Visualisation of Kiss1 Neurone Distribution Using a Kiss1-CRE Transgenic Mouse

Kisspeptin neuropeptides are encoded by the Kiss1 gene and play a critical role in the regulation of the mammalian reproductive axis. Kiss1 neurones are found in two locations in the rodent hypothalamus: one in the arcuate nucleus (ARC) and another in the RP3V region, which includes the anteroventral periventricular nucleus (AVPV). Detailed mapping of the fibre distribution of Kiss1 neurones will help with our understanding of the action of these neurones in other regions of the brain. We have generated a transgenic mouse in which the Kiss1 coding region is disrupted by a CRE-GFP transgene so that expression of the CRE recombinase protein is driven from the Kiss1 promoter. As expected, mutant mice of both sexes are sterile with hypogonadotrophic hypogonadism and do not show the normal rise in luteinising hormone after gonadectomy. Mutant female mice do not develop mature Graafian follicles or form corpora lutea consistent with ovulatory failure. Mutant male mice have low blood testosterone levels and impaired spermatogenesis beyond the meiosis stage. Breeding Kiss-CRE heterozygous mice with CRE-activated tdTomato reporter mice allows fluorescence visualisation of Kiss1 neurones in brain slices. Approximately 80-90% of tdTomato positive neurones in the ARC were co-labelled with kisspeptin and expression of tdTomato in the AVPV region was sexually dimorphic, with higher expression in females than males. A small number of tdTomato-labelled neurones was also found in other locations, including the lateral septum, the anterodorsal preoptic nucleus, the amygdala, the dorsomedial and ventromedial hypothalamic nuclei, the periaquaductal grey, and the mammillary nucleus. Three dimensional visualisation of Kiss1 neurones and fibres by CLARITY processing of whole brains showed an increase in ARC expression during puberty and higher numbers of Kiss1 neurones in the caudal region of the ARC compared to the rostral region. ARC Kiss1 neurones sent fibre projections to several hypothalamic regions, including rostrally to the periventricular and pre-optic areas and to the lateral hypothalamus.

Cytidine deaminase may be a useful marker in differentiating elderly onset rheumatoid arthritis from polymyalgia rheumatica/giant cell arteritis

OBJECTIVE

PMR/GCA is a relatively common inflammatory disease in the elderly population. Clinical differentiation from a polymyalgic onset of RA in the elderly can be difficult. We have examined in a preliminary study the hypothesis that serum cytidine deaminase (CD) may be valuable in the differential diagnosis of these disorders.

METHODS

CD was assayed by a spectrophotometric method in 20 patients with active PMR/GCA, both before and after treatment with prednisolone, and was compared with serum CD levels in 20 patients with active RA.

RESULTS

CD levels were within the normal range (< 10 units/ml) in 36 of the 40 samples from patients with PMR/GCA: The mean CD in pre-treatment samples was 8.64 units/ml (SD 7.09), and after treatment 7.20 units/ml (SD 3.53). The mean serum CD in the RA patients was 21.33 units/ml (SD 8.94), significantly higher than in PMR/GCA (p < 0.0001).

CONCLUSION

Serum CD levels were significantly different when proven PMR was compared with established, long-standing RA. Therefore, serum CD could be a useful diagnostic marker for differentiating PMR/GCA from active RA in older patients.

The clinical and laboratory course of polymyalgia rheumatica/giant cell arteritis after the first two months of treatment

OBJECTIVES

To examine the clinical course of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) in a prospective study, after the initial two months.

METHODS

Seventy four patients with PMR/GCA were followed for a median of 60 weeks. Detailed clinical and laboratory records were made on each visit.

RESULTS

Twenty per cent of patients with PMR developed GCA and 24% of patients with GCA developed PMR from the onset of symptoms. After two months, most patients experienced at least one relapse. Relapses and persistence of abnormal symptoms and signs were most common in patients with both PMR and GCA and least common in those with GCA alone. Relapses were most common in the first year and 54% occurred in association with steroid reduction. Major complications were rare. Laboratory parameters and temporal artery histology were not helpful in predicting relapse. Only 24% of patients were able to stop steroid treatment after two years.

CONCLUSIONS

Clinicians should consider more frequent review in patients at times of steroid reduction and especially within the first six months of treatment.

Laboratory investigations including liver in polymyalgia rheumatica/giant cell arteritis

The most useful investigation in supporting the clinical diagnosis of PMR/GCA is elevation of the ESR or viscosity. Acute phase proteins, particularly C-reactive protein, are also elevated but in most cases are not more helpful than the ESR in either diagnosis or follow-up. The definitive investigation is the demonstration of giant cell arteritis histologically, usually from temporal artery biopsy. The classical changes are internal elastic lamina fragmentation and destruction, with marked intimal thickening and an inflammatory infiltrate in the vessel wall with giant cells. Changes of healed arteritis can be distinguished from ageing changes and can therefore confirm the diagnosis. Positive biopsies are found in about 70% of patients with clinical GCA but are unlikely to be helpful in pure PMR. Elevation of alkaline phosphatase of liver origin is seen in one-third to half of patients with both PMR and GCA. Abnormal tracer uptake has been reported in radionuclide scans with a variety of non-specific abnormalities on liver biopsy. Promising developments include measurement of CD8+ lymphocytes and interleukins.

Treatment of polymyalgia rheumatica/giant cell arteritis

Corticosteroids control arteritis in GCA and suppress polymyalgic symptoms within days of starting treatment. PMR patients can be treated with approximately 15 mg prednisolone/day, reducing the dose to 7.5-10 mg by 8 weeks. GCA is normally controlled on 40 mg prednisolone/day, although patients with persistent visual symptoms may need 60-80 mg. Slow reduction to about 20 mg by 8 weeks should minimize relapses. For both PMR and GCA a maintenance dose of 7.5 mg after 6-9 months should be enough. Steroid withdrawal is possible within 2 years of starting treatment, although some will need 4 years or more. Relapse should be defined clinically; the ESR is the most useful laboratory parameter. Steroid side-effects can be minimized by using low doses of prednisolone whenever possible and azathioprine may be used as a steroid-sparing agent.

Humanized monoclonal antibody treatment in rheumatoid arthritis

A 41-year-old woman with active, seropositive erosive rheumatoid arthritis was treated with the humanized monoclonal antibody Campath 1H. She had not responded or developed side effects to myocrisin, sulfasalazine and penicillamine, and had not responded to inpatient bedrest and physiotherapy. There was a rapid clinical improvement within 24 hours of infusion, which was maintained for about 12-14 weeks after the infusion. The lymphocyte count was suppressed for 7 months after treatment. There were no significant side effects during or after treatment. No anti-Campath 1H response was detected. This preliminary study suggests humanized monoclonal antibody therapy may be of value in the treatment of rheumatoid arthritis.

Liver scan abnormalities in polymyalgia rheumatica/giant cell arteritis

Liver involvement in polymyalgia rheumatica/giant cell arteritis (PMR/GCA) before treatment and during follow-up of up to 3 1/2 years was assessed in 74 patients clinically, with liver function tests, isotope scans and blood flow studies. Twenty-seven patients had elevated alkaline phosphatase levels which fell to normal after 2.6 weeks treatment. Both PMR and GCA patients were affected, the latter more commonly. Isotope scans were abnormal in 7 of 29 patients and remained abnormal on follow-up. The arterial fraction of hepatic flow was significantly reduced in GCA patients in comparison with those having PMR only; values became normal after treatment. These abnormalities may be due to hepatic arteritis.

Salmonella enteritidis causing joint sepsis

A 22-year-old male taking dexamethasone following resection of a medulloblastoma developed an acutely painful swollen knee from which salmonella enteritidis was cultured. He had no gastrointestinal symptoms; one stool culture was positive. Active metalloproteinases without inhibitors were detected in the synovial fluid, a characteristic finding in septic joints. S. enteritidis infecting joints is extremely rare despite being the second most frequent salmonella species after S. typhimurium causing infections in man. The recent findings of S. enteritidis in eggs, and poultry points to one more source of infection. Immunosuppression is likely to facilitate infection.

Rarity of synovitis in polymyalgia rheumatica

The joints of 56 patients with polymyalgia rheumatica were examined for evidence of inflammatory synovitis. x Rays, isotope scans, and thermography supplemented clinical examination. Control sternoclavicular joints were examined at necropsy. Peripheral and axial synovitis were uncommon and the results contrast with the findings of several recent studies.

Synovial fluids from infected joints contain metalloproteinase--tissue inhibitor of metalloproteinase (TIMP) complexes

Samples of synovial fluids aspirated from patients with septic arthritis prior to the commencement of any treatment contained active metalloproteinases but no proteinase inhibitory activity. We therefore assayed these samples for proteinase-inhibitor complexes. Although no biologically active alpha 2-macroglobulin or tissue inhibitor of metalloproteinase (TIMP) was present in the fluids, immunoassay of the samples clearly showed that high molecular weight proteinase-TIMP complexes were present. It is proposed that high levels of active metalloproteinases are released from neutrophils into septic synovial fluids and that these proteinases complex all the available TIMP, forming metalloproteinase-TIMP complexes.

Treatment of polymyalgia rheumatica and giant cell arteritis. II. Relation between steroid dose and steroid associated side effects

In a prospective study of 74 patients and a retrospective study of 35 patients with polymyalgia rheumatica/giant cell arteritis steroid related side effects occurred in at least one third of patients, and in two thirds if weight gain was included. Side effects were significantly related to an initial prednisolone dose of more than 30 mg and to the cumulative prednisolone dose. Patients taking a mean daily dose of 5 mg prednisolone or less were significantly less likely to develop side effects.

Erythrocyte sedimentation rate and C reactive protein in the assessment of polymyalgia rheumatica/giant cell arteritis on presentation and during follow up

The erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) were measured in 74 patients with polymyalgia rheumatica (PMR)/giant cell arteritis (GCA) on presentation, in the first month of treatment, and at long term follow up (up to 177 weeks). Before treatment the ESR was raised (greater than 30 mm/h) in all cases and the CRP was raised (greater than 6 mg/l) in 49/55 cases. The ESR was a better indicator of clinical disease activity except in patients who felt completely well at week 1. 'False positive' increases of ESR or CRP were rare. During relapses ESR was normal in 37/77 (48%) of cases and CRP in 41/73 (56%). It is suggested that ESR is the most useful laboratory parameter in assessing PMR/GCA.

Treatment of polymyalgia rheumatica and giant cell arteritis. I. Steroid regimens in the first two months

Thirty nine patients with polymyalgia rheumatica (PMR) and 35 with giant cell arteritis (GCA) were treated with high or low dose steroid regimens in a prospective study of the first two months of treatment. Patients with PMR needed 15-20 mg prednisolone initially; 13/20 (65%) relapsed on an initial dose of 10 mg/day. All but two patients with GCA were successfully treated with 40 mg/day prednisolone initially but relapsed on a reduction to 20 mg/day. One patient with GCA receiving 30 mg/day relapsed after four weeks. Six patients with PMR developed GCA during the first two months and required an increased prednisolone dose to control symptoms. The erythrocyte sedimentation rate or C reactive protein did not predict relapse.

Beneficial effect of monoclonal antibody to interleukin 2 receptor on activated T cells in rheumatoid arthritis

Campath 6, a rat IgG2b monoclonal antibody to the interleukin 2 receptor on activated T cells, was used to treat three patients with active rheumatoid arthritis unresponsive to conventional treatment. Two patients had an excellent response for about three months. There were no significant side effects. The results suggest that activated T cells are of importance in the pathogenesis of rheumatoid arthritis. Although infusions of rat monoclonal antibodies could not be repeated because of the risk of sensitisation, the development of humanised monoclonal antibodies targeted against specific T cell sets would allow repeated courses of treatment to be given.

Antibodies to intermediate filaments in polymyalgia rheumatica and giant cell arteritis: a sequential study

Serum specimens from 35 patients with polymyalgia rheumatica and giant cell arteritis (PMR/GCA) were obtained sequentially at variable time intervals up to a year from onset of disease. These were tested for antibodies to intermediate filaments by indirect immunofluorescence using HEp2 cells as substrate. Twenty four of 35 (68%) patients' sera at onset of disease were positive at an anti-intermediate filament antibody (AIFA) titre of greater than 1/40 compared with three outs of 19 (15%) control sera. AIFA were predominantly of IgM class, and there was no significant change in AIFA titres on follow up despite clinical remission of disease.

Isolation and analysis of immune complexes from sera of patients with polymyalgia rheumatica and giant cell arteritis

Serum samples were obtained from patients with polymyalgia rheumatica (PMR: n = 10) or giant cell arteritis (GCA; n = 7), or both. Samples were taken either before treatment or within one week of starting prednisolone. Immune complexes (IC) were concentrated by polyethylene glycol (PEG) precipitation then purified with either IgG anti-C1q-Sepharose or IgG anti-C3c-Sepharose. Complex components were separated by sodium dodecyl sulphate (SDS) gradient polyacrylamide gel electrophoresis then transferred to nitrocellulose by Western blotting. Identification of proteins was carried out using specific antisera. All the IC contained IgM (mu chain), some contained IgA (alpha chain), and IgG (gamma chain). C1r, C1s, C1q, C3, C4, and C reactive protein (CRP), where tested, were found in most but not all IC. The occurrence of properdin, factor B, alpha 2 macroglobulin (alpha 2M), factor H (beta 1H), C1 esterase inhibitor, and C4 binding protein was also investigated. Immune complexes in PMR and GCA differed from those previously characterized in rheumatoid arthritis (RA)1 purified by anti-C1q-Sepharose which contained immunoglobulins and C1q only. No properdin or factor B were detected in RA IC purified with either anti-C1q-Sepharose or anti-C3c-Sepharose.

Giant cell arteritis of myometrial and axillary arteries and polymyalgia rheumatica

Giant cell arteritis (GCA) of the uterus and adnexa is extremely rare--only nine cases have been reported. We report a further case, in which the patient was found to have GCA of the myometrial arteries on routine hysterectomy. She then developed another rare manifestation of GCA, involvement of the axillary arteries causing arm claudication and chronically ischaemic hands.

Assessment of inflammation in the rheumatoid knee joint: correlation between clinical, radioisotopic, and thermographic methods

Standard clinical methods of assessing joint inflammation are being supplemented increasingly by radioisotopic and thermographic studies. However, the correlation between these different methods has not been firmly established. In the quantification of synovitis by infrared thermography we have shown that the heat distribution index (HDI) based on thermal pattern is more reliable and is less affected by diurnal variations in joint temperature than the commonly used thermographic index, which is based on average skin temperature values. In 20 patients with rheumatoid arthritis whose knees were being treated with intra-articular steroid we obtained 184 serial paired observations over a period of 24 weeks for clinical assessment, HDI, and 99mTc pertechnetate uptake. We found significant correlations (p less than 0.001) between the three methods of assessment (except for pain and HDI (p = 0.116)).

Polymyalgia rheumatica/giant cell arteritis in a Cambridge general practice

The aim of this study was to establish the incidence and prevalence of polymyalgia rheumatica/giant cell arteritis in general practice. Patients with this disorder, whether previously diagnosed or not, were ascertained by using a questionnaire administered by interview, and all received full clinical and laboratory assessment. A total of 579 patients aged 65 and over was seen, and 19 (33/1000) had been diagnosed or developed symptoms within the previous eight years. Thus the calculated annual incidence in those aged 65 and over was about 4/1000. The figures from this first large scale study of polymyalgia rheumatica/giant cell arteritis in general practice are much higher than those from studies carried out in hospital. The questionnaire was effective in both identifying known cases of polymyalgia rheumatica/giant cell arteritis and detecting new cases. As this is a treatable disorder, it is important that doctors become aware of how common it is in elderly people.

Prostaglandin E1 vasospastic disease and thermography

This is the first study to show a quantitative thermographic difference between patients with Raynaud's syndrome and normal controls after cold stress testing. An improved thermographic response to cold stress testing after treatment of Raynaud's syndrome with PGE1 has also been shown for the first time. Discriminant analysis of the change in temperature of a finger after cold stress, and the mean thermal gradient along the finger during rewarming, clearly separated patients from controls. After treatment with PGE1 the patients' discriminant values moved into the normal range. Symptomatic improvement after PGE1 correlated well with thermographic improvement, and both persisted for up to 12 weeks.

Yttrium-90 therapy and 99MTc pertechnetate knee uptake measurements in the management of rheumatoid arthritis

Twenty-eight knees with chronic arthritis and effusion were treated with intra-articular 90Y. Synovial activity was assessed by measuring 99mTc pertechnetate uptake. There was a significant difference in uptake between controls and patients. Those who had a good response to 90Y (15 patients) showed a significant decrease in uptake, not seen in those who failed to respond. The pattern of 90Y distribution was examined and appeared to correspond to areas of increased synovial activity; these patterns and their significance have not been previously reported. Factors which could help to predict response to 90Y are discussed.