Bone scintigraphy of the hands in early stage lupus erythematosus and rheumatoid arthritis

OBJECTIVE

To evaluate retrospectively the discriminatory value of bone scintigraphy, especially spot images of the hands, in differentiating early stage systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).

METHODS

Data from 19 patients with SLE (3 men, 16 women) and 20 patients with RA (6 men, 14 women), presenting with early stage articular disease (arbitrarily defined as articular complaints for no longer than 3 mo), were reviewed. At this stage, radiographs were normal in all patients. In all 39 patients, total body bone scintigraphy with spot images of the hands was performed as part of a complete diagnostic investigation. For differentiation between SLE and RA in early disease stage, less extensive semiquantitative description in 3 categories (normal, diffuse mildly increased, and (multi)focal moderately to markedly increased tracer accumulation) proved to be sufficient. Locations of bone scintigraphic findings were correlated to clinical findings.

RESULTS

In RA, bone scintigraphy revealed foci of moderate to markedly increased tracer accumulation, corresponding to the sites of clinical synovitis in all patients. In 10 patients with SLE, bone scintigraphy images of the hands were normal, and in 9 patients diffuse mildly increased tracer accumulation was observed.

CONCLUSION

The data suggest bone scintigraphy may be useful to differentiate SLE from RA in early stage disease.

Dominant T cell receptor rearrangements in interleukin 2 expanded lymphocytes from rheumatoid nodules suggest antigen driven T cell activation in situ

OBJECTIVE

To study at a molecular level the clonality of interleukin 2 (IL-2) expanded T cell lines derived from rheumatoid nodules. Such cell lines were reported in earlier studies with flow cytometry and antiidiotypic monoclonal antibodies (MAb) to be obligoclonal.

METHODS

T cell lines were derived from rheumatoid nodules in 2 patients with rheumatoid arthritis (RA) and expanded in medium containing IL-2. Clonality was assessed by flow cytometry and T cell receptor (TCR) idiotype specific Mab and by polymerase chain reaction with primers for V alpha and V beta gene families. Sequence analysis was performed in selected cell lines.

RESULTS

In one patient, one cell line was identified with marked overexpression of V alpha 2 cells. Eleven V alpha 2 CDR3 sequences were derived from this cell line: 8 of these clones had an identical CDR3 sequence and one other clone showed a related sequence. Five cell lines derived from a second patient displayed a marked clonal bias to V beta 8 cells. One cell line with strong V beta 8 expression was chosen for further sequence analysis. Twelve V beta 8 sequences were obtained; 11 showed identical CDR3 sequences.

CONCLUSION

Molecular analysis of TCR rearrangements in IL-2 expanded T cell lines from rheumatoid nodules strongly suggests that in situ T cell activation is related to classical antigen induced immune activation.

A randomized, double-blind study comparing twenty-four-week treatment with recombinant interferon-gamma versus placebo in the treatment of rheumatoid arthritis

OBJECTIVE

To evaluate the safety and efficacy of recombinant interferon-gamma (rIFN gamma) in patients with active rheumatoid arthritis (RA), using an induction and maintenance regimen.

METHODS

A multicenter, randomized, double-blind trial of 197 patients with RA was conducted to compare the effects in a group receiving 50 micrograms of rIFN gamma, given subcutaneously in a decreasing regimen over 24 weeks, with those in a placebo group receiving injections of placebo at the same time frequency. Standard clinical assessments were performed.

RESULTS

Both rIFN gamma and placebo produced a significant improvement from baseline to end point visit for most measurements (except erythrocyte sedimentation rate, duration of morning stiffness, and grip strength), but no significant intergroup differences were seen. Regarding adverse effects, mild local skin reactions at the site of injection were observed, and among the cardiovascular events, mild edema and vasodilatation were reported.

CONCLUSION

IFN gamma proved no more effective than placebo in this group of patients with RA. IFN gamma was well tolerated in this group of patients, without increased toxicity compared with placebo.

Etiological factors and underlying conditions in patients with leucocytoclastic vasculitis

This study concerns a retrospective analysis of 63 consecutive patients presenting with leukocytoclastic vasculitis at the Departments of Dermatology or Rheumatology of the University Hospital Ghent (Belgium) (period 1988-1993). The diagnosis of leukocytoclastic vasculitis was confirmed by histopathology in all cases. All patients were screened for underlying causes, including drugs, infection, systemic autoimmune disease or neoplasia. In 34 patients, an etiological factor was identified: drugs (5 patients), infection (6 patients), drugs or infection (4 patients), systemic autoimmune disease (10 patients), Henoch Shönlein (6 patients), neoplasia (2 patients) and cryoglobulinemia (1 patient). In the group of patients with leukocytoclastic vasculitis in the context of systemic autoimmune disease, 4 patients suffered from systemic lupus erythematosus, 2 from Wegener's disease, 2 from Behçet's disease, 1 from polyarteritis nodosa and 1 from rheumatoid arthritis. In the remaining 29 patients, no cause for the vasculitis could be identified.

Spondylarthropathies: from gut to target organs

Recent studies strongly support the concept that gut and joint inflammation are closely related. Progress also has been made in identifying individual mechanisms that contribute to the pathogenesis of joint disease in IBD and in undifferentiated SpAs. However, the interrelationship of these mechanisms that result in chronic disease manifestations at a site distant from the initiating event remain to be elucidated. The local absence of homing molecule receptors in the gut wall combined with an expression of these receptors in target organs can be responsible for the transformation of the synovial membrane and/or the enthesis into an aberrant tertiary lymphoid organ of the gut.

Course of gut inflammation in spondylarthropathies and therapeutic consequences

Gut inflammation plays a crucial role in the pathogenesis of spondylarthropathies (SpA) since ileocolonoscopic studies have demonstrated the presence of gut inflammation in different forms of this concept: in ankylosing spondylitis (AS) (60%), in enterogenic (90%) and urogenital reactive arthritis (20%), in undifferentiated SpA (65%), in the pauciarticular and axial forms of psoriatic arthritis (16%), in late onset pauciarticular juvenile chronic arthritis (80%) and in acute anterior uveitis (66%). The strong relationship between gut and joint inflammation was demonstrated by performing a second ileocolonoscopy: remission of the joint inflammation was always connected with a disappearance of gut inflammation, whereas persistence of locomotor inflammation was mostly associated with the persistence of gut inflammation. During further evolution 20% of the non-ankylosing spondylitis SpA patients can develop AS. About 6% of the total group SpA patients, in whom inflammatory bowel disease (IBD) was excluded, developed Crohn's disease 5 to 9 years later. All these patients initially presented with gut inflammation, which indicates that this finding has prognostic value. The high prevalence of evolution to IBD in SpA patients confirms the thesis that both disease entities bear common pathogenic mechanisms, and confirms the place of IBD in the concept of SPA. Sulphasalazine (SASP), a successful drug in the treatment of IBD, has demonstrated its effectiveness in the treatment of SpA. The beneficial effect of the drug in this disease entity could be due to its anti-inflammatory effect on the gut wall, by normalizing its permeability and by preventing the entrance of antigens through the defective gut wall. However, SASP could not prevent the evolution to IBD.

Numerical scoring systems for the anatomic evolution of osteoarthritis of the finger joints

OBJECTIVE

To assess and score the progression of osteoarthritis (OA) of the distal and proximal interphalangeal (DIP and PIP) and metacarpophalangeal (MCP) joints.

METHODS

Forty-six patients with OA of the finger joints were followed up for 3 years; 36 of them were followed up for 5 years. Posteroanterior radiographs of the hands were obtained at the start of this prospective study and at yearly intervals. The scoring systems used were based on the increased incidence of OA during consecutive years in previously normal joints, the radiologic progression of anatomic lesions in the affected finger joints, and the consecutive pathologic phases recognized in the course of the disease.

RESULTS

Significant increases both in the numbers of affected DIP, PIP and MCP joints per subject and in the anatomic progression of the disease (changes in osteophyte growth, loss of joint space, and subchondral cysts or sclerosis) in the different finger joints of each patient were recorded during the 3 and 5 years of followup. In approximately 40% of the patients, the classic picture of OA was complicated by erosive changes, which preceded a period in which repair phenomena in the "eroded" finger joints led to the generation of a new subchondral plate covered by cartilaginous tissue. Huge osteophytes were then responsible for the nodular aspect of the affected finger joints.

CONCLUSION

OA of the finger joints is progressive in nature and passes through predictable phases. The recognition of and the attribution of a score to these respective phases made assessing the progression of OA less time-consuming and led to the same conclusions as when the anatomic progression was scored.

[Significance of intestinal inflammation in the pathogenesis of spondylarthropathies]

The concept of spondylarthropathy (SpA) gathers together a group of chronic diseases with common clinical, biological, genetic and therapeutic characteristics. The concept forms a distinct entity, different from other rheumatic diseases. The target organs are not only the joint, but also the axial skeleton, the enthesis, the eye, the gut, the urogenital tract, the skin and sometimes the heart. The prevalence of this entity in the general population is estimated 1%, equal to the prevalence of rheumatoid arthritis. Genetical predisposition (HLA-B27) is one of the clues to the pathogenesis of the disease. Since reactive arthritis is induced by specific urogenital or enterogenic bacteria, and since the gut is implied in different forms of spondylarthropathies, especially in IBD, it was clear that the gut could play an important role by permitting exogenous factors to enter the body. This hypothesis was the rationale for investigating the gut in the spondylarthropathies by performing ileo-colonoscopies. In the first ileo-colonoscopic studies of SpA patients, histological signs of gut inflammation were found in a relatively great number of patients, mostly not presenting any clinical intestinal manifestations. These lesions were not seen in other inflammatory joint diseases. Further ileo-colonoscopic studies confirmed the strong relationship between gut and joint inflammation. In patients in whom a second ileo-colonoscopy was performed, remission of the joint inflammation was always connected with a disappearance of the gut inflammation, whereas persistence of locomotor inflammation was mostly associated to the persistence of gut inflammation. The hypothesis was proposed that some patients with a spondylarthropathy had a form of subclinical Crohn's disease in which the locomotor inflammation was the only clinical expression. This hypothesis was confirmed in prospective long-term studies in which the ileo-colonoscopied patients were reviewed 2 to 9 years later:about 6% of SpA patients not presenting any sign of Crohn's disease at first investigation but demonstrating gut inflammation on biopsy, developed full-blown Crohn's disease. By performing electronmicroscopy it was described that in patients with SpA the number of membranous (M) cells, which are scarce in normal ileum, is increased in number in inflamed mucosa. They showed a thin rim of cytoplasm covering groups of lymphocytes. In chronic inflammatory lesions necrotic M-cells, rupture of M-cells and lymphocytes entering the gut lumen was observed. The bursting of M-cells at the top of the lymphoid follicles leads to interruption of the gut epithelial lining and gives the luminal content access to the lymphoid tissue. This can be responsible for an exponential increase of local antigen stimulation. Accelerated luminal antigen presentation through a break in the epithelial layer, together with cytokines released from activated monocytes, might induce a second line of defense aiming at elimination of the massive antigen penetration into the mucosa. The postulated switch from secretory local immunity to a systemic type of local immune reaction could have different consequences:the local down-regulation of J chain in the IgA immunocytes could shift the production of polymeric IgA to monomers, jeopardizing secretory immunity; the disproportionate increase of IgG-producing cells could favor further inflammation and tissue damage through complement activation and arming of the killer cells, and cause autoimmune responses locally and in target organs at a distance (e.g. joint organs). The discovery of subclinical gut inflammation in the SpA had therapeutic consequences. Sulphasalazine (SASP) has been proven to be an active drug in the treatment of IBD. Since the gut could play a crucial role in SpA, it was logic to use this drug in the treatment of this disease. Multiple open and double-blind studies have proven the effectiveness of this drug in SpA.

The role of gut inflammation in the pathogenesis of spondyloarthropathies

The concept of spondyloarthropathy (SpA) gathers together a group of chronic diseases with common clinical, biological, genetic and therapeutic characteristics. The concept forms a distinct entity, different from other rheumatic diseases. The target organs are not only the joint, but also the axial skeleton, the enthesis, the eye, the gut, urogenital tract, the skin and sometimes the heart. The prevalence of this entity in the general population is estimated 1%, equal to the prevalence of rheumatoid arthritis. Genetical predisposition (HLA-B27) is one of the clues to the pathogenesis of the disease. Since reactive arthritis is induced by specific urogenital or enterogenic bacteriae, and since the gut is implicated in different forms of spondyloarthropathies, especially in IBD, it was clear that the gut could play an important role by permitting exogenous factors to enter the body. This hypothesis was the rationale for investigating the gut in the spondyloarthropathies by performing ileocolonoscopies. In the first ileocolonoscopic studies of SpA patients, histological signs of gut inflammation were found in a relatively great number of patients, mostly without any clinical intestinal manifestations. These lesions were not seen in other inflammatory joint diseases. Further ileocolonoscopic studies confirmed the strong relationship between gut and joint inflammation. In patients in whom a second ileocolonoscopy was performed, remission of the joint inflammation was always connected with a disappearance of the gut inflammation, whereas persistence of locomotor inflammation was mostly associated to the persistence of gut inflammation. The hypothesis was proposed that some patients with a spondyloarthropathy had a form of subclinical Crohn's disease in which the locomotor inflammation was the only clinical expression. This hypothesis was confirmed in prospective long-term studies in which the ileocolonoscoped patients were reviewed 2 to 9 years later: about 6% of SpA patients not presenting any sign of Crohn's disease at first investigation but demonstrating gut inflammation on biopsy, developed full-blown Crohn's disease. The discovery of subclinical gut inflammation in the SpA had therapeutic consequences. Sulphasalazine (SASP) has been proven to be an active drug in the treatment of IBD. Since the gut could play a crucial role in SpA, it was logic to use this drug in the treatment of this disease. Multiple open and double-blind studies have proven the effectiveness of this drug in SpA; recent studies concluded that the beneficial effect of the drug in this disease entity is more prominent on the peripheral arthritis than on the axial disease.

Human meniscal proteoglycan metabolism in long-term tissue culture

For the purpose of human meniscal allografting, menisci have been maintained viable in in vitro culture. The influence of long-term tissue culture on the extracellular matrix metabolism of the meniscus has been studied. Fetal calf serum (FCS) was used as a supplement for the growth factors necessary to maintain optimal meniscal cell metabolism. A series of semilunar cartilage samples was cultured under serum-free conditions since foreign proteins could be responsible for immunological problems after eventual allografting. The proteoglycan metabolism in human menisci cultured in FCS-supplemented and in serum-free culture media was compared. To rule out any influence of topographical variations in glycosaminoglycan (GAG) content on proteoglycan (PG) metabolism, GAG concentrations within the tissue were determined, and sulphate (35S) incorporation was studied in tissue samples with a comparable biochemical composition. Sulphate incorporation was preserved when 20% FCS was added to the nutrient medium. The meniscal tissue fibroblasts continued to produce 35S-PG during 4 weeks of culture. The PG molecules were shown to consist of PG-aggregates, monomers and a low molecular-weight PG population. Newly synthesized GAG consisted of approximately 55% chondroitin 4- and 6-sulphate and 33% dermatan sulphate. In the presence of serum, 35S incorporation in PG and in the PG-aggregate fraction significantly increased during the first 2 weeks and then decreased during the following 2 weeks of in vitro culture. Newly synthesized PG-aggregates were almost entirely accumulated in the tissue during these weeks. In the 3rd week the values for this parameter decreased slightly. 35S-PG synthesis dramatically declined after 4 weeks of in vitro culture. Catabolism probably resulted in increased proportions of 35S-PG in the incubation media. In the absence of serum, 35S-PG production also increased in the 2nd week of culture. However, 35S activity was almost exclusively found in small PG, and this material apparently diffused to the incubation media. Consequently, catabolism is higher, and the immobilization of 35S-PG is poor when FCS is not added to the culture media. Our findings suggest that menisci are maintained in viable condition and may serve for allografting at least during 2 weeks of tissue culture.

The evolution of spondyloarthropathies in relation to gut histology. II. Histological aspects

OBJECTIVE

To study prospectively the clinical evolution of different forms of spondyloarthropathy (SpA) in relation to the type of gut histology in ileocolonoscopic biopsy specimens.

METHODS

Ileocolonoscopy was performed in 217 patients with SpA (149 men, 68 women). Three types of gut histology (normal gut histology and acute and chronic inflammatory gut lesions) were found. Clinical, laboratory, and radiological examinations were performed at start and 2 to 9 years later in 123 patients who were regularly monitored. For the remaining 94 patients clinical data were obtained by telephone.

RESULTS

Of the 123 patients monitored regularly, 40 (32%) had normal gut histology, and 28 (23%) had acute and 55 (45%) chronic inflammatory gut lesions. Acute lesions were preferentially found in patients with non-ankylosing spondylitis SpA (non-AS-SpA). In the groups with normal gut histology and with chronic gut inflammation, patients with ankylosing spondylitis (AS) and non-AS-SpA were present in equal numbers. At review, clinical evolution was identical in the 3 histological subgroups. Eight patients developed idiopathic inflammatory bowel disease (IBD), one with initially acute gut inflammation, 7 with initially chronic gut inflammation. All had active AS at review. Fourteen patients with non-AS-SpA developed AS; 13 of them had initially presented inflammatory gut lesions. Three patients in the telephone group also developed IBD; all had active AS at review and initially presented chronic inflammatory gut lesions. Persistently high inflammatory serum variables, HLA-B27 negativity in the presence of sacroiliitis or AS, and inflammatory gut lesions at the first ileocolonoscopy indicate patients with SpA are at risk for developing IBD.

CONCLUSION

Gut inflammation, mainly subclinical, could be demonstrated in 68% of patients with SpA. Acute gut inflammation was predominant in patients with reactive arthritis (ReA). The evolution to clinical remission was not influenced by the presence or the type of gut inflammation at start. Patients with non-AS-SpA with inflammatory gut lesions have greater risk of developing AS. One patient with Yersinia induced ReA developed AS and IBD. In total, 11 patients (66%) developed IBD, all initially presenting inflammatory gut lesions. Ten had chronic gut lesions, suggesting this type of gut inflammation is related to the inflammation of Crohn's disease. This type of gut inflammation, the persistence of high inflammatory serum variables, and the absence of HLA-B27 in patients with AS are risk factors for developing IBD.

The evolution of spondyloarthropathies in relation to gut histology. III. Relation between gut and joint

OBJECTIVE

To study prospectively the clinical evolution of different forms of spondyloarthropathy (SpA) in relation to the evolution of gut histology in consecutive ileocolonoscopic biopsy specimens.

METHODS

Ileocolonoscopy was performed in 49 patients with SpA (34 men, 15 women). They also underwent clinical, laboratory, and radiological examinations. Two to 9 years later, a 2nd and sometimes a 3rd or 4th ileocolonoscopy was performed, and the other examinations were repeated.

RESULTS

At first ileocolonoscopy, 34 patients (69%) showed inflammatory gut lesions. At the 2nd ileocolonoscopy, 16 patients (32%) were in clinical remission; none were found to have inflammatory gut lesions. Of the 33 patients with persistent locomotor inflammation, 14 had persistent inflammatory gut lesions, predominantly the chronic type. Of these 14 patients, 6 had developed inflammatory bowel disease (IBD). None of the 15 patients with an initially normal gut histology had gut inflammation at 2nd examination. Of the 9 with initially acute lesions, 3 developed chronic lesions (1 Crohn's disease). Initial chronic lesions in 25 patients persisted in 9, of whom 5 had developed IBD. Seven of the 19 patients with non-SpA ankylosing spondylitis (non-AS-SpA) developed ankylosing spondylitis (AS); all had initially presented inflammatory gut lesions, which persisted at 2nd examination. In the 11 patients with more than 2 consecutive ileocolonoscopies, clinical remission was always associated with normal gut histology, and flares of the joint disease were related temporally to the reappearance of gut inflammation.

CONCLUSION

This study demonstrates the close relationship between gut and locomotor inflammation in SpA. Clinical remission was always associated with normal gut histology, whereas active locomotor inflammation was usually associated with the presence of gut inflammation. Absence of gut inflammation in the SpA is a good prognostic indicator, since gut inflammation or IBD never develops in these patients. Evolution of non-AS-SpA to full blown AS or of uncomplicated SpA to a form of IBD was always associated with gut inflammation at disease onset.

The evolution of spondyloarthropathies in relation to gut histology. I. Clinical aspects

OBJECTIVE

To study prospectively the clinical evolution of different forms of spondyloarthropathy (SpA) (excluding inflammatory bowel disease, IBD): reactive arthritis, undifferentiated SpA, and ankylosing spondylitis (AS).

METHODS

Ileocolonoscopy was performed on 217 patients with SpA (149 men, 68 women). They also underwent clinical, laboratory, and radiological examinations. Two to 9 years later, 123 patients (84 men, 39 women) who had been regularly monitored were reviewed and given the same examinations. For the remaining 94 patients clinical data were obtained by telephone.

RESULTS

At the time of clinical review, 53 (43%) of the regularly monitored patients were in clinical remission. The remission rate was higher in patients with non-ankylosing spondylitis SpA (non-As-SpA) than in patients with AS (19%). Fourteen patients with non-AS-SpA had developed AS; 4 of them also had IBD. IBD was also found in 4 patients with AS and in 3 patients from the telephone group. The prevalence of HLA-B27 was significantly higher in all SpA subgroups, while HLA-BW62 was elevated in the undifferentiated SpA. At review, HLA-B27 was significantly more prevalent in patients with persistent locomotor inflammation compared to patients in clinical remission, while HLA-BW62 was predominant in the latter group.

CONCLUSION

Patients with SpA, especially those with non-AS-SpA, have a good longterm prognosis. However, patients with non-AS-SpA may develop AS. Six percent of the patients with SpA in whom manifestations of IBD are absent will develop this disease. This confirms the hypothesis that some of these patients with SpA initially have a form of subclinical Crohn's disease, of which locomotor inflammation is the only clinical expression. HLA-B27 positivity predisposes to a more severe course of locomotor inflammation, while HLA-BW62 has a protective effect but is associated with gut inflammation.

Standardization of nutrient media for isolated human articular chondrocytes in gelified agarose suspension culture

Human articular cartilage cells were cultured in 1.5% agarose in Dulbecco's modified Eagle's medium (DMEM) with 10% fetal calf serum or in serum-free DMEM with 0.15% bovine serum albumin. 35S-aggrecan synthesis in serum-free DMEM was between 20% and 30% of the value observed in DMEM supplemented with 10% fetal calf serum. The extent to which different growth or differentiation factors were able to restore 35S incorporation in aggrecan in serum-free DMEM was determined: human serum transferrin had no effect on aggrecan synthesis levels; bovine pancreas insulin, insulin-like growth factor (IGF)-1 and IGF-2 restored 35S-aggrecan synthesis to 35-50% of the control levels. The effects were dose-dependent, to level off at 100 ng/mL for the three factors. No cumulative or synergistic activities were observed when these factors were combined. Transforming growth factor (TGF)-beta, at concentrations ranging from 10-50 ng/mL stimulated aggrecan synthesis to approximately 50% of the control values in the chondrocytes obtained from two out of four donors, while the cells of the other two maintained within the range of the control levels. In th presence of insulin (100 ng/mL) 10 ng/mL of TGF-beta stimulated aggrecan synthesis to more than 90% of the control level in the chondrocytes of all donors.

Comparison of aceclofenac with diclofenac in the treatment of osteoarthritis

A multicentre randomised, double-blind, parallel group, general practice study was undertaken to investigate the efficacy and safety of aceclofenac (200 patients, 100 mg twice daily and placebo once daily) in comparison with diclofenac (197 patients, 50mg three times daily) in patients with osteoarthritis of the knee. The treatment period of twelve weeks was preceded by a washout period of two weeks duration. At end point, patients in both aceclofenac and diclofenac-treated groups exhibited significant improvement in pain intensity (p = 0.0001). Although both treatment groups showed significant improvement in all investigators' clinical assessments (joint tenderness, swelling, pain on movement, functional capacity, overall assessment), there were no significant differences between the groups. There was, however, a trend towards greater improvement in complete knee movement and reduced pain on movement with aceclofenac. In patients with initial flexion deformity, aceclofenac was significantly more effective than diclofenac in improving knee flexion after 2-4 weeks treatment. Patients' subjective assessment of pain relief demonstrated significantly greater efficacy with aceclofenac. At end point, 71% of patients in the aceclofenac group reported improvement in pain intensity as compared to 59% treated with diclofenac (p = 0.005). Tolerability of aceclofenac was better than with diclofenac as fewer patients experienced gastrointestinal adverse events. In particular, the incidence of treatment related diarrhoea was less with aceclofenac (1%) than the diclofenac (6.6%). In summary, this study supports a therapeutic role for aceclofenac in arthritis and suggests that it is an alternative NSAID to diclofenac in the treatment of osteoarthritis.

The role of T cells in rheumatoid arthritis

The most striking arguments in favor of a T cell dependent nature of RA are the strong association of the disease with selected class II HLA haplotypes (the "shared epitope" hypothesis) and the fact that, in experimental animal models such as adjuvant arthritis, the disease can be transferred by isolated T cell lines. It is true that T cell activation at the site of inflammation is not excessive. However, there is now unequivocal evidence for focal synthesis of IL-2 and IFN-gamma in the RA synovial membrane and one may realise that a limited but specific T cell activation may be sufficient to induce or perpetuate the immune process. This same argument may explain the lack of clear TCR restriction at the sites of inflammation. Until now, no antigen has been demonstrated to initiate and/or perpetuate RA. Different antigens though have been incriminated in the pathogenesis of RA, including cartilage antigens (collagen, proteoglycans, chondrocyte antigens), heat shock proteins or exogenous (viral/bacterial) antigens. Unless one can pick up the right antigen and clone the relevant T cells, it will be very hard to directly prove a T cell-dependent nature of the disease.

Churg-Strauss syndrome presenting as polymyositis

Churg-Strauss syndrome is a vasculitis-based pathology, predominantly characterized by asthma and eosinophilia. Histopathologically, the vessel wall infiltration contains a substantial proportion of eosinophils and extravascular granulomata can be demonstrated. We report a case of Churg-Strauss syndrome presenting as polymyositis.

Numerical scoring systems for the progression of osteoarthritis of the finger joints

We developed methods to assess and to score progression of osteoarthritis (OA) of the distal and proximal interphalangeal (DIP and PIP) and metacarpophalangeal (MCP) finger joints. Thirty-six patients with osteoarthritis (OA) of the finger joints were followed for five years. Anteroposterior radiographs of the hands were obtained at the start of this prospective study and at yearly intervals. The scoring systems used were based on: -1- the increase in incidence of OA during consecutive years in previously normal joints. -2- the radiological progression of the anatomical lesions (changes in osteophyte growth, loss of joint space, subchondral cysts or sclerosis) in pathological finger joints. -3- the consecutive pathological phases recognized in the course of the disease. Significant increases in both the numbers of affected DIP, PIP and MCP joints per subject and the anatomical progression of the disease in the different finger joints of each individual patient were recorded during the 5-year follow-up. In approx. 40% of the patients the classical picture of OA was complicated by manifest erosive changes, which preceded a period in which repair phenomena in the 'eroded' finger joints led to generation of a new subchondral plate covered by cartilaginous tissue. Huge osteophytes were then responsible for the nodular aspect of the affected finger joints. OA of the finger joints in our patients was progressive in nature and went through predictable phases. Recognition and scoring of these phases allowed faster assessment of OA progression and led to the same conclusions as scoring the anatomical progression.

Gut inflammation in psoriatic arthritis: a prospective ileocolonoscopic study

OBJECTIVE

Some forms of psoriatic arthritis (PsA) are classified as spondylarthropathy, and subclinical gut inflammation is found in spondylarthropathies. Our study was designed to determine if inflammatory gut lesions were also present in PsA, and if the prevalence of subclinical gut involvement was different in the subgroups of this disease. The relationship with HLA subtypes was also determined.

METHODS

Ileocolonoscopy was performed on 64 patients with PsA (37 men, 27 women).

RESULTS

Inflammatory gut lesions were found in 10 of the 64 patients (16%): in 3 of the 15 patients (20%) with oligoarthritis and in 7 of the 23 patients (30%) with axial involvement. None of the 26 patients with polyarthritis showed these lesions. The prevalence of HLA-B27, Bw62, and B17 was significantly raised in our total group of patients with PsA. HLA-B27 and Bw62 were significantly more prevalent in patients with gut inflammation, 60 and 50%, respectively.

CONCLUSION

Gut inflammation is only present in PsA subgroups that belong to the spondylarthropathy concept. This suggests that the gut plays a role in the pathogenesis of locomotor inflammation in these subgroups. The prevalence of gut inflammation in psoriatic spondylarthropathy is significantly lower than in nonpsoriatic spondylarthropathies. Consequently, not only the gut but also the skin may be a portal of entry for causative antigens in PsA.

Coculture of human articular chondrocytes with peripheral blood mononuclear cells as a model to study cytokine-mediated interactions between inflammatory cells and target cells in the rheumatoid joint

A model for the coculture of chondrocytes in gelified agarose with mononuclear cells was developed to serve as an in vitro equivalent for cytokine-mediated events at the cartilage-synovial pannus junction in destructive arthropathies. Chondrocytes cultured in agarose keep their phenotypic stability. They release cartilage-specific aggrecans into the surrounding artificial matrix. When activated with lipopolysaccharide for 1 h, mononuclear cells release Interleukin 1 beta and Tumor Necrosis Factor alpha, thereby stimulating the chondrocytes to produce Interleukin 6, to diminish incorporation of 35S into aggrecans, and to degrade these intercellular macromolecules. This coculture model is a useful tool for studying interactions between inflammatory cells and target cells. To demonstrate its usefulness, the effect of three anti-inflammatory drugs (piroxicam, sulphasalazine, and hydrocortisone) on cytokine release by mononuclear cells, and subsequently on chondrocyte aggrecan metabolism was studied. The drugs were unable to abrogate Interleukin 1 and Tumor Necrosis Factor alpha release by activated mononuclear cells. Therefore, these pharmacological agents did not protect the artificial target tissue against cytokine-mediated degradation.

Cervical spine involvement in rheumatoid arthritis: a clinical, neurological and radiological evaluation

OBJECTIVE

This study was designed to reveal any correlation between radiological signs and clinical findings of cervical spine involvement in rheumatoid arthritis (RA).

METHODS

Fifty patients with definite rheumatoid arthritis were evaluated for cervical spine involvement by a clinical neurological examination, a somatosensory evoked potential (SEP) study and different radiological techniques including tomograms, computerized tomography (CT) and magnetic resonance imaging (MRI).

RESULTS

Anterior atlantoaxial subluxation was a common finding, frequently associated with superior migration of the dens and subaxial subluxation. Two patients presented a posterior atlantoaxial subluxation due to complete erosion of the dens. Both had cervical cord compression and one of them had hypoglossal nerve paresis. The delineation of peridental pannus formation was clearly demonstrated by MRI. In the majority of cases cervical cord compression was caused by pannus formation or by vertical atlantoaxial subluxation.

CONCLUSION

The correlation between the severity of the radiological findings and the clinical-neurological signs was poor. A 4-limb SEP study appeared to be a useful screening method for the detection of cervical medullary compression.

[Viable meniscus transplantation]

The integrity of the semilunar cartilages has proved to be the best safeguard against mechanical degenerative changes. One can postulate that restoring normal congruency between the femur and tibia with intact menisci would be the ideal solution to many mechanical knee problems. Several semilunar cartilages have been transplanted with good functional results in medial and lateral compartmental meniscal disease. However, this form of chondroprotection in the load-bearing area of the femur and tibia can only be properly evaluated after 10 to 20 years of follow-up. In order to obtain functional results, meniscal allografts have to be incorporated in the knee joint by intimate meniscofemoral synovial bonding. The synovial fibroblasts must grow into the collagen meshwork of the meniscal allograft. Such ingrowth has been shown in freeze-dried and deep-frozen meniscal allografts. However, in a small number of transplants shrinking has been observed on repeat arthroscopy at 6 months. Satisfactory incorporation of meniscal allografts has been obtained with fresh allografts, but availability remains a problem when this method is used for meniscal substitution. For this reason viable meniscal allograft implantation was initiated in a series of 25 patients and the value of this method studied. The meniscal allograft can be kept in an adequate semisynthetic nutrient medium for approximately 2-3 weeks without apparent loss of viability, during which period the appropriate recipient can be selected and prepared, a thorough laboratory screening can be conducted, and the culture results and disease transmission factors can be evaluated. In this way, live transplant hazards can be avoided, resulting in a higher success rate.

An optimized method for routine HLA-B27 screening using flow cytometry

Flow cytometry and monoclonal antibodies are promising tools for HLA-antigen detection. Previous approaches have been hampered by the lack of a carefully standardized system for calibration and sample analysis. A new system for HLA-B27 screening was developed using a FACScan flow cytometer, software for automated calibration and analysis, calibration beads, and the anti-HLA-B27-FITC/anti-Leu4-PE (CD3) monoclonal antibodies. The median fluorescence channel result for the HLA-B27-FITC signal of CD3+ T lymphocytes is compared to a decision marker. Values lower than this threshold are read as HLA-B27 negative and those above are recommended for retesting with the classic microcytotoxicity assay on the presumption of HLA-B27 positivity. The anti-HLA-B27 antibody reacts with all six HLA-B27 subtypes and shows a weaker binding to HLA-B7. The screening test results were compared with those from the microcytotoxicity assay for HLA-typing in studies involving several European centers. The observed sensitivity was 100% (95% Cl:98.6-100) and the specificity was 97.4% (95% Cl: 96.4-98.3). Other performance studies verified the reproducibility and reliability of results obtained with the screening system.

Comparative and combined effects of interleukin 6, interleukin 1 beta, and tumor necrosis factor alpha on proteoglycan metabolism of human articular chondrocytes cultured in agarose

OBJECTIVE

To study the effects of recombinant tumor necrosis factor alpha (TNF-alpha), interleukin 1 beta (IL-1 beta) and interleukin 6 (IL-6) on proteoglycan metabolism of isolated chondrocytes.

METHODS

Human articular cartilage cells were cultured in agarose gel. In these culture conditions, chondrocytes keep their phenotypic stability. They release cartilage specific proteoglycans into the surrounding artificial matrix. Proteoglycan synthesis was measured by the incorporation of 35sulfate (35S).

RESULTS

TNF-alpha and IL-1 beta depressed proteoglycan synthesis and induced proteoglycan degradation. The effects of both cytokines were additive, when used in submaximal doses. No mutual induction of TNF-alpha and IL-1 beta was shown, but both cytokines stimulated the chondrocytes to release IL-6, up to 100,000 pg/ml. Equal amounts of human recombinant IL-6 did not affect proteoglycan synthesis. IL-6 did not alter proteoglycan quality, nor did it modulate the IL-1 beta activities on proteoglycan metabolism.

CONCLUSION

These findings illustrate the role of IL-1 beta and TNF-alpha in cartilage degradation and suggest that the role of the large amounts of IL-6 released in response to IL-1 in chronic arthritis is not directly protective with regard to proteoglycan metabolism.