that which present an exogenous protein antigen to T lymphocytes. Spleen DC present alloantigens or ovalbumin to primed T lymphocytes with equal frequency, showing that DC are equipotent for presenting endogenous and exogenous antigens. Also, antigen-presenting cell (APC) frequencies among DC were compared with other APC populations. DC were enriched about 1000-fold for APC compared to unfractionated spleen cells.

Hormone-sensitive lipase is responsible for the neutral cholesterol ester hydrolase activity in macrophages

Anti-hormone-sensitive lipase (HSL) immunoglobulin selectively immunoprecipitates a single 84 kDa 32P-phosphoprotein from macrophage homogenates previously phosphorylated by cyclic AMP-dependent protein kinase in the presence of [gamma-32P]ATP-Mg. This immunoglobulin also completely removes the neutral cholesterol ester hydrolase activity from macrophage homogenates. These data demonstrate that HSL is responsible for the neutral cholesterol ester hydrolase activity in macrophages and hence plays a key role in cholesterol metabolism in these cells.

A limiting dilution assay to determine the frequency of antigen presenting cells

A limiting dilution assay to measure the functional frequency of antigen presenting cells (APC) has been developed and used to measure the frequency of mouse lymphoid cells which stimulated the mixed leucocyte response. The experiments utilised measurements of proliferation in 20 microliter hanging drop microcultures of activated T lymphocytes. When the data supported a model of single-hit kinetics, the APC frequency in the titrated stimulating cell population was calculated by the method of maximum likelihood. The assay was validated by measuring the frequency of unpurified spleen cells and enriched spleen dendritic cells which presented alloantigens in mixed leucocyte culture. APC frequency in unpurified spleen cells was 1:7254 (SE +/- 2134, 8 experiments) and was increased markedly to 1:15 (SE +/- 7, 7 experiments) when enriched populations consisting 70-95% of dendritic cells were used as stimulators.

Studies with an enthesis index as a method of clinical assessment in ankylosing spondylitis

The histopathological characteristic of ankylosing spondylitis (AS) is the presence of chronic enthesitis. Our aim was to develop a clinical measurement of the severity of tenderness over entheses. The scoring system was based on the patients' response to palpation over entheses easily accessible to examination. The enthesis index (EI) correlated with pain (r = 0.67, p less than 0.01) and stiffness (r = 0.46, p less than 0.05) scores. A single, blind, crossover study was conducted to determine the sensitivity of the index to change in clinical state associated with non-steroidal antirheumatic drug therapy and to record the interobserver variability. The index showed significantly lower scores after one week's drug treatment (p less than 0.05). The EI is a convenient, non-invasive measure of disease severity in patients with AS. Potential applications include the assessment of enthesitis in other polyarthritides and a means of distinguishing clinically between severity of enthesitis and synovitis in different types of polyarthritis.

A reinvestigation of the cross-reactivity between Klebsiella and HLA-B27 in the aetiology of ankylosing spondylitis

The existence of cross-reactivity between Klebsiella antigens and cells from donors who are HLA-B27 positive and exhibit ankylosing spondylitis (AS) has been reinvestigated. Cells and antisera from different laboratories have been tested together using simultaneously microcytoxicity, chromium release and enzyme linked immunosorbent assays (ELISA). No reproducible interaction has been found. Mitogenic stimulation did not induce cross-reactivity and 'transformation' of B27+AS- cells by Klebsiella culture supernatants failed. Two transformed cell lines from B27+ AS+ donors exhibited specific cross reaction with two anti-Klebsiella antisera but only by chromium release. Immunoprecipitation with these cells and antisera showed the absence of any AS+ -specific antigen. It is concluded that the involvement of Klebsiella in ankylosing spondylitis through simple immunological cross-reactivity or through interaction with HLA-B27 is unlikely.