A decrease in disease activity score (DAS) level is associated with a decrease in health assessment questionnaire (HAQ) score, independent of follow-up duration, during 5 years of tightly controlled treatment: results from the BeSt study

OBJECTIVE

To assess the relationship between a decrease in disease activity score (DAS) and functional ability during 5 years of DAS-steered treatment in recent-onset rheumatoid arthritis (RA) patients, taking into account absolute DAS levels and follow-up duration.

METHODS

Data from the BeSt study were used, in which treatment was aimed at achieving DAS ≤2.4. The longitudinal relationship between 3-monthly measured DAS and health assessment questionnaire (HAQ) score was assessed using linear mixed modelling during 5 years of treatment, with DAS and HAQ 3 months earlier, change in DAS in last 3 months (delta DAS), time (log-transformed) and their interactions as determinants.

RESULTS

Predictors for HAQ were: previous DAS, delta DAS, ln time, the interaction previous DAS×delta DAS, and previous HAQ. The interaction ln time×delta DAS was non-significant, indicating that the association between delta DAS and HAQ was independent of follow-up duration. A decrease from a higher DAS was associated with a smaller HAQ decrease than for a similar decrease from a lower DAS, indicating a non-linear relationship between DAS and HAQ.

CONCLUSION

At any time during 5 years of follow-up, a decrease in DAS was associated with a better functional ability. The magnitude of HAQ improvement depends on the DAS decrease and on the absolute DAS level.

Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): A randomized, controlled trial

OBJECTIVE

Several treatment strategies have proven value in the amelioration of rheumatoid arthritis (RA), but the optimal strategy for preventing long-term joint damage and functional decline is unclear. We undertook this study to compare clinical and radiographic outcomes of 4 different treatment strategies, with intense monitoring in all patients.

METHODS

In a multicenter, randomized clinical trial, 508 patients were allocated to 1 of 4 treatment strategies: sequential disease-modifying antirheumatic drug monotherapy (group 1), step-up combination therapy (group 2), initial combination therapy with tapered high-dose prednisone (group 3), and initial combination therapy with the tumor necrosis factor antagonist infliximab (group 4). Treatment adjustments were made every 3 months in an effort to obtain low disease activity (a Disease Activity Score in 44 joints of < or =2.4).

RESULTS

Initial combination therapy including either prednisone (group 3) or infliximab (group 4) resulted in earlier functional improvement than did sequential monotherapy (group 1) and step-up combination therapy (group 2), with mean scores at 3 months on the Dutch version of the Health Assessment Questionnaire (D-HAQ) of 1.0 in groups 1 and 2 and 0.6 in groups 3 and 4 (P < 0.001). After 1 year, mean D-HAQ scores were 0.7 in groups 1 and 2 and 0.5 in groups 3 and 4 (P = 0.009). The median increases in total Sharp/Van der Heijde radiographic joint score were 2.0, 2.5, 1.0, and 0.5 in groups 1-4, respectively (P < 0.001). There were no significant differences in the number of adverse events and withdrawals between the groups.

CONCLUSION

In patients with early RA, initial combination therapy including either prednisone or infliximab resulted in earlier functional improvement and less radiographic damage after 1 year than did sequential monotherapy or step-up combination therapy.

Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial

OBJECTIVE

Several treatment strategies have proven value in the amelioration of rheumatoid arthritis (RA), but the optimal strategy for preventing long-term joint damage and functional decline is unclear. We undertook this study to compare clinical and radiographic outcomes of 4 different treatment strategies, with intense monitoring in all patients.

METHODS

In a multicenter, randomized clinical trial, 508 patients were allocated to 1 of 4 treatment strategies: sequential disease-modifying antirheumatic drug monotherapy (group 1), step-up combination therapy (group 2), initial combination therapy with tapered high-dose prednisone (group 3), and initial combination therapy with the tumor necrosis factor antagonist infliximab (group 4). Treatment adjustments were made every 3 months in an effort to obtain low disease activity (a Disease Activity Score in 44 joints of < or =2.4).

RESULTS

Initial combination therapy including either prednisone (group 3) or infliximab (group 4) resulted in earlier functional improvement than did sequential monotherapy (group 1) and step-up combination therapy (group 2), with mean scores at 3 months on the Dutch version of the Health Assessment Questionnaire (D-HAQ) of 1.0 in groups 1 and 2 and 0.6 in groups 3 and 4 (P < 0.001). After 1 year, mean D-HAQ scores were 0.7 in groups 1 and 2 and 0.5 in groups 3 and 4 (P = 0.009). The median increases in total Sharp/Van der Heijde radiographic joint score were 2.0, 2.5, 1.0, and 0.5 in groups 1-4, respectively (P < 0.001). There were no significant differences in the number of adverse events and withdrawals between the groups.

CONCLUSION

In patients with early RA, initial combination therapy including either prednisone or infliximab resulted in earlier functional improvement and less radiographic damage after 1 year than did sequential monotherapy or step-up combination therapy.

Cigarette smoking and pulmonary diffusion defects in rheumatoid arthritis

The pathogenesis of lung disease in rheumatoid arthritis (RA) has still to be defined. Risk factors associated with lung involvement in RA were investigated by means of pulmonary function studies in 40 RA patients without apparent lung disease. A decreased carbon monoxide (CO) diffusion capacity indicative of interstitial lung disease (ILD) was the main pulmonary function defect found in the first 20 patients. The occurrence was associated with current cigarette smoking. This association was confirmed in a case control study performed subsequently. These data suggest that ILD in RA is stimulated by smoking and provide an additional argument that modification of smoking behaviour in RA patients might lead to less severe complications.

Factors associated with the development of vasculitis in rheumatoid arthritis: results of a case-control study

OBJECTIVE

To investigate those characteristics of patients with rheumatoid arthritis (RA) that are associated with the development of rheumatoid vasculitis (RV).

METHODS

Demographic and clinical data of 69 patients who had been diagnosed as having RV were compared with those of 138 contemporaneous control patients with RA who were not suspected to have vasculitis. Vasculitis was confirmed histologically in 96% of the subjects with RV.

RESULTS

Variables associated with the development of RV were: 1) male gender, presence of increased serum concentrations of rheumatoid factor, joint erosions, subcutaneous nodules, number of disease modifying antirheumatic drugs previously prescribed, treatment (ever) with D-penicillamine or azathioprine; 2) presence of nail fold lesions and any other extrarticular feature one year before the time of diagnosis of RV; 3) treatment with corticosteroids at the time of diagnosis of RV.

CONCLUSIONS

The development of RV is associated with male gender, extra-articular features, and a severe course of RA as indicated by the presence of joint destruction and need for intensive treatment with antirheumatic drugs. The strongest association was found with the presence of increased concentrations of rheumatoid factor.

Increased bone mass with pamidronate treatment in rheumatoid arthritis. Results of a three-year randomized, double-blind trial

OBJECTIVES

Osteoporosis is a frequent complication of rheumatoid arthritis (RA). We therefore investigated the effect of oral pamidronate therapy as a specific bone-sparing agent in RA.

METHODS

The study design was a 3-year randomized, double-blind trial of 300 mg oral pamidronate/day compared with placebo in 105 RA patients. Bone mineral density (BMD) measured at 12-month intervals was the primary efficacy parameter.

RESULTS

In 3 years, lumbar spine and forearm BMD increased significantly in the pamidronate-treated group (by 8.4 +/- 6.9% [mean =/- SEMI] [P < 0.00011 and 5.2 =/- 6.5% [P < 0.005], respectively), compared with nonsignificant changes in the placebo-treated patients (increase of 0.6 =/- 5.2% and decrease of 1.2 =/- 5.8%, respectively). Femoral neck BMD increased in the pamidronate-treated group (by 2.6 =/- 8.6%) and decreased significantly in the placebo-treated group (by 4.0=/- 1.3% [P < 0.005]). The changes in BMD with time at all 3 measurement sites were significantly different between the treatment groups (P < 0.0001). Changes in radiographic signs of joint damage and in disease activity were similar in the 2 groups.

CONCLUSION

The present study provides the first evidence that long-term treatment with an orally administered bisphosphonate overcomes bone loss and increases bone mass when compared with placebo. This finding may have significance with regard to the treatment of patients with RA.

The mortality of rheumatoid vasculitis compared with rheumatoid arthritis

OBJECTIVE

To determine whether the mortality of patients with rheumatoid vasculitis (RV) is increased in comparison with that of patients with rheumatoid arthritis (RA).

METHODS

The mortality of all RV patients identified in 1980-1992 (n=61) was compared with that of 244 RA controls matched for the year the diagnosis was made in the RV cases. Hazard ratios (HR) of death were calculated with a multivariate survival analysis, adjusting for age, sex, comorbidity, treatment, and parameters of RA severity.

RESULTS

The unadjusted risk of death (HR) in RV patients compared with RA controls was 1.65 (95% confidence interval [95% CI] 1.05-2.58). After adjustment for prognostic factors, the HR was reduced to 1.26 (95% CI 0.79-2.01), mainly due to removal of the effects of age and sex. No excess mortality was seen in RV patients with severe organ involvement when compared with RV patients without severe organ involvement, although the former patients were treated more often with cytostatic and immunosuppressive drugs. Infection was the main cause of death in the RV patients, and cardiovascular disease in the RA controls. Vasculitis was reported as the cause of death in only 1 RV patient.

CONCLUSION

After allowance for general risk factors such as age and sex, there remains only a slight excess mortality in RV patients compared with RA controls.

Value of 99mTc-IgG scintigraphy in the prediction of joint destruction in patients with rheumatoid arthritis of recent onset

The ability of technetium-99m-labelled polyclonal human immunoglobulin G (99mTc-IgG) scintigraphy to predict joint destruction in patients with rheumatoid arthritis (RA) was investigated in this study. The progression of radiographically determined joint destruction in wrists, hands and feet was compared with the results of physical and laboratory examination, as well as 99mTc-IgG scintigraphy, measured at the beginning of a year-long study on 30 patients with RA of recent onset. The sensitivity of joint swelling in predicting the progression of radiographically determined joint destruction ranged between 57% and 74%. The sensitivity of 99mTc-IgG scintigraphy ranged between 71% and 100%. The specificity and positive predictive value both of joint swelling and 99mTc-IgG scintigraphy were low. Multiple regression analysis showed that for the total joint score, and for the metacarpophalangeal and forefeet joints, progression of radiographically determined joint destruction was primarily predicted by 99mTc-IgG scintigraphy. Joint swelling, ESR and IgM rheumatoid factor did not contribute to this prediction. We concluded that 99mTc-IgG scintigraphy is superior to conventional clinical and laboratory measurements in RA with respect to prediction of joint destruction.

Technetium-99m labelled polyclonal human IgG scintigraphy before and 26 weeks after initiation of parenteral gold treatment in patients with rheumatoid arthritis

OBJECTIVE

To determine effectiveness of technetium-99m labelled polyclonal human immunoglobulin G (99mTc-IgG) scintigraphy to monitor variation in arthritis activity in patients with rheumatoid arthritis (RA).

METHODS

The results of semiquantitative 99mTc-IgG scintigraphy were compared with those of examination before and 26 weeks after initiation of parenteral gold treatment in 19 patients with RA.

RESULTS

Clinical and laboratory variables of arthritis activity as well as the scores of 99mTc-IgG scintigraphy were significantly lower after gold treatment compared to the scores before treatment. However, the difference between the mean scores of 99mTc-IgG scintigraphy before and after treatment was statistically significant for more joints than such difference in scores for joint pain and joint swelling.

CONCLUSION

99mTc-IgG scintigraphy is able to reflect variations in arthritis activity in patients with RA.

[Comparison of azathioprine and methotrexate in rheumatoid arthritis: an open-randomized clinical study]

Thirty-eight patients with active rheumatoid arthritis (RA) were entered in an open randomized 24-week study comparing azathioprine (AZA; initial daily dose 1 mg/kg) with methotrexate (MTX; initial weekly dose 7.5 mg). The patients had previously been treated with antimalarials, gold salts and/or D-penicillamine. The groups were well balanced in baseline characteristics. There were three premature withdrawals in each group, all of which were due to toxicity. The present study did not show any significant differences between AZA and MTX in ability to reduce activity in RA after 24 weeks of treatment.

Bone metabolism in rheumatoid arthritis; relation to disease activity

Biochemical parameters of bone metabolism were investigated in 105 ambulant, non-steroid treated patients with RA and compared with parameters of disease activity. Urinary calcium (Ca) and hydroxyproline (OHP) excretions, as parameters of bone resorption and serum alkaline phosphatase (AP), as a parameter of bone formation, were positively related to parameters of disease activity. Serum osteocalcin, another parameter of bone formation, was not related to parameters of disease activity. Patients with active disease (ESR > or = 28 mm and Ritchie articular index > or = 8) had a significant higher urinary Ca and OHP excretion (62 and 42% higher, respectively) than patients with inactive disease. Serum AP and OC were slightly higher (19 and 16%, respectively) in patients with active disease. These results suggest that in RA patients bone metabolism is related to disease activity. In active disease bone resorption seems to be increased more than bone formation, suggesting that prolonged disease activity may contribute to generalized and/or localized osteopenia.

[Rheumatic disease as initial symptom of HIV infection]

A 47-year old man presented with general malaise, pain in several joints and muscles, lymphadenopathy, livedo reticularis, an elevated sedimentation rate and mild pancytopenia. A positive ANF, anticardiolipin antibodies and circulating immune complexes raised suspicion of an autoimmune disease. A perivascular infiltrate in muscle and fascia was found, but a specific diagnosis could not be made. The patient appeared to be infected with the human immunodeficiency virus (HIV) type I, with the cellular immunity already decreased. During treatment with zidovudine the symptoms and signs diminished, suggesting a causal relation between the HIV infection and this clinical presentation. The rheumatic manifestations and autoimmune phenomena with which HIV infection can be associated are discussed.

Anti-neutrophil cytoplasmic autoantibodies in patients with symptomatic HIV infection

Antibodies against cytoplasmic antigens of neutrophils, producing perinuclear (p-ANCA) as well as cytoplasmic staining with central accentuation (c-ANCA), have been described in non-HIV-infected patients with specific pathology such as glomerulonephritis and vasculitis. Here, we report on a patient with a vasculitis-like syndrome and a positive ANCA-test who appeared to be infected by HIV. Further analysis revealed that ANCA, p-ANCA as well as c-ANCA without central accentuation can be demonstrated in the serum of HIV+ individuals. In a cross-sectional study on individuals in different stages of HIV infection, we found that the occurrence of ANCA was limited to the symptomatic stages of HIV infection: p-ANCA was found in one out of 10 ARC patients and in two out of 11 AIDS patients with malignancies (AIDS-MAL), but not in AIDS patients with opportunistic infections (AIDS-OI). c-ANCA was found in four of the ARC patients, in two of the 14 AIDS-OI patients and in two AIDS-MAL patients. The presence of ANCA was not related to the degree of hypergammaglobulinaemia nor to specific symptomatology. ANCA containing sera from HIV+ individuals did not react with HEp2 cells nor with cytoplasmic antigens of lymphocytes, natural killer (NK) cells or eosinophils. Five out of the 11 (two p-ANCA and three c-ANCA) sera reacted weakly with cytoplasmic antigens of monocytes. All sera reacted with karyoplasts but not with cytoplasts prepared from neutrophils. These results suggest that HIV-ANCA might be directed against myeloid cell-specific granule constituents. However, sandwich-ELISAs with MoAbs against granule antigens that are frequently the target antigens of ANCA in HIV- individuals were negative. Also immunoprecipitation and immunoblotting, using lysates of neutrophil granules, did not allow further identification of the target antigens of HIV-ANCA.

Prednisone plus azathioprine treatment in patients with rheumatoid arthritis complicated by vasculitis

The therapeutic effect of prednisone combined with azathioprine was studied in 28 patients with rheumatoid vasculitis. Nine patients with severe systemic vasculitis were treated initially with 60 mg of prednisone and 2 mg/kg of body weight of azathioprine daily. Clinical signs of vasculitis decreased in all patients. Nineteen patients with only cutaneous vasculitis entered a randomized controlled study comparing prednisone plus azathioprine treatment vs continuation of various conventional antirheumatic drugs. Although measures of both vasculitis and arthritis activity improved to a greater degree in the patients treated with prednisone plus azathioprine in the first 3 months of therapy, no significant differences between the results of the two treatments were observed at the end of the follow-up period. Prednisone plus azathioprine treatment was associated with a low incidence of relapse of vasculitis, few serious complications, and a relatively low mortality. We conclude that the combination of prednisone and azathioprine is effective in the treatment of severe systemic rheumatoid vasculitis; rheumatoid vasculitis with only cutaneous manifestations has a relatively good prognosis, and there is probably no indication for therapy specifically directed at the vasculitic process.

Uptake and degradation of soluble aggregates of IgG by monocytes of patients with rheumatoid arthritis: relation to disease activity

Monocytes from patients with rheumatoid arthritis (RA) and rheumatoid vasculitis have a diminished ability to degrade soluble complexes of aggregated IgG in the absence (mediated by Fc receptors) as well as in the presence of complement (C) (mediated by (Fc + C) receptors). To investigate whether a relation exists between the receptor mediated degradation of aggregated IgG by adherent monocytes and disease activity a longitudinal study was performed in 79 patients with RA and rheumatoid vasculitis over a period of 16 months. Adherent monocytes were incubated in vitro with 125I labelled IgG aggregates of restricted size in the absence or presence of fresh serum and the percentage of catabolised IgG aggregates was measured. Cross sectionally the degradation of aggregated IgG by monocytes, mediated by Fc and (Fc + C) receptors, correlated significantly with disease activity as scored by the Ritchie articular index, the presence of extra-articular features, and circulating immune complexes. A high number of Fc receptors on monocytes correlated with diminished degradation, whereas high numbers of complement receptors 1 and 3 correlated with enhanced degradation of aggregated IgG mediated by both Fc and (Fc + C) receptors. The degradation of aggregated IgG by monocytes did not correlate with disease activity in individual patients followed up longitudinally. When patient groups were formed according to the results of longitudinal studies, however, degradation of aggregated IgG mediated by Fc and (Fc + C) receptors was significantly decreased in patients with rheumatoid vasculitis and in patients with active RA in comparison with patients with inactive RA and healthy controls. Patients with active RA and rheumatoid vasculitis also expressed significantly more Fc receptors and less complement receptors on the monocytes than patients with inactive RA. Drug treatment did not correlate with receptor expression or the degradation of aggregated IgG by monocytes either in cross sectional or longitudinal studies. It is concluded that in RA disease activity is related to receptor expression and the degradation of soluble immune aggregates by monocytes.

IgG autoantibodies against C1q are correlated with nephritis, hypocomplementemia, and dsDNA antibodies in systemic lupus erythematosus

We investigated the association between serum titers of IgG antibodies against C1q (C1qAb) and clinical and laboratory variables of disease activity in systemic lupus erythematosus (SLE). C1qAb were measured by ELISA in serum samples of 88 patients. Thirty patients (34%) had increased C1qAb titers. No correlation between C1qAb titers and a score for general disease activity was found. However, significant positive correlations were found between C1qAb titers and the presence of several clinical and laboratory variables of disease activity. These included nephritis, dermatitis, hypocomplementemia, antibodies against dsDNA, and circulating immune complexes. A negative correlation was found with neurological disease manifestations. The correlations between C1qAb titers and clinical features indicate that the pathogenetic role for C1qAb in certain disease manifestations of SLE deserves further study.

IgE-containing immune complexes in synovial fluid of patients with rheumatoid arthritis

The prevalence and composition of IgE-containing immune complexes in paired synovial fluid and serum of 42 patients with classical or definite rheumatoid arthritis were studied. IgE-containing immune complexes were found in 15/42 synovial fluids; 15 sera were also positive. The correlation between serum and synovial fluid complexed IgE levels was high (r = 0.77). The mean ratio of synovial fluid/serum levels was 1.96, i.e. significantly higher than 0.33, the synovial fluid/serum ratio for alpha-2-macroglobulin (molecular weight 820 kD), which was taken as high molecular weight control protein (p less than 0.0001). Apart from IgE in immune complex form, monomeric IgE was also significantly higher in synovial fluid compared to serum (ratio = 2.94). Other constituents which could be found in the immune complexes, i.e. anti-IgE antibodies, rheumatoid factors and anticollagen antibodies, were also higher in synovial fluid than predicted. Our results suggest intra-articular production of IgE-containing complexes in the synovial fluid, in addition to possible exudation of the complexes from the serum. These findings provide further evidence for the role of IgE-containing immune complexes in rheumatoid synovitis.

Cutaneous immunofluorescence in ankylosing spondylitis. Absence of correlation with disease activity

Biopsy specimens of normal skin from 43 patients with ankylosing spondylitis (AS) were studied for immunoglobulin and complement deposition by immunofluorescence and for histological abnormalities by light microscopy. The results were compared with those of 17 healthy subjects. Perivascular deposits of IgA, IgG, IgM and C3 were found in 26, 47, 56 and 33%, respectively, of the patients with AS. Skin deposits of IgA, IgG and C3 occurred significantly more frequently in patients with AS compared to healthy subjects. Perivascular mononuclear cell infiltration was found in only 8 (19%) of the patients with AS. The results of both immunofluorescence and histologic studies did not correlate with disease duration, disease activity, extraarticular features or the presence of circulating immune complexes. Our findings suggest a role of humoral immunopathological mechanisms in AS but also show that cutaneous immunofluorescence cannot serve as a marker of disease activity.

Humoral immunity and composition of immune complexes in patients with rheumatoid arthritis, with special reference to IgE-containing immune complexes

IgE-containing circulating immune complexes (IgE-CIC) were determined with a 2.5% PEG-precipitation assay in 98 patients with classical or definite rheumatoid arthritis (RA). Of the 45 IgE-CIC positive sera, only 4 had elevated total serum IgE. IgE-CIC positive patients had more active disease than patients without IgE-CIC, as determined by their more swollen joints and higher Ritchie indices (p less than 0.04 and 0.02, respectively). Apart from IgE, other immunoglobulin isotypes, rheumatoid factor (RF) of the IgG-, IgA- and IgM-classes, C3 and antinuclear antibodies could be demonstrated in the IgE-containing PEG-precipitates. IgE-RF could not be demonstrated in serum or in IgE-CIC. Anti-IgE of the IgM-class (IgMaIgE) were frequently found (28/45 patients) in the IgE-positive PEG-precipitates. All 14 patients positive for IgGaIgE in the IgE-CIC were also positive for IgMaIgE in the CIC. As in the serum, there was a good correlation in the CIC between the level of IgGaIgE and the level of IgMaIgE (r = 0.64). The correlation between the respective levels of IgGaIgE and IgMaIgE in serum and in CIC was high (r = 0.93 and 0.79, respectively). On the other hand, only 1 patient was positive for IgAaIgE in the IgE-CIC. We conclude that IgE and aIgE of the IgM- and IgG-classes are frequently present in the immune complex form in RA and that they are correlated with the clinical activity of arthritis.

Diminished clearance of soluble aggregates of human immunoglobulin G in patients with rheumatoid arthritis

Investigation of the capacity of the mononuclear phagocyte system to remove immune complexes from the circulation was performed by the administration of 125I-labelled aggregates of human immunoglobulin G (AIgG) to patients with seropositive rheumatoid arthritis and healthy volunteers. It was found that the rate at which AIgG disappeared from the circulation was significantly prolonged in patients with RA, t1/2 61 +/- 49 min, versus 26 +/- 8 min in healthy volunteers (p less than 0.01). We were not able to establish a correlation between the t1/2 of AIgG and immune complex levels in the circulation, or between t1/2 and articular disease activity (Ritchie index). The sites of removal of AIgG from the circulation were analysed by determining radioactivity levels detectable over liver, spleen and heart. No correlation was found between t1/2 and liver/spleen uptake ratios. We have demonstrated that the removal of AIgG from the circulation of patients with RA is abnormal, though the biological significance of this finding remains to be determined.

IgA containing immune complexes and hematuria in ankylosing spondylitis. A prospective longitudinal study

The occurrence of circulating immune complexes containing IgA (IgA-IC) was studied in groups of patients with ankylosing spondylitis (AS) selected for the presence or absence of hematuria. In studies done with 4 kinds of assays, IgA-IC were found more frequently and in higher titers in the 18 patients with AS with hematuria than in the 40 patients with AS without hematuria. Comparison of clinical indices of disease activity in these patient groups showed that the disease was more active in patients with AS with hematuria. Our findings confirm those made in a previous retrospective study on the relation between hematuria and circulating IgA-IC in AS and suggest that circulating IgA-IC play a role in the pathogenesis of hematuria in AS.

Relation of microscopic haematuria in ankylosing spondylitis to circulating IgA containing immune complexes

Ankylosing spondylitis (AS) is associated with IgA nephropathy. To study the pathogenetic mechanism of this association the presence of haematuria and circulating IgA containing immune complexes (IgA ICs) in 70 patients with AS was determined. In this retrospective study haematuria was present in 15 patients and 25 patients had IgA ICs. Circulating IgA ICs were shown in 9/15 (60%) of the patients with haematuria and in 16/55 (29%) of those without haematuria. These results suggest that IgA ICs in patients with ankylosing spondylitis have a pathogenetic role in causing IgA nephropathy.

Perivascular deposits of IgM in the skin of transplant recipients during active cytomegalovirus infections. Correlation with IgM rheumatoid factors and IgM immune complexes

Skin biopsies from 30 renal transplant patients were investigated for cellular infiltrates and deposits of IgM, IgA, IgG, C3, and C5-9 neoantigen. Granular perivascular deposits of IgM were detected in biopsies of 8 of 14 patients during active cytomegalovirus (CMV) infections and in none of 16 controls. In 5 biopsies, the IgM deposits were accompanied by little or no IgG, IgA, or C, while in 3 biopsies definite C3 deposits were present. One of the biopsies with C3 deposits also had C5-9 deposits and another had C5-9 and IgA deposits. Three monoclonal antibodies failed to detect early or late nuclear antigens of CMV in the deposits. These deposits were not associated with clinically evident manifestations of vasculitis. A strong correlation was found between IgM deposits in the skin and IgM circulating immune complexes (CIC) and also IgM rheumatoid factor (RF). The deposition of IgM was not more frequent in primary than in secondary CMV infections, and it did not correlate with the production of IgM antibodies that were specific for CMV antigens.

Membrane attack complex of complement in leukocytoclastic vasculitis of the skin. Presence and possible pathogenetic role

The presence of the membrane attack complex of complement (MAC) was studied by a two-step immunofluorescence method in 15 patients with leukocytoclastic vasculitis of the skin, using an antibody against MAC neoantigen. Perivascular deposits of MAC were present in 13 specimens of lesional skin and only two specimens of clinically uninvolved skin, suggesting a possible pathogenetic role for MAC in the development of a skin lesion. Control studies were performed on the clinically normal skin of 15 individuals (11 patients with various nonbullous skin diseases and four healthy volunteers) and on skin lesions of seven patients with inflammatory skin diseases. In the clinically normal skin of only one patient, perivascular deposits of MAC were detected. This patient had rheumatoid arthritis and a cutaneous eruption due to the administration of aurothioglucose. We conclude that the activation of the terminal components of the complement system may play an important role in the formation of lesions in leukocytoclastic vasculitis of the skin, but is not an indispensable condition.

Diminished uptake and degradation of soluble aggregates of IgG by monocytes of patients with rheumatoid arthritis and vasculitis

We investigated the capacity of monocytes to degrade soluble aggregates of IgG in vitro in the absence (Fc receptor [FcR] mediated) and presence of complement (FcR and C3 receptor mediated). Adherent monocytes from 33 patients with active rheumatoid arthritis (RA) and rheumatoid vasculitis, 32 patients with inactive RA alone, and 20 healthy controls were incubated with 125I-aggregated IgG (125I-AIgG) of restricted size with or without fresh serum. Normal monocytes degraded 9.8% of 125I-AIgG via FcR alone and the presence of complement enhanced degradation to 2.7%. Degradation of 125I-AIgG via FcR from patients without active RA suggested a depressed function of FcR. The maximal amount of 125I-AIgG which was bound by monocytes from patients with inactive and active RA, however, was increased compared to normals, suggesting a defect in intracellular processing in patients with RA. The degradation of 125I-AIgG in the presence of complement was also significantly depressed for both groups of patients. The monocytes from the patients also had decreased numbers of C3b receptors (CR1). Since CR1 are involved in the enhanced uptake of immune complexes bearing complement, the depressed capacity of monocytes from patients with RA to degrade 125I-AIgG in vitro may be caused both by a diminished uptake as well as a diminished capacity to degrade soluble AIgG.

Association of rheumatoid factors in renal transplant recipients with cytomegalovirus infection and not with rejection

Because rheumatoid factors (RF) were detected in the circulation of the majority of early renal transplant recipients and could be eluted from rejected transplants, RF were hypothesized to be related to antibody responses to the histoincompatible graft. The possibility that RF production might have been related to infection and not rejection has not been considered previously. Therefore, we investigated serial serum samples from 147 adult renal transplant recipients for RF with latex agglutination and radioimmune assays. RF were detected in the sera of 32 patients, 30 of whom had coincident active cytomegalovirus (CMV) infections. Another 45 patients with active CMV infections did not have detectable circulating RF. In contrast, of 74 patients who experienced a total of 103 treated reversible or irreversible rejection episodes in the absence of evidence of active CMV infections, only 2 patients produced RF during their rejection episodes. Nine of the patients who did not produce RF during a rejection episode subsequently produced RF during a later CMV infection. These data indicate that RF production in renal transplant recipients is associated with CMV infection and not rejection. Moreover, RF production was found to be more frequently associated with primary and severe CMV infections than with secondary or milder CMV infections. RF production was not more frequent in patients who were HLA-DR-4-positive., older, or female, characteristics that have been associated with RF production in other populations. All of the sera with detectable RF contained IgM antibodies that were directed to the Fc portion of human IgG, and about half contained additional IgM antibodies directed to Fab. Thus CMV infections may be the stimuli for the IgM anti-Fab antibodies that have been reported in pretransplant serum samples. Eleven patients produced IgG or IgA RF in addition to IgM RF during CMV infections.

Mononuclear phagocyte system Fc-receptor function in patients with seropositive rheumatoid arthritis

Mononuclear phagocyte system (MPS) Fc-receptor function in 20 patients with seropositive rheumatoid arthritis (RA) was investigated using radiolabelled autologous erythrocytes coated with an average of 5,800 molecules of anti-rhesus IgG (E. IgG). Although clearance times (T1/2) of E. IgG tended to be longer in RA patients than those in healthy controls (46 +/- 6 min vs 38 +/- 5 min, mean +/- s.e.m., P = 0.38), this did not reach statistical significance. Liver spleen uptake ratios (LS ratios) were increased in patients with RA (13/100 +/- 1/100 vs 7/100 +/- 1/100, P less than 0.05). There was no correlation of T1/2 or LS ratios with articular disease activity, vasculitis, ESR, IgM containing immune complex levels or Clq-binding immune complex levels. Although Clq-binding immune complex levels were significantly higher in patients with vasculitis than in those without (P less than 0.01), T1/2 and LS ratios did not differ in these two groups of patients. The T1/2 and LS ratios of E.IgG did not reveal a defect in MPS Fc-receptor function and did not correlate with one of the above-mentioned clinical and immunological parameters. We suggest that in order to establish a possible defect in Fc-receptor function correlating with disease activity and immune complex levels in RA patients, soluble immune complexes or immune complex-like material should be used as probes.

Immunopathological abnormalities in the normal skin of patients with rheumatoid arthritis in relation to clinical and serological findings: a one year follow up study

Fifty two patients with seropositive rheumatoid arthritis (RA) were studied over a period of one year to investigate possible relationships among changes of circulating immune complexes (CIC), deposits of immunoglobulins and complement around the cutaneous blood vessels, clinical activity of the disease, and the presence of extra-articular manifestations (EAM). The presence or absence of IgM and C3 in and around the cutaneous blood vessels correlated significantly with the presence or absence of extra-articular features in cross sectional and longitudinal studies. Patients with evidence of these cutaneous immune deposits also had a greater prevalence of CIC as determined by the Clq binding assay (ClqBA) or polyethylene glycol (PEG) assay for IC containing IgM (IgM IC). Although the degree of perivascular mononuclear cell infiltration around the blood vessels in the papillary dermis was related to the patients' clinical state at the initial assessment, it did not correlate with the later changes in the activity of the joint disease or the occurrence of EAM. Thus the deposition of immunoglobulin or complement, or both, seems to be independent of cellular infiltration. The meaning of these cellular infiltrates is not yet fully understood. Our study has shown that many patients with RA who appeared to have only joint disease in fact had subclinical systemic disease as reflected by a positive skin biopsy or CIC. Moreover, the disappearance of IgM deposits from the skin correlated with the disappearance of EAM and improvement of joint disease.

Coronary arteritis complicating rheumatoid arthritis

The case is described of a patient with rheumatoid arthritis (RA) who developed heart failure and vasculitis and died of a myocardial infarction. Autopsy showed vasculitis of several major epicardial coronary arteries. Coronary arteritis in a patient with RA is seldom diagnosed during their lifetime but should be suspected when such a patient develops ischaemic heart disease.

Spontaneous immunoglobulin synthesis by peripheral mononuclear cells in active rheumatoid arthritis

Spontaneous production of immunoglobulins (Igs) by peripheral blood mononuclear cells (PBMC) in vitro was investigated to assess B cell activity in a group of 24 patients with rheumatoid arthritis (RA) with or without active joint disease and with or without rheumatoid vasculitis (RV) at the time of study. PBMC of patients with active arthritis (Ritchie index above 16) produced significantly more IgG and IgA than those of patients with inactive joint disease or those of 12 healthy controls. Enhanced production of IgG was found mainly among RA patients with concomitant RV, whereas markedly enhanced IgA production could also be found in patients without symptoms of RV. IgM production was only enhanced in two patients who had both active arthritis and RV. High production of IgG and IgA was probably due to increased numbers of Ig-secreting cells among freshly isolated PBMC, since the concentrations of Ig produced in vitro rose steadily, starting on day 0 and persisting throughout the entire culture period. Moreover, IgG and IgA concentrations measured after 7 days of culture showed significant correlations with the numbers of IgG- and IgA-containing plasma cells in PBMC on day 0. Comparison of the spontaneous production of Igs by PBMC with the levels of circulating immune complexes (CIC), showed that CIC levels were also significantly higher in active arthritis and in RV, but that there was no correlation between the CIC levels in individual patients and Ig production by their PBMC in vitro.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum immune complexes containing IgA appear to predict erosive arthritis in a longitudinal study in rheumatoid arthritis

Fifty seven patients with rheumatoid arthritis (RA) were studied longitudinally, and the presence of rheumatoid factor (RF) and various types of immune complexes (IC) was correlated with joint activity and the presence of extra-articular features (EAF). In a cross sectional study it was found that the levels of circulating IC and RF correlated significantly with joint disease activity and the presence of EAF. Longitudinally, levels of IC measured by the C1q binding activity and IC containing IgG and IgM correlated significantly with fluctuations in joint disease activity, whereas IC containing IgG and IgA correlated with the occurrence of EAF. RF and IC levels, however, did not predict the clinical course of the disease. IC containing C3 and C4 were found infrequently and were only present in patients with active rheumatoid vasculitis (RV). The continuous presence of these IC appeared to be linked to the recurrence of vasculitis, irrespective of treatment. Significantly more erosions of hands and feet were found after one year follow up in those RA patients who presented early (disease duration less than one year) who initially had a raised serum IgA IC level (r = 0.72; p less than 0.005).

Immunogenetic heterogeneity of rheumatoid arthritis

Association of HLA-DR4/Dw4 with rheumatoid arthritis (RA) is well established, but conflicting data exist on a possible association with the severity of the disease, including its extra-articular manifestations. In order to investigate whether a subgroup of RA is preferentially associated with DR4, HLA typing was performed in two groups of patients with severe extra-articular manifestations (Felty's syndrome and histologically proved leucocytoclastic vasculitis), patients with severe joint destruction (seropositive and seronegative), a group with only mild joint destruction, and in healthy controls. The frequency of HLA-DR4 was significantly raised in all patient groups compared with that in healthy controls. The two groups with severe extra-articular manifestations, however, both had a DR4 frequency of 92%, which was significantly (p = 0.002) higher than the 62.7% found in the remaining patients. No significant differences were observed between severe or mild joint destruction and seropositivity or seronegativity in the groups without the above-mentioned extra-articular manifestations. From these data we concluded that DR4 is preferentially associated with severe extra-articular disease manifestations of RA. This observation provides an immunogenetic basis for the disease heterogeneity and for the immunological analogy between RA and leprosy.

Genetic heterogeneity of rheumatoid arthritis

In a population survey in The Netherlands we investigated 6584 individuals for the presence of rheumatoid diseases and their determinants. We observed no overall association of rheumatoid arthritis (RA) with HLA-DR4 or GM. This result is in contrast to the marked association of HLA-DR4 with RA found in studies based mainly on hospital rheumatology clinics. The findings thus suggest a genetic basis for the disease heterogeneity. A study of 16 multicase RA families showed a co-segregation of RA with the DR4 carrying haplotype from the unaffected parent, whereas the non-DR4 haplotype was preferentially segregating to the healthy siblings (p = 0.001). These data suggest that HLA-DR4 is associated with disease susceptibility rather than with a disease modifying factor. In a further attempt to define a genetic basis for disease heterogeneity we compared five well-defined clinical groups of patients with RA. Although the frequency of HLA-DR4 was significantly elevated in all patient groups as compared to healthy controls, we observed a preferential association of HLA-DR4 with severe extra-articular manifestations as compared to patients without extra-articular manifestations (p = 0.002). These results provide an immunogenetical basis for the disease heterogeneity observed in RA and further extend the immunological analogy between RA and leprosy.

Comparison of immune complexes and complement components in arterial and venous blood of patients with rheumatoid arthritis

Immune complexes (IC) are frequently found in the venous blood and synovial fluid of patients with rheumatoid arthritis (RA). Although IC are claimed to have a pathogenetic role in RA, there is generally poor correlation between different IC tests and between individual tests and clinical features. We have therefore sought differences in the levels of IC detected by the Clq binding assay (ClqBA) and the indirect polymorphonuclear phagocytosis test (IPPT) in the arterial and venous blood of 16 patients with RA and 6 disease control subjects to determine which IC are pathogenetically important. Complement components, IgA, IgG, and rheumatoid factor were also measured. Eight of 10 patients with clinically active RA had higher ClqBA results in arterial blood while IgA IC in the IPPT and most complement components were higher in venous blood. No such differences were seen in patients with inactive RA or controls. These results suggest that IC other than those containing IgA are not formed in limb tissues including the synovium and may explain the variable results previously seen in patients with RA.

IgE deposition in normal skin of patients with rheumatoid arthritis in relation to clinical and laboratory findings

Biopsy specimens from apparently normal skin of 28 patients with classical or definite rheumatoid arthritis (RA) were examined for the presence of IgE deposition by a direct immunofluorescence technique. IgE deposition was found in 12 patients (43%) and in none of the 10 controls. This deposition was mainly localised on mast cells, and in three patients perivascular IgE staining was also noted. The skin from nine of the 12 patients also showed deposition of IgM and complement C3 or C4 factor, or both. All 12 patients with skin IgE deposition had raised levels of IgM rheumatoid factor (RF) in the serum. Nine of these also had IgE RF. IgE-containing circulating immune complexes (IgE CIC), raised serum IgE levels, and extra-articular (EA) manifestations were present in respectively 10, nine, and eight skin IgE positive patients. It is suggested that IgE and IgE CIC may be involved in the pathogenesis of RA and its EA manifestations.

Rheumatoid factors in rheumatoid arthritis and vasculitis

To study the occurrence of rheumatoid factors (RF) in relation to the activity of rheumatoid arthritis and the occurrence of vasculitis, RF of IgM, IgA, and IgG classes were measured in sera from 35 patients with definite or classic rheumatoid arthritis (RA) using ELISA. For 26 patients, the RF levels were studied longitudinally and compared with changes in the articular index. Although IgM RF was occasionally found in patients without RA, IgA and/or IgG RF were almost exclusively associated with RA. The titers of IgM, IgA, and IgG RF were significantly higher in sera from patients with clinically diagnosed rheumatoid vasculitis than in sera from patients without vasculitis. No significant correlation between changes in the articular index and changes in titer of any class-specific RF could be found for the group of RA patients as a whole. However, in individual patients, increases or decreases in IgM and IgG RF titer were significantly correlated with an increase or decrease in the articular index.

Rapidly progressive glomerulonephritis with glomerular crescent formation in rheumatoid arthritis

Systemic vasculitis is a well-known complication of rheumatoid arthritis (RA). Rapidly progressive glomerulonephritis is commonly associated with vasculitis syndromes but rarely found in RA. This report describes two RA patients with complicating systemic vasculitis who developed rapidly progressive glomerulonephritis with glomerular crescent formation. One recovered after treatment with corticosteroids and cytostatic drugs and the other died of severe systemic vasculitis despite similar therapy.

IgA containing immune complexes in rheumatoid vasculitis and in active rheumatoid disease

Serum and synovial fluid (SF) from 68 patients with rheumatoid arthritis (RA) were studied for the presence of immune complexes (IC) and the results correlated with extraarticular features and/or disease activity. IC were measured by the 125I Clq binding assay (ClqBA) and with one detecting IgG, IgA, C3 or C4 in IC. Disease activity correlated significantly with IgG or IgA containing and Clq binding IC. The IgA containing IC were found only in 25% of the patients, including all but one case of rheumatoid vasculitis, but otherwise only in seropositive active RA. C3 and C4 IC did not correlated with disease activity, seropositivity or vasculitis. IC in serum did not correlate with SF levels, but C4 containing IC were more frequent in SF (60%) than in serum (30%). Thus serum IC did not reflect SF levels. Patients with vasculitis showed more IC in the sera than in SF.

Systemic lupus erythematosus and invasive thymoma: report of two cases

Two cases of invasive thymoma in patients with systemic lupus erythematosus (SLE) are described. In both instances the suspected diagnosis of a mediastinal tumour proved difficult to confirm. Neither surgical removal of the thymoma in one case nor irradiation in the other had any apparent clinical or serological effect on the course of the SLE. Both patients subsequently suffered from respiratory problems and the distinction between recurrent tumour and pulmonary involvement by SLE proved difficult. One patient had a good response, however, to pulse methylprednisolone, but the other later developed recurrence of tumour and died of Pneumocystis carinii infection following cytotoxic therapy three years after discovery of the tumour.

Rheumatoid arthritis--the clinical significance of histo- and immunopathological abnormalities in normal skin

Biopsies of normal skin from 64 patients with rheumatoid arthritis (RA) were studied for histological abnormalities in dermal blood vessels. Thirty percent of patients had a moderate or dense infiltrate of mononuclear cells (predominantly T lymphocytes) around the vessel walls not seen in controls. This infiltrate correlated with disease activity and the presence of extraarticular manifestations. Vascular deposits of IgM often with C3 were seen in seropositive patients only and correlated with the amount of cellular infiltrate. No Ig and C deposits were seen in biopsies of seronegative patients and healthy controls. Apart from IgM and C3, IgG and/or IgA were found perivascularly in the areas of skin with leukocytoclastic vasculitis, indicating participation of other classes of immunoglobulins in immune complexes. The histological and/or immunopathological features that we found in uninvolved skin may serve as markers of disease activity and extraarticular manifestations.

The detection of circulating immune complexes containing immunoglobulin G

An immune complex assay using radiolabelled immunospecific antibodies against human IgG and polyethylene glycol precipitation (IgG-PEG assay) is described. The material reactive in this assay was evaluated using aggregated immunoglobulins, immune complexes prepared in vitro, sera of patients with a variety of disorders and normal human serum. Sucrose density gradient ultracentrifugation showed that only large-sized immune complexes (greater than 25 S) were detected. Comparison of the results of the IgG-PEG assay with those of the C1q binding assay showed a highly significant positive correlation (p less than 0.001). It was found that rheumatoid factors do not influence the results of the IgG-PEG assay. The method described in this study detects specifically immune complexes containing IgG and might be extended to the detection of other constituents of circulating immune complexes.