NFAT transcription factors--new players in the pathogenesis of inflammatory arthropathies?

Inflammatory arthropathies are characterized by major changes in gene expression, which-ultimately-result from differential activities of intracellular signaling pathways and their associated inducible transcription factors. The nuclear factor of activated T cells' (NFAT) family of transcription factors plays diverse roles in a variety of processes in the immune system and other tissues. Preliminary evidence has recently emerged implicating NFAT family members directly in the pathogenesis of inflammatory arthropathies. Specific anti-NFAT drug therapy may add to the pharmacologic armamentarium against rheumatoid arthritis, other inflammatory arthropathies, and related autoimmune disorders.

Chlamydia pneumoniae present in the human synovium are viable and metabolically active.

We demonstrated that chromosomal DNA from Chlamydia pneumoniae is present in synovial tissue in at least some patients with reactive arthritis/Reiter's syndrome and other arthritides. Here, we provide initial molecular evidence that the bacterium is viable and metabolically active when present in the synovium. We used reverse transcription-polymerase chain reaction (RT-PCR) assays targeting primary transcripts from the chlamydial rRNA operons, and mRNA from several C. pneumoniae genes (hsp60, ompA, KDO transferase, Mr=76000 protein), to analyse RNA preparations from synovial tissue of 10 patients with various forms of arthritis; each patient was known to be PCR-positive for C. pneumoniae DNA in synovium prior to RT-PCR assays. Two PCR-negative patients served as controls for RT-PCR assays. In the 10 patients PCR-positive for C. pneumoniae DNA, RT-PCR assays targeting primary transcripts from the rRNA operons of the organism showed that these molecules were present in each sample, as were transcripts from the bacterial hsp60 gene. Assays targeting mRNAs from the Mr=76000 protein and the KDO transferase genes of C. pneumoniae gave positive results for 6/10 preparations. We were unable to identify mRNA from the chlamydial major outer membrane protein gene (ompA) in any preparation. RNA preparations from the two control patients were negative in all RT-PCR assays targeting C. pneumoniae transcripts. These results indicate that in patients infected with the organism, synovial C. pneumoniae are viable and metabolically active, as are C. trachomatis cells in the same context. Such viability is consistent with a role in long-term contribution to pathogenesis in joint disease.

Yoga.

Yoga is an ancient tradition that has been westernized and often practiced for its proposed health benefits. Traditional texts describe its benefits for many types of arthritis. Two limited studies of yoga in osteoarthritis of the hands and carpal tunnel syndrome show greater improvement in pain than in control groups. Yoga uses stretching and improves strength so that it theoretically should be beneficial for some musculoskeletal problems. Yoga merits further study into its cellular and physiologic effects.

Frequency of apolipoprotein E (APOE) allele types in patients with Chlamydia-associated arthritis and other arthritides.

Genetic background is important in determining whether certain infecting bacteria disseminate to the joint and cause arthritis. We assessed whether APOE genotype is associated with the presence of DNA from Chlamydia or other bacteria in synovial tissues of patients with various arthritides. Nucleic acids from synovial tissues of 135 patients were screened by PCR for DNA from Chlamydia trachomatis, C. pneumoniae and other bacteria (pan-bacteria). APOE genotype was determined by a PCR-based method for all patients in each of four resulting groups comprised of about 35 individuals each, positive for C. trachomatis only, C. pneumoniae only, other bacteria, or no bacteria. RT-PCR was used to assess synovial APOE expression. The latter assays confirmed that APOE mRNA is present in synovial tissue. Determination of APOE genotype showed that patients PCR-negative in all assays, and those positive in the C. trachomatis - and pan-bacteria- (excluding Chlamydia) directed assays, had distributions of the APOE epsilon2, epsilon3 and epsilon4 alleles mirroring those of the general population (i.e. about 8%, 79% and 13%, respectively). In contrast, 68% of patients with C. pneumoniae DNA in synovium possessed a copy of the epsilon4 allele. These results indicate that no association exists between APOE genotype and synovial presence of C. trachomatis or other bacteria. However, individuals bearing at least one copy of the APOE epsilon4 allele may be at increased risk for synovial infection by C. pneumoniae.

Yoga-based intervention for carpal tunnel syndrome: a randomized trial.

CONTEXT: Carpal tunnel syndrome is a common complication of repetitive activities and causes significant morbidity. OBJECTIVE: To determine the effectiveness of a yoga-based regimen for relieving symptoms of carpal tunnel syndrome. DESIGN: Randomized, single-blind, controlled trial. SETTING: A geriatric center and an industrial site in 1994-1995. PATIENTS: Forty-two employed or retired individuals with carpal tunnel syndrome (median age, 52 years; range, 24-77 years). INTERVENTION: Subjects assigned to the yoga group received a yoga-based intervention consisting of 11 yoga postures designed for strengthening, stretching, and balancing each joint in the upper body along with relaxation given twice weekly for 8 weeks. Patients in the control group were offered a wrist splint to supplement their current treatment. MAIN OUTCOME MEASURES: Changes from baseline to 8 weeks in grip strength, pain intensity, sleep disturbance, Phalen sign, and Tinel sign, and in median nerve motor and sensory conduction time. RESULTS: Subjects in the yoga groups had significant improvement in grip strength (increased from 162 to 187 mm Hg; P = .009) and pain reduction (decreased from 5.0 to 2.9 mm; P = .02), but changes in grip strength and pain were not significant for control subjects. The yoga group had significantly more improvement in Phalen sign (12 improved vs 2 in control group; P = .008), but no significant differences were found in sleep disturbance, Tinel sign, and median nerve motor and sensory conduction time. CONCLUSION: In this preliminary study, a yoga-based regimen was more effective than wrist splinting or no treatment in relieving some symptoms and signs of carpal tunnel syndrome.

Soluble urate in sera and synovial fluids from patients with different joint disorders.

OBJECTIVE: To evaluate simultaneous serum and synovial fluid (SF) urate levels in various inflammatory and noninflammatory joint disorders and to correlate SF white blood cell (WBC) counts with serum and joint fluid urate levels. METHODS: Sixty-three paired samples of sera and SF from 58 patients including 25 patients with inflammatory arthropathies, 18 patients with gout and 15 patients with noninflammatory joint disorders, were measured for urate concentrations by a UV enzymatic method. RESULTS: In inflammatory arthropathies other than gout, urate concentrations in SF were significantly lower than in paired sera (p < 0.0001). There was no difference between the SF and serum urate levels in noninflammatory arthropathies and in gout. In gout, however, SF urate occasionally were found to be considerably higher than in sera. This phenomenon was observed in fluids with massive amounts of monosodium urate crystals. There was no correlation between SF WBC counts and serum of SF urate levels in any of the disease groups studied. CONCLUSIONS: Serum and synovial fluid levels vary more than previously recognized. SF urate levels tend to reflect serum levels in gout and noninflammatory arthropathies but not in inflammatory joint disorders. Disturbed purine metabolism in inflammatory arthropathies may reflect a component in the pathophysiology of inflammation. The elevations of SF urate levels seen in gout are unique for this disease and most likely reflect crystal dissolution in joints.

Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands.

OBJECTIVE: Yoga and relaxation techniques have traditionally been used by nonmedical practitioners to help alleviate musculoskeletal symptoms. The objective of this study was to collect controlled observations of the effect of yoga on the hands of patients with osteoarthritis (OA). METHODS: Patients with OA of the hands were randomly assigned to receive either the yoga program or no therapy. Yoga techniques were supervised by one instructor once/week for 8 weeks. Variables assessed were pain, strength, motion, joint circumference, tenderness, and hand function using the Stanford Hand Assessment questionnaire. RESULTS: The yoga treated group improved significantly more than the control group in pain during activity, tenderness and finger range of motion. Other trends also favored the yoga program. CONCLUSION: This yoga derived program was effective in providing relief in hand OA. Further studies are needed to compare this with other treatments and to examine longterm effects.

A randomized, double blind, placebo controlled trial of intravenous loading with S-adenosylmethionine (SAM) followed by oral SAM therapy in patients with knee osteoarthritis.

OBJECTIVE: We evaluated the effectiveness and rapidity of onset of S-adenosylmethionine (SAM), administered as daily intravenous boluses of 400 mg for 5 days, followed by oral tablets, 200 mg thrice daily for 23 days, versus a matching placebo regimen, in the treatment of 81 patients with symptomatic knee osteoarthritis (OA). METHODS: The study was bicentric, randomized, double blinded, and placebo controlled. Patients underwent a 7-day washout of arthritis medications prior to initiation of this study treatment. Major outcome measures were the Stanford Health Assessment Questionnaire disability and pain scales, and supplemental visual analog scales for rest and walking pain. RESULTS: At one site, patients had milder OA, the baseline characteristics of the treatment groups were well matched, and the SAM treated group showed significantly greater reduction in overall pain and rest pain (p < 0.05) than the placebo treated group. At the other site, the patients had more severe OA, randomization yielded markedly different treatment groups, and the response to treatment did not differ between groups. Onset of SAM effect was seen as early as 14 days after the start of treatment. CONCLUSION: SAM may be an effective treatment for some patients with symptomatic knee OA, and merits further study. Intravenous loading before oral maintenance therapy may be advantageous.

Suppression of acute and chronic inflammation by dietary gamma linolenic acid.

We examined the effect of diets enriched in gamma linolenic acid (GLA) on acute inflammation induced by monosodium urate crystals, and on subacute and chronic inflammation induced by complete Freund's adjuvant in the rat subcutaneous air pouch and in rats with adjuvant induced arthritis. Diets were enriched (15% fat) with borage seed oil (23% GLA) or safflower oil (less than 1% GLA). Diets enriched with GLA suppressed inflammation markedly in all models, whereas the safflower oil diet did not influence the inflammatory response. The degree of inflammation was quantified by measuring pouch exudate cell concentration, lysosomal enzyme activity, volume, protein concentration and prostaglandin E2 and leukotriene B4 concentrations. In the chronic air pouch model, the pouch lining was thickened, invaded by mononuclear cells and exhibited proliferation of lining cells 14 days after adjuvant injection. The lesion was far less severe and usual pouch lining architecture was maintained in animals given dietary GLA. Livers of rats fed borage seed oil were enriched in GLA and dihomo gamma linolenic acid (DGLA), and the DGLA/arachidonate ratio was increased 5-fold compared with animals fed safflower oil. Enrichment of diet with plant seed oils rich in GLA may provide a way to alter generation of prostaglandins and leukotrienes and to influence acute and chronic inflammatory responses.

Is it mandatory to examine synovial fluids promptly after arthrocentesis?

Fifty synovial fluid (SF) samples from patients with various types of arthritis were examined promptly after joint aspiration and after storage at room temperature (22 degrees C) or at refrigerator temperature (4 degrees C) for 1 hour, 2 hours, 3 hours, 6 hours, 1 day, and 3 days, then weekly for 3 weeks and monthly for 2 months. We found that the leukocyte count (white blood cell [WBC] count) decreased within a few hours. In 4 SF samples from patients with mild inflammation (initial range 3,150-6,200 WBC/mm3), the WBC count decreased into a "noninflammatory" range (less than 2,000/mm3) within 5-6 hours. In 3 of 5 SF samples that on the first day were found to be laden with crystals of calcium pyrophosphate dihydrate (CPPD), the crystals were much less abundant and were difficult to recognize by the next day. CPPD crystals dissolved completely in all SF samples by 3-8 weeks of the study. Monosodium urate crystals remained detectable throughout the 8 weeks of study, but they became smaller, less birefringent, and less numerous with time. Clumps of apatite-like crystals persisted for several months. Most SF samples initially negative for apatite-like crystals remained negative over time. New, artifactual crystals, including alizarin red S-positive clumps or star-shaped arrays, plate-like structures, positively birefringent Maltese crosses, and hematoidin crystals, developed with time. Because of these observations, we urge prompt examination of SF specimens to avoid the problems of misdiagnosing borderline inflammatory fluids, missing CPPD crystals that dissolve with time, or over-interpreting the findings because of the new, artifactual crystals.

Suppression of monosodium urate crystal-induced acute inflammation by diets enriched with gamma-linolenic acid and eicosapentaenoic acid.

A subcutaneous air pouch formed in Sprague-Dawley rats was used to study the effect of diets enriched in gamma-linolenic acid (GLA) (in plant seed oil) and eicosapentaenoic acid (EPA) (in fish oil) on acute inflammation induced by monosodium urate crystals. The GLA-enriched diet suppressed significantly the cellular phase of inflammation (polymorphonuclear leukocyte accumulation, crystal phagocytosis, and lysosomal enzyme activity), but it had little effect on the fluid phase (exudate volume and protein concentration). In contrast, the EPA-enriched diet suppressed the fluid phase but not the cellular phase of inflammation. The findings indicate that the fluid and cellular phases of acute inflammation can be controlled independently. A combined diet of fish oil and plant seed oil (EPA-enriched and GLA-enriched) reduced both the cellular and fluid phases of inflammation. Thus, dietary provision of alternative substrates for oxidative metabolism (other than arachidonic acid) modifies monosodium urate crystal-induced acute inflammation.

Inflammation after blood injection into a synovial-like space is a result of the cellular component rather than the plasma.

The rat subcutaneous air pouch, a model for a synovial-like space, has been used to study the effect of blood as an inducer of inflammation. Six-day-old pouches were injected with autologous whole blood, with plasma or with blood cell pellets. We found significantly more inflammation and proliferation of pouch lining in pouches injected with whole blood or with the blood cell pellets than with the plasma. After the injection of blood or the cell component, large numbers of hemoglobin crystals and lipid droplets were found in the pouch fluid and were associated with erosions of the pouch membrane.

Calcinosis at the site of leakage from extravasation of calcium disodium edetate intravenous chelator therapy in a child with lead poisoning.

Painful calcinosis appeared at the wrist of an eight-year-old girl with lead poisoning. Careful history revealed that calcification occurred at the site of previous extravasation of calcium disodium edetate (EDTA) used in chelation therapy. Light microscopic, ultrastructural, electron activation, and X-ray diffraction studies demonstrated apatites with some suggestion of an admixture of octacalcium phosphate.

Immunochemical and ultrastructural characterization of serum proteins associated with monosodium urate crystals (MSU) in synovial fluid cells from patients with gout.

Immunoelectron microscopic (IEM) analysis of the surface coats of intracellular and extracellular monosodium urate (MSU) crystals in synovial fluid (SF) in gouty arthritis was performed using the ferritin-bridge method. Cells from patients with acute gout were fixed in 1% glutaraldehyde containing 0.05% saponin to permeabilize membranes for access of immunochemicals to intracellular antigens. Intracellular MSU crystals were observed in phagosomes of greater than 75% of both polymorphonuclear (PMNs) and mononuclear cells. Coating of crystals with IgG was more prominent than with IgM or IgA. Other proteins such as C3, and fibrinogen were also found to a lesser extent. Albumin was not detected in appreciable amounts on MSU crystals. Extracellular crystals also showed IgG to be bound more prominently than other proteins. The various proteins, shown here for the first time to be clearly associated with intracellular crystals by EM, and other materials associated with MSU crystals may influence the phlogistic properties of these crystals.

Acute monoarthritis associated with lipid liquid crystals.

We describe three women with unexplained acute monoarthritis and birefringent lipid spherules or lipid liquid crystals in their synovial fluid. Synovial fluid aspirated within 24 hours of onset showed leucocyte counts ranging from 10 X 10(9) to 46 X 10(9)/1 with 91-95% polymorphonuclear cells. Numerous positively birefringent 2-6 micron microspherules were seen inside and outside polymorphonuclear cells. These were dissolved in alcohol-ether but were not digested by uricase. Other non-birefringent globules of similar size that stained with Sudan black B were also seen. Transmission electron microscopy identified osmiophilic homogeneous or multilamellated material in phagocytic vacuoles. Serum lipids, lipase, and repeated joint radiographs were normal. Arthritis subsided completely after treatment with colchicine in one patient and nonsteroidal anti-inflammatory agents in two. Thus birefringent microspherules can be found in association with acute, otherwise unexplained, arthritis. It seems possible that certain lipid liquid crystals may induce synovial inflammation similar to inflammation seen in other crystal induced arthritides.

Prospective study of morphology and phagocytosis of synovial fluid monosodium urate crystals in gouty arthritis.

Crystals can be identified in synovial fluids (SF) in the absence of acute inflammation as well as during acute gouty arthritis. We examined gouty joint effusions to evaluate whether observable properties of the crystals correlate with the clinically detectable inflammation. Higher SF leukocyte counts and more crystal phagocytosis were confirmed during more severe arthritis. We found no differences between crystal sizes, numbers of shapes in severe versus mild inflammation. Some patients with severe acute gout had few crystals or only punctate birefringent fragments. Factors other than those we examined must affect the severity of the inflammatory response in gouty arthritis.