Prevalence of antibodies against Chlamydia trachomatis and incidence of C. trachomatis-induced reactive arthritis in an early arthritis series in Finland in 2000

[Postinfectious reactive arthritis after chlamydia infection in competitive sports : Clinical management and current literature review]

BACKGROUND

Reactive arthritis following infection with chlamydia is a rare but important differential diagnosis in atraumatic joint swelling. A delayed diagnosis often leads to prolonged periods of absence from physical activity. This can have serious consequences, especially for the career of competitive athletes.

OBJECTIVES

Recommendation for the clinical management of postinfectious reactive arthritis for rapid diagnosis and targeted treatment in the symptomatic clinical course.

MATERIALS AND METHODS

Review of the literature on the topics "chlamydia", "reactive arthritis", "postinfectious arthritis" and "sexually acquired reactive arthritis", including presentation of two clinical cases of postinfectious reactive arthritis after chlamydia infection from competitive sports.

RESULTS AND CONCLUSION

Reactive arthritis following chlamydia infection in competitive athletes is a rare entity. However, it can be accompanied by far-reaching individual consequences, especially with regard to possible downtime in sports. Long-term consequences such as chronic joint damage in maintained synovitis must also be considered. In order to make a diagnosis, a specific anamnesis and the direct detection of the pathogen in the specimen of synovial fluid by polymerase chain reaction is essential. This allows a reliable diagnosis to be made with immediate initiation of therapy. However, a prolonged course of the disease cannot be excluded even if therapy is started in due time.

Recent Developments in HLA B27 Anterior Uveitis

There has been steady progress in understanding the pathogenesis, clinical features, and effective treatment of acute anterior uveitis (AU) over the past 5 years. Large gene wide association studies have confirmed that AU is a polygenic disease, with overlaps with the seronegative arthropathies and inflammatory bowel diseases, associations that have been repeatedly confirmed in clinical studies. The role of the microbiome in AU has received increased research attention, with recent evidence indicating that human leukocyte antigen B27 (HLA B27) may influence the composition of the gut microbiome in experimental animals. Extensive clinical investigations have confirmed the typical features of acute AU (AAU) and its response to topical, regional and systemic immunosuppressive treatment. Increased understanding of the role of cytokines has resulted in studies confirming the value of anti-cytokine therapy [anti-tumor necrosis factor (anti-TNF) and interleukin 6 (IL-6) therapy] in severe and recurrent cases of AAU, particularly in subjects with an associated spondyloarthopathy (SpA) and in juvenile idiopathic arthritis (JIA)-associated AAU.

Elucidating potential molecular signatures through host-microbe interactions for reactive arthritis and inflammatory bowel disease using combinatorial approach

Reactive Arthritis (ReA), a rare seronegative inflammatory arthritis, lacks exquisite classification under rheumatic autoimmunity. ReA is solely established using differential clinical diagnosis of the patient cohorts, where pathogenic triggers linked to enteric and urogenital microorganisms e.g. Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia have been reported. Inflammatory Bowel Disease (IBD), an idiopathic enteric disorder co-evolved and attuned to present gut microbiome dysbiosis, can be correlated to the genesis of enteropathic arthropathies like ReA. Gut microbes symbolically modulate immune system homeostasis and are elementary for varied disease patterns in autoimmune disorders. The gut-microbiota axis structured on the core host-microbe interactions execute an imperative role in discerning the etiopathogenesis of ReA and IBD. This study predicts the molecular signatures for ReA with co-evolved IBD through the enveloped host-microbe interactions and microbe-microbe 'interspecies communication', using synonymous gene expression data for selective microbes. We have utilized a combinatorial approach that have concomitant in-silico work-pipeline and experimental validation to corroborate the findings. In-silico analysis involving text mining, metabolic network reconstruction, simulation, filtering, host-microbe interaction, docking and molecular mimicry studies results in robust drug target/s and biomarker/s for co-evolved IBD and ReA. Cross validation of the target/s or biomarker/s was done by targeted gene expression analysis following a non-probabilistic convenience sampling. Studies were performed to substantiate the host-microbe disease network consisting of protein-marker-symptom/disease-pathway-drug associations resulting in possible identification of vital drug targets, biomarkers, pathways and inhibitors for IBD and ReA.Our study identified Na(+)/H(+) anti-porter (NHAA) and Kynureninase (KYNU) to be robust early and essential host-microbe interacting targets for IBD co-evolved ReA. Other vital host-microbe interacting genes, proteins, pathways and drugs include Adenosine Deaminase (ADA), Superoxide Dismutase 2 (SOD2), Catalase (CAT), Angiotensin I Converting Enzyme (ACE), carbon metabolism (folate biosynthesis) and methotrexate. These can serve as potential prognostic/theranostic biomarkers and signatures that can be extrapolated to stratify ReA and related autoimmunity patient cohorts for further pilot studies.

Spondyloarthritis, Acute Anterior Uveitis, and Fungi: Updating the Catterall-King Hypothesis

Spondyloarthritis is a common type of arthritis which affects mostly adults. It consists of idiopathic chronic inflammation of the spine, joints, eyes, skin, gut, and prostate. Inflammation is often asymptomatic, especially in the gut and prostate. The HLA-B*27 allele group, which presents intracellular peptides to CD8+ T cells, is by far the strongest risk factor for spondyloarthritis. The precise mechanisms and antigens remain unknown. In 1959, Catterall and King advanced a novel hypothesis explaining the etiology of spondyloarthritis: an as-yet-unrecognized sexually acquired microbe would be causing all spondyloarthritis types, including acute anterior uveitis. Recent studies suggest an unrecognized sexually acquired fungal infection may be involved in prostate cancer and perhaps multiple sclerosis. This warrants reanalyzing the Catterall-King hypothesis based on the current literature. In the last decade, many links between spondyloarthritis and fungal infections have been found. Antibodies against the fungal cell wall component mannan are elevated in spondyloarthritis. Functional polymorphisms in genes regulating the innate immune response against fungi have been associated with spondyloarthritis (CARD9 and IL23R). Psoriasis and inflammatory bowel disease, two common comorbidities of spondyloarthritis, are both strongly associated with fungi. Evidence reviewed here lends credence to the Catterall-King hypothesis and implicates a common fungal etiology in prostate cancer, benign prostatic hyperplasia, multiple sclerosis, psoriasis, inflammatory bowel disease, and spondyloarthritis. However, the evidence available at this time is insufficient to definitely confirm this hypothesis. Future studies investigating the microbiome in relation to these conditions should screen specimens for fungi in addition to bacteria. Future clinical studies of spondyloarthritis should consider antifungals which are effective in psoriasis and multiple sclerosis, such as dimethyl fumarate and nystatin.

Causality of Chlamydiae in Arthritis and Spondyloarthritis: a Plea for Increased Translational Research

Current molecular genetic understanding of the metabolically active persistent infection state of Chlamydia trachomatis and Chlamydia pneumoniae in the synovium in patients with arthritis and spondyloarthritis favors a causal relationship. Here, we examine how adequately the accepted criteria for that etiologic relationship are fulfilled, emphasizing the situation in which these microorganisms cannot be cultivated by standard or other means. We suggest that this unusual situation of causality by chlamydiae in rheumatic disease requires establishment of a consensus regarding microorganism-specific terminology as well as the development of new diagnostic and classification criteria. Recent studies demonstrate the value of molecular testing for diagnosis of reactive arthritis, undifferentiated spondyloarthritis, and undifferentiated arthritis caused by C. trachomatis and C. pneumoniae in clinical practice. Data regarding combination antibiotic therapy is consistent with the causative role of chlamydiae for these diseases. Observations of multiple intra-articular coinfections require more research to understand the implications and to respond to them.

Incidence of Chlamydia trachomatis infection in patients with reactive arthritis

Objectives

The aim of the study was to evaluate the incidence of Chlamydia trachomatis in patients with reactive arthritis (ReA) within the area of the Podlaskie province (north eastern Poland).

Material and methods

The study concerned 323 patients including 132 women and 191 men diagnosed with ReA. The material for C. trachomatis was collected from the urethra in men and the cervical canal in women. Also, every patient was tested for the presence of anti-C. trachomatis IgG class antibodies, while 121 individuals were additionally tested for IgA class antibodies. In the direct studies, the direct immunofluorescence (DIF) method or polymerase chain reaction (PCR) was used. The immunoenzymatic method was used to detect anti-C. trachomatis antibodies. The control group in the case of direct studies comprised 125 individuals, while in the case of serology research it included 127 (IgG) and 109 (IgA) persons.

Results

Chlamydia trachomatis infection in the urethral and cervical smears was found in 42 patients (13.0%) including 20 women (15.2%) and 22 men (11.5%). In the control group chlamydia was detected in 3 patients (2.4%) including 4% of women and 2% of men. IgA class antibodies were present in 10/121 (8.3%) patients, similarly in women and in men (8.2% and 8.3% respectively). In the control group the specific IgA class antibodies were found in 3/85 patients (3.5%). Anti-C. trachomatis IgG antibodies were found in 70/323 patients (21.7%), similarly in men and women.

Conclusions

Chlamydia trachomatis is a common bacterial factor observed in the genitourinary system of patients with ReA. The outcomes of studies within the Podlaskie province indicate less frequent presence of chlamydial infection compared with Dolnośląskie province.

No correlations between detecting the presence of C. trachomatis in the urogenital tract and the presence of specific antibodies in the serum of ReA patients were observed.

Concurrent direct studies of the urogenital tract and a serological blood test increase the chance of detecting C. trachomatis infection.

Reactive arthritis

Reactive arthritis (ReA) is an immune-mediated seronegative arthritis that belongs to the group of spondyloarthropathies and develops after a gastrointestinal or genitourinary system infection. The condition is considered to be characterized by a triad of symptoms (conjunctivitis, arthritis and urethritis) although a constellation of other manifestations may also be present. ReA is characterized by psoriasiform dermatological manifestations that may resemble those of pustular psoriasis and, similar to guttate psoriasis, is a post-infectious entity. Also, the articular manifestations of the disorder are similar to those of psoriatic arthritis and both conditions show a correlation with HLA-B27. These facts have led several authors to suggest that there is a connection between ReA and psoriasis, listing ReA among the disorders related to psoriasis. However, the pathogenetic mechanism behind the condition is complex and poorly understood. Bacterial antigenicity, the type of host response (i.e. Th1/Th2 imbalance) and various genetic factors (i.e. HLA-B27 etc.) play an important role in the development of the disorder. It is unknown whether all the aforementioned factors are part of a mechanism that could be similar to, or share basic aspects with known psoriasis pathogenesis mechanisms.

Recent Chlamydia pneumoniae infection is highly associated with active ankylosing spondylitis in a Chinese cohort

OBJECTIVE

The aim of the present study was to investigate the presence of anti-Chlamydia pneumoniae (Cp) antibodies in patients with ankylosing spondylitis (AS) to determine whether there is an association with AS disease activity.

METHODS

Seventy-nine AS outpatients and 73 normal controls were enrolled in this case-control study. Serum anti-Cp immunoglobulins (CpIg) were detected by enzyme-linked immunosorbent assay (ELISA). Antibodies to Epstein-Barr virus (EBV), cytomegalovirus (CMV), and Chlamydia trachomatis (Ct) were also measured. Clinical and experimental data were collected, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was determined. Patients with positive Cp IgM or Cp IgA were considered to have had a recent Cp infection.

RESULTS

Cp IgG was detected in the majority of AS patients and also controls (88.8% vs. 91.8%, respectively). The seroprevalence of Cp IgA and Cp IgM was significantly higher in AS patients than in the controls (51.9% vs. 31.5%, p = 0.010 for Cp IgA; 79.7% vs. 20.5%, p < 0.0001 for Cp IgM). Seropositivity of Cp IgM was associated with elevation of the disease activity index, including erythrocyte sedimentation rate (ESR; p = 0.021), C-reactive protein (CRP; p = 0.007) and the BASDAI (p = 0.009). Persistent positive Cp IgM was associated with active disease, while seroreversion of Cp IgM was associated with a reduction in these disease activity indices. There was no correlation between Cp IgM or Cp IgA and symptomatic upper respiratory infections or other clinical manifestations.

CONCLUSIONS

Recent Cp infections occur frequently in AS patients and Cp IgM antibody is correlated with active disease. These findings indicate that Cp infections may be a triggering factor for active AS.

Association between intracellular infectious agents and Tourette's syndrome

The underlying pathophysiological mechanisms in Tourette's syndrome (TS) are still unclear. Increasing evidence supports the involvement of infections, possibly on the basis of an altered immune status. Not only streptococci but also other infectious agents may be involved. This study investigates the association between the neurotrophic agents Chlamydia, Toxoplasma and TS. 32 patients with TS and 30 healthy matched controls were included. For each individual, IgA/IgG antibody titers against Chlamydia trachomatis/pneumoniae and Toxoplasma gondii were evaluated and analyzed with Fisher's exact test. We found a significantly higher rate of TS patients with elevated antibody titers against Chlamydia trachomatis (P = 0.017) as compared to controls. A trend toward a higher prevalence in the Tourette's group was shown for Toxoplasma (P = 0.069). In conclusion, within the TS patients a higher rate of antibody titers could be demonstrated, pointing to a possible role of Chlamydia and Toxoplasma in the pathogenesis of tic disorders. Because none of these agents has been linked with TS to date, a hypothesis is that infections could contribute to TS by triggering an immune response. It still remains unclear whether tic symptoms are partly due to the infection or to changes in the immune balance caused by an infection.