Frequency of triggering bacteria in patients with reactive arthritis and undifferentiated oligoarthritis and the relative importance of the tests used for diagnosis.

OBJECTIVE: Reactive arthritis (ReA) triggered by Chlamydia trachomatis or enteric bacteria such as yersinia, salmonella, Campylobacter jejuni, or shigella is an important differential diagnosis in patients presenting with the clinical picture of an undifferentiated oligoarthritis (UOA). This study was undertaken to evaluate the best diagnostic approach. PATIENTS AND METHODS: 52 patients with ReA, defined by arthritis and a symptomatic preceding infection of the gut or the urogenital tract, and 74 patients with possible ReA, defined by oligoarthritis without a preceding symptomatic infection and after exclusion of other diagnoses (UOA), were studied. The following diagnostic tests were applied for the identification of the triggering bacterium: for yersinia induced ReA-stool culture, enzyme immunoassay (EIA), and Widal's agglutination test for detection of antibodies to yersinia; for salmonella or campylobacter induced ReA-stool culture, EIA for the detection of antibodies to salmonella and Campylobacter jejuni; for infections with shigella-stool culture; for infections with Chlamydia trachomatis-culture of the urogenital tract, microimmunofluorescence and immunoperoxidase assay for the detection of antibodies to Chlamydia trachomatis. RESULTS: A causative pathogen was identified in 29/52 (56%) of all patients with ReA. In 17 (52%) of the patients with enteric ReA one of the enteric bacteria was identified: salmonella in 11/33 (33%) and yersinia in 6/33 (18%). Chlamydia trachomatis was the causative pathogen in 12/19 (63%) of the patients with urogenic ReA. In patients with the clinical picture of UOA a specific triggering bacterium was also identified in 35/74 (47%) patients: yersinia in 14/74 (19%), salmonella in 9/74 (12%), and Chlamydia trachomatis in 12/74 (16%). CONCLUSIONS: Chlamydia trachomatis, yersinia, and salmonella can be identified as the causative pathogen in about 50% of patients with probable or possible ReA if the appropriate tests are used.

Construction of urease-negative mutants of Yersinia enterocolitica serotypes O:3 and o:8: role of urease in virulence and arthritogenicity.

Yersinia enterocolitica serotype O:3 and O:8 urease-negative mutants unable to express the 19-kDa beta subunit of urease were constructed and tested for virulence and arthritogenicity. Our results indicate that urease is needed for full virulence in oral infections and that it is not an arthritogenic factor in the rat model.

No benefit of long-term ciprofloxacin treatment in patients with reactive arthritis and undifferentiated oligoarthritis: a three-month, multicenter, double-blind, randomized, placebo-controlled study.

OBJECTIVE: To investigate the effect of long-term antibiotic treatment in patients with reactive arthritis (ReA) and undifferentiated oligoarthritis. METHODS: One hundred twenty-six patients were treated with ciprofloxacin (500 mg twice a day) or placebo for 3 months, in a double-blind, randomized study. Of these patients, 104 (48 treated with ciprofloxacin and 56 treated with placebo) were valid for clinical evaluation: 55 were diagnosed as having ReA with a preceding symptomatic urogenic or enteric infection and 49 as having undifferentiated oligoarthritis. These 2 groups were randomized separately. The triggering bacterium was sought by serology and/or culture. The percentage of patients in remission after 3 months of treatment was chosen as the primary efficacy parameter. RESULTS: A triggering bacterium could be identified in 52 patients (50%): Chlamydia trachomatis in 13, Yersinia in 14, and Salmonella in 25. No patient was positive for Campylobacter jejuni or for Shigella. No difference in outcome was found between treatment with ciprofloxacin or placebo in the whole group or in subgroups of patients with ReA or undifferentiated oligoarthritis. No difference was seen in patients with a disease duration <3 months. Ciprofloxacin was not effective in Yersinia- or Salmonella-induced arthritis but seemed to be better than placebo in Chlamydia-induced arthritis. This difference was not significant, however, which might be due to the small sample size. CONCLUSION: Long-term treatment of ReA with ciprofloxacin is not effective; however, it might be useful in the subgroup of patients who have Chlamydia-induced arthritis. This has to be proven in a bigger study focusing on patients with Chlamydia-induced arthritis.

Ankylosing spondylitis in monozygotic twins: studies on immunological parameters.

OBJECTIVE: To examine immunological parameters that might explain disease discordance in monozygotic twin pairs with ankylosing spondylitis (AS). METHODS: 11 monozygotic twin pairs (nine with AS, two with undifferentiated spondyloarthropathy) were investigated. The peripheral T cell receptor Vbeta repertoire was investigated using FACS analysis and 14 different Vbeta antibodies. In addition serum samples were tested for antibodies to Klebsiella pneumoniae, Streptococcus pyogenes, Candida albicans, Proteus mirabilis, and Escherichia coli. Peripheral blood lymphocyte reactivity against a number of bacteria was investigated by interferon gamma ELISPOT assays. RESULTS: Twins suffering from AS showed cellular hyporeactivity against K pneumoniae, S pyogenes, C albicans in the ELISPOT assays compared with healthy twins. In contrast with the antibody data, where no significant differences were observed between the two groups, AS concordant twins showed the most pronounced differences in their Vbeta repertoire on CD4+ and CD8+ lymphocytes. CONCLUSIONS: Cellular hyporeactivity of peripheral blood cells to bacterial antigens might reflect defective T cell responses allowing bacterial antigens to persist in diseased patients. There are probably other environmental factors that influence disease concordance.

IgM, IgG and IgA class enterobacterial antibodies in serum and synovial fluid in patients with ankylosing spondylitis and rheumatoid arthritis.

IgM, IgG and IgA class antibodies against three Klebsiella pneumoniae capsular types, Escherichia coli and Proteus mirabilis, as well as total immunoglobulin concentrations, were measured by enzyme immunoassay and radial immunodiffusion technique, respectively, in paired serum and synovial fluid samples from eight patients with ankylosing spondylitis and 10 with rheumatoid arthritis. No clear evidence for intra-articular antibody production against any of the studied microbes was found.

Antibiotic prophylaxis and treatment of reactive arthritis. Lessons from an animal model.

OBJECTIVE: To study the effect of antibiotic prophylaxis and treatment of reactive arthritis (ReA), using an experimental model. METHODS: Yersinia enterocolitica O:8, when injected intravenously into Lewis rats, causes a sterile arthritis closely resembling human ReA in 70% of the animals. Arthritis develops in 1-2 weeks; in some of the animals it remains chronic, and exacerbations occur. This model was applied to study the effect of a 7-day treatment with ciprofloxacin, using 2 different dosages (20 or 100 mg/kg/day) and 4 different schedules for initiation of treatment. The effects were evaluated by determining the daily arthritis score, the number of rats developing arthritis, and fecal excretion of Yersinia. In addition, weight gain was monitored. At autopsy (35 or 60 days after inoculation with bacteria), samples were obtained for determination of Yersinia-specific antibodies in the serum. At the same time, samples were collected from mesenteric lymph nodes, lung, spleen, and liver for bacterial cultures, and from the ankle joints for histologic evaluation. In a separate experiment, ciprofloxacin concentrations in samples from serum and mesenteric lymph nodes were analyzed by high performance liquid chromatography. RESULTS: A 7-day course with 100 mg/kg/day of ciprofloxacin, started on day 3 after bacterial inoculation, completely prevented the development of ReA and eliminated Yersinia during the 60-day experiment. If a dosage of 20 mg/kg/day was used, development of acute arthritis was prevented, but some of the animals had positive fecal cultures at the end of experiment. If antibiotic treatment was started on day 5, the preventive effect was still observed, but was less pronounced. If the treatment was started at the peak of the development of arthritis, no effect on arthritis was observed. CONCLUSION: These results indicate that if any effect of antibiotic treatment in Yersinia-triggered ReA is to be expected, the treatment must be started early and given in sufficient dosage. However, antibiotic treatment has no effect on fully developed arthritis.

Role of YadA-mediated collagen binding in arthritogenicity of Yersinia enterocolitica serotype O:8: experimental studies with rats.

Outer membrane protein YadA, Yersinia adhesin, is one of the plasmid-encoded virulence factors of yersiniae. YadA protects bacteria against host defense through several different mechanisms. One important role of YadA is to mediate binding to several collagen types. Our recent study revealed that a yadA null mutant of Yersinia enterocolitica serotype O:8 has a drastically reduced arthritogenic capacity when injected intravenously into Lewis rats. To further characterize the arthritogenic role of YadA, we repeated the rat experiments with strain Y. enterocolitica O:8/pYV082; this strain expresses a YadA deletion derivative lacking 22 amino acids from the amino-terminal hydrophobic region and does not bind to collagen. Y. enterocolitica O:8/pYV082 induced arthritis in 5 to 14% of rats inoculated with arthritogenic doses, whereas the arthritis incidence with the wild-type parent strain was 65%. The parent strain was slightly more virulent than Y. enterocolitica O:8/pYV082, as determined by rat mortality. It also frequently induced skin abscesses, whereas Y. enterocolitica O:8/pYV082 did not. Infection kinetics in spleen and mesenteric lymph nodes were about the same with both of the bacterial strains used, and the same was true of the Yersinia-specific antibody response. Altogether, these results suggest that YadA-mediated collagen binding contributes to the arthritogenicity of Y. enterocolitica O:8.

Yersinia-associated arthritis in rats: effect of 65 kDa heat shock protein, bovine serum albumin and incomplete Freund's adjuvant.

OBJECTIVE: We have previously shown that the microbial load of rats has a significant effect on their susceptibility to Yersinia-associated arthritis. In this study our aim was to see whether mycobacterial 65 kDa heat shock protein (hsp) could induce the same suppressive effect in experimental Yersinia-associated arthritis as has been reported for arthritides induced by adjuvant, pristane, or streptococcal cell walls (SCW). METHODS: Arthritis was induced by the intravenous injection of Yersinia enterocolitica 0:8 into Lewis rats. Hsp, bovine serum albumin (BSA) or NaCl, administered in incomplete Freund's adjuvant (IFA), was given subcutaneously on day -5 or +5 with regard to the bacterial inoculation. RESULTS: Mycobacterial hsp given in IFA on day -5 significantly suppressed the development of arthritis. However, a similar suppression was observed with BSA or NaCl given in IFA. CONCLUSION: These results, together with those known from the effect of microbial load, suggest that susceptibility to Yersinia-associated arthritis is easily affected by external factors.

Role of YadA in arthritogenicity of Yersinia enterocolitica serotype O:8: experimental studies with rats.

Outer membrane protein YadA, the Yersinia adhesin, is one of the plasmid-encoded virulence factors of yersiniae. To evaluate the role of YadA in the pathogenesis of reactive arthritis experimentally, we used YadA- strain YeO8-116, a kanamycin GenBlock insertion mutant derived from Yersinia enterocolitica O:8 wild-type strain 8081. As control strains, a plasmid-cured derivative (8081-c) of 8081 and a YopH- mutant (8081-yoph) were used. In addition, YeO8-116, with the yadA mutation transcomplemented with plasmid pMW10, was used. YeO8-116 induced arthritis to a considerably lesser extent than did wild-type strain 8081 when inoculated intravenously into Lewis rats. In rats surviving for over 14 days after the bacterial inoculation, the arthritis incidences were 6% (4 of 72) among those inoculated with the yadA mutant and 51% (33 of 65) among those inoculated with wild-type strain 8081. When the yadA gene was transcomplemented back to YeO8-116, YeO8-116/pMW10 induced arthritis in 47% (9 of 19) of the inoculated rats. Plasmid-cured strain 8081-c did not induce arthritis in any of the 24 inoculated rats, whereas YopH- mutant 8081-yoph induced arthritis in 20% (5 of 25) of the rats inoculated. Although the 50% lethal dose of YeO8-116 was about sixfold higher than that of 8081, the kinetics of bacterial elimination from the spleen and mesenteric lymph nodes were about the same with both strains. Antibody responses in rats infected with the two strains were also indistinguishable. Our results indicate that YadA contributes to the arthritogenicity of Y. enterocolitica in the rat model.

Variability in the induction of experimental arthritis: Yersinia associated arthritis in Lewis rats.

Lewis rats of different microbiological status were studied for susceptibility to experimentally-induced Yersinia associated arthritis. Status A rats were serologically positive for Bacillus piliformis, Kilham rat virus and Toolan H-1 virus, whereas status B rats were serologically negative for these same microorganisms. When status A and status B rats were kept in the same room, incidence of arthritis was low (0-13% for status A rats and 27-33% for status B rats). When status B rats only were kept in different environments, increased incidence (up to 89%) of arthritis was observed. These findings suggest that the microbiological status of the host has an effect on the susceptibility to experimentally-induced arthritis. They call attention to the need for strictly defined conditions, including those of the host and the environment, in studies on experimental arthritides.

Yersinia associated arthritis in SHR rats: effect of the microbial status of the host.

Following the intravenous injection of live Yersinia enterocolitica O:8, 50-69% of SHR rats developed arthritis; these rats were antibody free against all rat pathogens tested. In contrast, only 20-25% of SHR rats which had serum antibodies against Bacillus piliformis, Kilham rat virus, and Toolan H-1 virus developed arthritis. The results indicate that the microbial load of the host has a profound effect on the susceptibility to experimental arthritis.

Long term follow up of SHR rats with experimental yersinia associated arthritis.

One hundred and one SHR rats were injected intravenously with live Yersinia enterocolitica O:8. The rats were randomly divided into two groups consisting of 48 and 53 rats. The group of 48 rats was monitored for 245 days to establish the incidence and the clinical features of the arthritis. The remaining 53 rats were killed in groups of three to five rats at intervals from four to 245 days after inoculation to examine the clearance of bacteria and the development of histological changes in the synovial membrane. Arthritis developed in 23/48 (48%) rats at seven to 27 days after inoculation. The arthritis subsided in most rats within four weeks, without leading to ankylosis of the affected joints. The arthritis was prolonged in three rats and recurrent in two. In the group of 53 rats Yersinia enterocolitica O:8 was cleared from most of the internal organs by day 77, but persisted in the inguinal lymph nodes in many of the rats up to day 245. All macroscopically arthritic joints showed clear histological signs of non-suppurative synovitis. No histological synovitis was detected in those joints observed macroscopically to be non-arthritic. Yersinia associated arthritis in SHR rats provides a potential model for reactive arthritis. There are strong similarities in the course of the arthritis and histopathological changes in the synovium between this animal model and reactive arthritis in humans. This study supports the association between poor elimination of the causative agent and the development of arthritis.

Risk of Yersinia infection among butchers.

The purpose of this study was to evaluate the risk of yersinia infection among butchers. Serum samples were collected from 146 abattoir workers, stratified into 3 groups according to exposure to swine throats and intestines. 100 healthy blood donors were used as controls. Antibodies against Yersinia enterocolitica O:3 and O:9 and Y. pseudotuberculosis I and III were measured using ELISA. Symptoms associated with yersiniosis were recorded in a questionnaire. Antibodies against Y. enterocolitica O:3 were observed more often in the sera of abattoir workers (19%), especially in butchers handling swine throats and intestines (27%), than in the sera of healthy blood donors (10%). During the 6 months preceding this study, 30-40% of the workers reported symptoms of abdominal pains and diarrhoea. However, the symptoms did not correlate with the occurrence of antibodies. One butcher had developed a yersinia-triggered prolonged reactive arthritis. Tonsil samples were collected from 120 pigs to determine the extent of yersinia contamination. Positive isolates were obtained from 54 pigs (45%). Y. enterocolitica O:3 was isolated from 31 pigs and Y. pseudotuberculosis III from 11 pigs. All of these strains shared characteristics typical for virulent strains. We conclude that yersinia infections are an occupational health risk to workers slaughtering swine in the abattoirs.