Pathogenesis of urinary tract infection. Role of host defenses

In the last decade, there have been modest strides made in our understanding of the pathogenesis of urinary tract infections (UTIs). Matching the advances achieved in unraveling the complexities of bacterial virulence factors using molecular-genetic techniques has been a parallel increase in knowledge of host defense mechanisms. Host susceptibility to UTI in the past has been predominantly studied in patients with structural (obstruction) or functional abnormalities (diabetes mellitus); however, most patients with UTIs have no such demonstrable abnormalities, hence attention has now focused on host behavioral factors in addition to genetically determined cellular mechanisms that predispose to sporadic and recurrent UTI.

Expression of the CD15 differentiation antigen in the reproductive tract of the female rat during fetal and early postnatal ontogeny

The expression of the (alpha1-->3)-fucosyl-N-acetyl-lactosamine (CD15) epitope in the genital tract of the female rat during fetal and early postnatal ontogeny was investigated by means of immunohistochemistry. CD15 was exclusively associated with epithelial cells and was mainly located along the cell membrane. The CD15 expression was characterized, firstly, by considerable differences within the various structures and even substructures of the genital tract and secondly, by the high degree of time-related changes which accompanied the morphological development. In the Mullerian duct, CD15 was present from embryonic day (E) 14 until birth on the apical membranes throughout the epithelial cell layer. In the Wolffian duct, CD15 expression was present between E16 and E19. Along the longitudinal extent of the Wolffian duct, expression intensity differed, showing moderate to high levels in the epithelial cells of the cranial and caudal parts, but without recognizable CD15 expression in the intermediate part. In the urogenital sinus, CD15 was expressed from E15 until E21. In the cranial parts, all epithelial cells were positive, whereas in the caudal parts, CD15 was present only on their apical membranes. In the ovarian tube, uterine horn, and vagina, a moderate to high CD15 expression at birth gradually diminished to very low levels during postnatal days (P) 8 and 9. After P9, re-expression of CD15 occurred in the caudal part of the ovarian tube and in the uterus, increasing to a maximum at about P32. The findings provide (indirect) evidence for a correlation between the intensity of CD15 immunoreactivity and the serum concentrations of estrogens as well as of estrogen receptors in the urogenital tract. Since steroid hormone dependency can be regarded as a gauge of the differentiation of malignancies, it would be worthwhile correlating CD15 levels with those parameters.

Histopathological and immunohistochemical investigation of naturally occurring chlamydial conjunctivitis and urogenital inflammation in koalas (Phascolarctos cinereus)

Formalin-fixed conjunctival and urogenital (urinary bladder, urogenital sinus and prostate or penis, or both) samples obtained from 29 free-living koalas were examined histopathologically and immunohistochemically for the presence and character of inflammation and for evidence of chlamydiae. Five koalas had no inflammation at any site examined and were chlamydia-negative. Twenty-four koalas had inflammation at one or more sites and 18 were positive for chlamydiae by serology or antigen detection tests, or both. Histopathological and immunohistochemical findings were consistent with those seen in chlamydial infections in other species. The inflammatory infiltrate was most dense in the lamina propria-submucosa and, in most tissues, predominantly consisted of lymphocytes and plasma cells. Neutrophils and macrophages were variable in number. Lymphocytes in uninflamed and inflamed tissues consisted largely of T cells. B lymphocytes and plasma cells were mainly distributed immediately beneath the epithelium, but T cells were widely distributed. MHC H-positive lymphoid cells were present in variable numbers and, in some inflamed tissue samples, epithelial cell labelling was also seen. Chlamydial inclusion bodies were uncommon in routinely stained sections. Immunoperoxidase labelling for chlamydiae was positive in 16 of 52 inflamed tissues. The proportion of positive test results for chlamydial antigen by any method was directly related to the severity of inflammation.

Distribution of monoclonal antibodies in intestinal and urogenital secretions of mice bearing hybridoma 'backpack' tumours

Mice bearing IgA hybridoma 'backpack' tumours have been used to demonstrate that secretion of a single monoclonal IgA can protect against mucosal infection, but the relevance of this model to normal IgA protection is not clear. The authors analysed the distribution of specific monoclonal and total antibodies in bile, local intestinal secretions, cervical-vaginal secretions, urine and serum of mice bearing anti-cholera toxin (CT) IgA and IgG backpack tumours, with and without bile duct ligation. Backpack tumours resulted in high levels of both anti-CT and total IgA or IgG in serum, and IgA (but not IgG) in bile. Secretions recovered by absorbent filter 'wicks' from mucosal surfaces throughout the intestines of backpack tumour mice contained significant concentrations of monoclonal anti-CT IgA, but total IgA levels were as in normal mice. Neither monoclonal nor total IgA levels on mucosal surfaces were altered by bile duct ligation. Furthermore, anti-CT monoclonal IgA levels in local intestinal secretions of backpack tumour mice were comparable to specific polyclonal IgA levels previously elicited by mucosal immunization with CT. Thus, IgA-mediated protection against enteric challenge in the backpack tumour model may be a valid predictor of protection provided by natural mucosal immunization in vivo. High monoclonal IgA levels in bile, urine and the female genital tract, however, may not reflect the situation in normal immunized mice.

Antigen presentation of mucosal pathogens: the players and the rules

A vast number of infectious pathogens gain entry into the host through mucosal surfaces, which have a much greater total surface area than the skin. Since the mucosa is continuously exposed to those pathogens, the development of an effective local immune response is of utmost importance. An obligatory step in the development of most immune responses is the presentation of antigens by specialized accessory cells, termed antigen-presenting cells (APC) to T lymphocytes. The recognition of antigens by T cells is largely determined by how the antigens are handled by the APC. Complex antigen-processing events generate a selected set of peptides which ultimately become associated with MHC molecules. The type of MHC molecules that bind the peptides in turn determine what T lymphocyte subset recognizes the peptides. Thus, an understanding of the molecular and cellular processes preceding the T cell recognition event is a prerequisite for understanding how mucosal immune responses develop, as well as for investigating alternative approaches to vaccine development and therapeutic strategies to control autoimmune diseases. This review discusses the cell biology of antigen processing and how various APC populations may participate in mucosal responses.

[The interrelations of mucosal epithelial cells with microbes--intracellular parasites]

On the basis of information at hand, it can be concluded that there are principal limits on the capture of bacteria by epithelial cells in the gastrointestinal tract and other cavities. Although entry is, however, a result both of bacteria and epithelial cells, it is frequently induced by parasite-directed endocytosis and may also accompanied by passive entry of nonpathogenic bacteria. The induction of parasite-induced endocytosis should be regarded as a consequence of a fundamental concept in biology, namely: molecular and cellular recognition wherein bacterial adhesion to the host's cell receptors is of great importance. In this connection, discussion covers the origin of corresponding receptors. The authors share the opinion in that epithelial cells, those of the gastrointestinal tract in particular, are part of the human common mucosal immune system.

Analysis of lymphocyte phenotype and cytokine activity in the inflammatory infiltrates of the upper genital tract of female macaques infected with Chlamydia trachomatis

Chlamydia trachomatis infects the upper genital tract of millions of women, causing infertility and pelvic inflammatory disease, yet the inflammatory response to C. trachomatis infection is poorly understood. The cytokine response and the phenotype of infiltrating lymphocytes during C trachomatis infection of fimbria and ampulla autografts in subcutaneous pockets in Macaca nemestrina were characterized. About two-thirds of the infiltrating lymphocytes were CD8 T cells, with the remainder being CD4 T cells and B cells. Interleukin (IL)-2, IL-6, IL-10, interferon-gamma (IFN-gamma), and perforin mRNA were produced by the infiltrating cells, but IL-4 mRNA was absent. The presence of CD8 T cells and perforin mRNA suggest that activated cytolytic T cells are present. The presence of IL-2 and IFN-gamma mRNA and the absence of IL-4 mRNA suggest that Th1-type cytokines predominate during the acute phase of C. trachomatis infection of the upper genital tract.

Sequence conservation in the major outer membrane protein gene among Chlamydia trachomatis strains isolated from the upper and lower urogenital tract

To determine the extent of nucleotide sequence variation in the major outer membrane protein (MOMP) gene among 27 clinical isolates of Chlamydia trachomatis, the MOMP gene was amplified from 13 strains isolated from the endometrium of patients with pelvic inflammatory disease and high titers of anti-chlamydial antibodies and from 14 strains isolated from the cervix of patients with presumed first-time chlamydial infection. Amplified MOMP variable domain DNA from these isolates was directly sequenced and compared with previously published results. Very little sequence heterogeneity in the MOMP variable domains was found in all 27 clinical isolates, suggesting that MOMP sequence heterogeneity is not often associated with the spread of C. trachomatis to the upper genital tract and is not common in the chlamydial strains in the patient population studied.

Comparative investigation of Langerhans' cells and potential receptors for HIV in oral, genitourinary and rectal epithelia

Human immunodeficiency virus (HIV) is commonly transmitted, during homosexual and heterosexual intercourse, through the rectal and cervicovaginal mucosa, foreskin and urethral epithelia. However, there is uncertainty about HIV transmission through the oral mucosa by oral sex. We have carried out a comparative immunohistological investigation of primate oral, cervicovaginal, foreskin, urethral and rectal epithelia for potential HIV receptors. We investigated epithelial tissues for CD4 glycoprotein, which is the principal receptor for HIV, Fc receptors of IgG for binding HIV-IgG antibody complexes, and HLA class II, which might enable HIV-bound CD4+ cells to gain access to the epithelial cells. CD4 glycoprotein was not found in oral, foreskin, urethral, vaginal or rectal epithelial cells, although CD4+ mononuclear cells were present in the lamina propria of each epithelium. Fc gamma II and Fc gamma III receptors were found in urethral, endocervical and rectal epithelia, and Fc gamma III and Fc gamma I receptors in the foreskin. However, Fc gamma receptors were not found in oral epithelium (buccal, labial, lingual or palatal) and only Fc gamma III receptors were detected in the gingival epithelial cells. HLA class II antigen was also not detected in foreskin, oral or rectal epithelium, but it was expressed by endocervical cells from most human specimens and in male urethral epithelia of non-human male primates. Langerhans' cells were found in all epithelia except those of the urethra and rectum, and they can express CD4 glycoprotein, Fc gamma receptors and HLA class II antigen. The mean number of Langerhans' cells expressing CD4 in the upper third of oral epithelium was significantly lower compared with vaginal epithelium or foreskin. The HIV-binding V1 domain of CD4 was significantly decreased in Langerhans' cells present in oral compared with vaginal epithelium. The results suggest that the foreskin in uncircumcised men and the cervicovaginal epithelium in females might become infected via the CD4+ Langerhans' cells. However, urethral infection might be mediated by HIV-antibody complexes binding to urethral epithelial Fc gamma receptors. The paucity of Langerhans' cells expressing the V1 domain of CD4, the absence of Fc gamma receptors, and a lack of expression of HLA class II antigens in most oral epithelial cells, argue against transmission of HIV through the normal intact oral mucosa.

Characterization of T lymphocytes and antigen-presenting cells in the murine male urethra

The male lower urogenital tract is exposed to sexually transmitted pathogens and is therefore a strategic site of immune defense. To further define the immunodynamics of this region, we studied the histology, immune cell distribution, and draining lymph nodes of the murine male lower urogenital tract. The external surface of the foreskin was covered by skin composed of keratinized stratified epithelium containing numerous hair follicles and sebaceous glands. Immunologically the penile foreskin was characterized by the presence of few T lymphocytes and macrophages. Numerous Langerhans cells, however, were detected within the epithelium. The penile urethra was composed of stratified columnar epithelium, with a meatus lined by keratinized squamous epithelium preceding the opening proper. The most abundant immune cells of the penile urethra were macrophages. In young adult, virgin males, these were found primarily underlying the urethral epithelium, but in older, mated mice, they were usually intraepithelial in location, and were more abundant. Langerhans cells could not be specifically identified in the urethral mucosa. T lymphocytes were found underlying and occasionally within the epithelium of the urethral mucosa, with CD4+ cells more abundant than CD8+ cells. The majority of lymphocytes observed around the urethra were positive for the integrin beta 7 alpha M290, which is selectively expressed by mucosal lymphocytes, providing indirect evidence that the urethra is part of the common mucosal system. Lymphocytes expressing the gamma delta T cell receptor and IgA-positive plasma cells were not detected. The primary draining nodes for the vas deferens and urethra were the lumbar nodes. Lymphatic drainage from the rectum also involved the lumbar nodes. Information obtained in this study should help to elucidate optimal genital tract vaccination strategies for defense of the male urogenital tract against sexually transmitted pathogens.

Targeted lymph node immunization with simian immunodeficiency virus p27 antigen to elicit genital, rectal, and urinary immune responses in nonhuman primates

A s.c. route of immunization was developed in non-human primates, which targets the genitourinary-rectal associated lymphoid tissue. A vaccine consisting of rSIV gag p27, expressed as hybrid Ty virus-like particles (p27: Ty-VLP) was administered in the proximity of the internal iliac lymph nodes. Secretory IgA and IgG Abs to the p27 Ag were elicited in the vaginal, male urethral, rectal and seminal fluids, urine and serum. Two or more immunodominant B cell epitopes were identified within peptides 51-90 and 121-170 of the sequence of p27, using serum or biliary IgA and IgG Abs. CD4+ T cell proliferative responses to p27 were elicited predominantly in the targeted internal iliac, as well as the inferior mesenteric lymph nodes and the spleen, but not in the unrelated lymph nodes. These cells were then studied for helper function in p27 specific B cell Ab synthesis. Specific IgA and IgG Abs were detected in the same lymphoid tissues as those that displayed proliferative responses. However, cross-over reconstitution experiments between splenic and iliac lymph node B and CD4+ T cells suggest that the iliac B cells are essential for specific IgA Ab synthesis, whereas splenic B cells preferentially synthesize IgG Ab. The targeted lymph node (TLN) route of immunization gave comparable B cell, proliferative T cell, and Th cell responses to the vaginal, male genitourinary, and rectal mucosal routes, which were augmented by oral immunization. However, the TLN route induced urinary and seminal fluid sIgA and IgG Abs in addition to genital and rectal Abs. Generating secretory IgA and IgG Abs at the mucosal surfaces, and T and B cell immunity in the regional draining lymph nodes, spleen and circulation by TLN immunization may prevent transmission of virus through the mucosa, dissemination of the virus, and the formation of a latent reservoir of infection.

Immune consequences of burn injury

The purpose of the immune system is to protect cells from invasion by microorganisms. The body has three equally important interactive immune defense systems, all of which are profoundly disrupted with major burn injury. The immune response to burn injury is immediate, prolonged, and severe. The end result in individuals surviving burn shock is immunosuppression, with increased susceptibility to potentially fatal systemic burn wound or pulmonary sepsis. Nursing actions to support the humoral and cell-mediated immune system of the burned patient include providing nutritional support to maintain serum protein levels at optimal levels; measures to decrease edema and promote angiogenesis in areas of partial-thickness injury; meticulous treatment of the wound to prevent infection and promote healing; monitoring of antibiotic use; conservative use of invasive techniques, including intubation and vascular access devices; maintenance of fluid and electrolyte balance and body temperature; and energy conservation measures.

The distribution of immunoreactive interferon-gamma-containing cells in normal human tissues

An immunohistochemical technique has been used to study the distribution of lymphocytes expressing interferon-gamma in normal adult tissues. The greatest concentrations of these cells were seen in mucosal sites exposed to a resident microflora. It is proposed that such organisms, by eliciting immune responses, provide the stimulus for the production of 'physiological' interferon-gamma. This in turn may act to preserve the 'tone' or readiness of the immune system.

Tissue distribution of human gamma delta T cells: no evidence for general epithelial tropism

In man and mice only a small proportion of T cells in the peripheral lymphoid compartment express the gamma delta T cell receptor (TCR). In mice, however, gamma delta T cells comprise the predominant population at particular epithelial sites--in epidermis and epithelia of intestine, reproductive organs, and tongue. The distribution of gamma delta T cells in normal human tissues was investigated, paying particular attention to epithelial layers. In all lymphatic organs and in epithelia of a wide variety of non-lymphatic organs, including the respiratory tract, male and female reproductive organs and tongue, gamma delta T cells constituted less than 5% of total T cells, with the remainder expressing TCR alpha beta. The only exception was the intestine, where gamma delta T cells were preferentially situated in the columnar epithelium of the crypts, rather than in the lamina propria. It is concluded, therefore, that human gamma delta T cells do not display a general epithelial tropism and are, in terms of relative numbers, no more able than alpha beta T cells to carry out continuous surveillance of the immune system against infection or transformation in epithelia. gamma delta T cells may, however, have a specialised function in the epithelium of the intestinal tract.

Association of type 1 blood group antigens with urinary tract infections in children with genitourinary structural abnormalities

Bacterial adherence to carbohydrate receptors on the surface of urothelial cells is important in the pathogenesis of urinary tract infections. Blood group-related antigens, genetically determined carbohydrate structures found on the urothelial cell surface, may influence the availability of these receptors thereby affecting bacterial adherence and the susceptibility to urinary tract infections. Recent evidence indicates that the immunoanatomical distribution of type 1 blood group-related antigens in urothelium is influenced by ABO, Lewis and secretor phenotypes, women with Le(a-b-) and Le(a+b-) blood phenotypes have more than a 3-fold greater risk of recurrent urinary tract infections compared to Le(a-b+) women and epithelial cells from nonsecretors have more bacterial receptors than cells from secretors. To determine the relation between the expression of type 1 blood group-related antigens and urinary tract infections we performed an immunohistochemical analysis using a well characterized panel of monoclonal antibodies on 72 surgical specimens obtained from children who underwent correction of a structural genitourinary anomaly at the University of Rochester Medical Center from December 1983 to May 1988. Of 72 children 48 had a history of at least 1 documented urinary tract infection. The differences in the distribution of children by type 1 blood group immunophenotype in the infection and noninfection groups were highly significant (p = 0.003, Fisher's exact test). There is an increased frequency of urinary tract infections in children with genitourinary structural anomalies whose urothelium reflects the nonsecretor phenotype, that is they have minimal or undetectable levels of ABO and Leb reactivity compared to those with intense ABO and/or Leb immunoreactivity. Of 17 children with minimal or no ABO or Leb immunoreactivity 16 (94.1%) belonged to the infection group. Furthermore, 23 of 24 patients (95.8%) without a history of urinary tract infection expressed intense ABO and/or Leb immunoreactivity. It appears that the type 1 blood group-related antigen profile of urothelium influences susceptibility to urinary tract infection and it may be important in identifying patients who would benefit from prophylactic antibiotic therapy or earlier surgical intervention.

Are pancarcinoma T and Tn differentiation antigens?

Human fetal tissues were studied for presence of immunoreactive Thomsen-Friedenreich (T) and Tn epitopes (EPs) using well-defined anti-T and anti-Tn rodent monoclonal antibodies. T and Tn are universal (pan) carcinoma (CA) markers that are occluded in normal postfetal tissues except in some immunoprivileged enclaves. Immunohistochemical methods using avidin-biotin immunoperoxidase for staining were employed. Tissues between 45 and 117 days after ovulation were studied. In most instances, anti-T and anti-Tn antibodies showed similar immunoreactivity as demonstrated by positive immunohistochemical staining. The most intense staining was in epithelial and mesothelial components; the mesenchyme stained more faintly. All human sera have anti-T and anti-Tn antibodies, stimulated largely by intestinal flora. The presence of immunoreactive T and Tn during an early phase of fetal development, as shown here, and their known absence in noncarcinomatous postfetal tissues suggests that T and Tn, in addition to their association with CA, are stage-specific oncofetal antigens in pretolerogenic differentiation phases.

Immunohistochemical localization of secretory component and immunoglobulin A in the urogenital tract of the male rodent

The mucosal immune system in the male rodent urogenital tract was studied by localizing secretory component (sc) in the rat and immunoglobulin A (IgA) in both rat and mouse by immunofluorescence. In the rat, bright labelling of sc was observed at several sites, including the ejaculatory ducts, excretory ducts of several accessory glands, and urethral glands in the pelvic and bulbous portions of the urethra. Pale labelling of sc was detected in epithelial cells of the ventral prostate gland. Plasma cells containing IgA were only observed in the urethral gland in the bulbous portion of the urethra in rats and mice. These results suggest that IgA may be transported into the urogenital tract of the male rat primarily at sites distal to the production of seminal fluid and spermatozoa. While locally synthesized IgA may be available in the bulbous urethra, it appears that serum may be the main source of IgA for transport into the rat urogenital tract at the other sites where its receptor, sc, was demonstrated.

Influenza specific antibodies in the female genital tract of mice after oral administration of live influenza vaccine

In order to investigate the possible stimulation of antibodies in the genital tract by immunization female NMRI-mice were given orally a live influenza vaccine (A/PR/8/34, H1N1) on two occasions which were 10 days apart. Subsequently, virus specific IgA antibodies measured by an enzyme immunoassay in homogenates of urinary bladder, uterus and vagina and also in uterine washings. Specific IgA antibodies were not detectable in the sera of immunized mice. The high IgA titer in uterine washings, and in the homogenates suggests enhancement by vaccine of IgA antibody production in the genital tract.

Sialylated Lea blood group substances detected by the monoclonal antibody Ca 19-9 in human seminal plasma and other organs

The glycoprotein fractions of human seminal plasma, amniotic fluid, urine, human saliva and human gastric juice have been found to contain sialyl-Lea blood group substance, an antigen and which is known to function as a tumor-marker in human pancreatic and gastrointestinal cancer (Ca 19-9). Tumor-associated carbohydrate structures may well occur in large amounts both in normal tissue and in secretions as organ-specific markers. In human seminal plasma typical variations have been found in relationship to the Lewis blood group of the donor. Accordingly, the Ca 19-9 antigen can be regarded as a marker of the main glycoprotein fraction of human seminal plasma, which could be useful as a tool for clinical investigations.

Immunoglobulin allotypes in patients in end-stage renal failure

In a population of 282 Caucasoid patients in end-stage renal failure (ESRF) Gm and Km typing has confirmed a significant increase in the frequency of the Gm1,2,17;21 haplotype. This was confined to an increase in the number of heterozygous Gm(1,2,3,17;21,5,10,13,14) individuals. A concomitant decrease in the frequency of presumptive Gm(3,5,10,13,14) heterozygotes was also confirmed. Analysis of individual renal diseases revealed significant immunoglobulin allotype, phenotype and haplotype frequency deviations in those patients presenting with hypertension, glomerulonephritis or pyelonephritis. The allotype distribution in patients with physical abnormalities of the urinary-genital tract, whether congenital or acquired, was normal.

Immunohistochemical detection of the Ca antigen in normal and tumor tissues of humans by use of Ca1 monoclonal antibody

The Ca1 monoclonal antibody was used to detect Ca antigen in paraffin sections with the use of a two-stage indirect immunoperoxidase technique. A range of normal and malignant human tissues was examined. The antibody reacted with squamous cell carcinomas, small cell carcinomas, adenocarcinomas, ductal carcinomas, and anaplastic carcinomas from gastrointestinal, lung, and breast tissues. Melanomas were negative. Reactivity was also observed against normal tissues: urinary transitional epithelium, fallopian tube epithelium, breast ducts, sweat glands, sebaceous glands, alveolar epithelium, bile duct, gallbladder, kidney tubules, and some digestive tract epithelial cells. Although the study confirms earlier reports that Ca1 is a marker for some normal, nonciliated epithelial cells and for epithelial and some other cancers, a more widespread distribution for normal tissues was found.

Prostatitis syndromes: pathophysiology, differential diagnosis, and treatment

Prostatitis syndromes are best understood in terms of the anatomy and physiology of the genitourinary tract. Infections of the prostate may occur despite numerous host defenses of the male lower urogenital tract. Histologic criteria for prostatitis correlate imperfectly with clinical and microbiologic findings. It is critical to distinguish patients with lower-urinary-tract complaints associated with bacteriuria from the larger number of patients without bacteriuria. Careful lower-urinary-tract localization studies may then be used to classify patients into four diagnostic groups: acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia. Considerable progress has been made in understanding the pathophysiology and developing rational approaches for treatment of patients with acute and chronic bacterial prostatitis. Unfortunately, few reliable data are available on the etiology of nonbacterial prostatitis or prostatodynia. Thus, current therapy for most patients with prostatitis syndromes is unsatisfactory. Occasional patients develop granulomatous prostatitis, a characteristic histologic reaction of the prostate to a variety of insults. Treatment of granulomatous prostatitis depends on accurate etiologic diagnosis.

Followup study on patients with Reiter's disease and reactive arthritis, with special reference to HLA-B27

An analysis of 160 patients with Reiter's disease, 144 with yersinia arthritis, and 9 with salmonella arthritis was performed, Complete or incomplete Reiter's syndrome was observed in one-third of the patients with yersinia arthritis and in most of those with salmonella arthritis. During the followup period, chronic back pain and joint symptoms were frequent in all the patient groups. Patients who were HLA-B27 positive had a more severe acute disease (more frequent back pain, urologic symptoms, mucocutaneous manifestations, and a longer duration of the disease) and more frequent chronic back pain and sacroiliitis.

Cell-mediated immune responses of synovial mononuclear cells to sexually transmitted, enteric and mumps antigens in patients with Reiter's syndrome, rheumatoid arthritis and ankylosing spondylitis

3H-thymidine uptake responses by synovial mononuclear cells to stimulation with sexually transmitted, enteric and mumps antigens were studied in 12 patients with "sexually transmitted Reiter's syndrome", 5 with "enteric Reiter's syndrome", 5 with rheumatoid arthritis, 4 with ankylosing spondylitis and 10 with "indolent arthritis of one knee." The "sexually transmitted" and salmonella cases were distinguishable by the responses. Synovial responses were sometimes marked when peripheral blood responses were negligible.