Specificity of T cells in synovial fluid: high frequencies of CD8(+) T cells that are specific for certain viral epitopes.

INTRODUCTION: Epstein-Barr virus (EBV) is transmitted orally, replicates in the oropharynx and establishes life-long latency in human B lymphocytes. T-cell responses to latent and lytic/replicative cycle proteins are readily detectable in peripheral blood from healthy EBV-seropositive individuals. EBV has also been detected within synovial tissue, and T-cell responses to EBV lytic proteins have been reported in synovial fluid from a patient with rheumatoid arthritis (RA). This raises the question regarding whether T cells specific for certain viruses might be present at high frequencies within synovial fluid and whether such T cells might be activated or able to secrete cytokines. If so, they might play a 'bystander' role in the pathogenesis of inflammatory joint disease. OBJECTIVES: To quantify and characterize T cells that are specific for epitopes from EBV, cytomegalovirus (CMV) and influenza in peripheral blood and synovial fluid from patients with arthritis. METHODS: Peripheral blood mononuclear cells (PBMCs) and synovial fluid mononuclear cells (SFMCs) were obtained from patients with inflammatory arthritis (including those with RA, osteoarthritis, psoriatic arthritis and reactive arthritis). Samples from human leucocyte antigen (HLA)-A2-positive donors were stained with fluorescent-labelled tetramers of HLA-A2 complexed with the GLCTLVAML peptide epitope from the EBV lytic cycle protein BMLF1, the GILGFVFTL peptide epitope from the influenza A matrix protein, or the NLVPMVATV epitope from the CMV pp65 protein. Samples from HLA-B8-positive donors were stained with fluorescent-labelled tetramers of HLA-B8 complexed with the RAKFKQLL peptide epitope from the EBV lytic protein BZLF1 or the FLRGRAYGL peptide epitope from the EBV latent protein EBNA3A. All samples were costained with an antibody specific for CD8. CD4+ T cells were not analyzed. Selected samples were costained with antibodies specific for cell-surface glycoproteins, in order to determine the phenotype of the T cells within the joint and the periphery. Functional assays to detect release of IFN- or tumour necrosis factor (TNF)- were also performed on some samples. RESULTS: The first group of 15 patients included 10 patients with RA, one patient with reactive arthritis, one patient with psoriatic arthritis and three patients with osteoarthritis. Of these, 11 were HLA-A2 positive and five were HLA-B8 positive. We used HLA-peptide tetrameric complexes to analyze the frequency of EBV-specific T cells in PBMCs and SFMCs (Figs 1 and 2). Clear enrichment of CD8+ T cells specific for epitopes from the EBV lytic cycle proteins was seen within synovial fluid from almost all donors studied, including patients with psoriatic arthritis and osteoarthritis and those with RA. In donor RhA6, 9.5% of CD8+ SFMCs were specific for the HLA-A2 restricted GLCTLVAML epitope, compared with 0.5% of CD8+ PBMCs. Likewise in a donor with osteoarthritis (NR4), 15.5% of CD8+ SFMCs were specific for the HLA-B8-restricted RAKFKQLL epitope, compared with 0.4% of CD8+ PBMCs. In contrast, we did not find enrichment of T cells specific for the HLA-B8-restricted FLRGRAYGL epitope (from the latent protein EBNA3A) within SFMCs compared with PBMCs in any donors. In selected individuals we performed ELISpot assays to detect IFN- secreted by SFMCs and PBMCs after a short incubation in vitro with peptide epitopes from EBV lytic proteins. These assays confirmed enrichment of T cells specific for epitopes from EBV lytic proteins within synovial fluid and showed that subpopulations of these cells were able to secrete proinflammatory cytokines after short-term stimulation. We used a HLA-A2/GILGFVFTL tetramer to stain PBMCs and SFMCs from six HLA-A2-positive patients. The proportion of T cells specific for this influenza epitope was low (<0.2%) in all donors studied, and we did not find any enrichment within SFMCs. We had access to SFMCs only from a second group of four HLA-A2-positive patients with RA. A tetramer of HLA-A2 complexed to the NLVPMVATV epitope from the CMV pp65 protein reacted with subpopulations of CD8+ SFMCs in all four donors, with frequencies of 0.2, 0.5, 2.3 and 13.9%. SFMCs from all four donors secreted TNF after short-term incubation with COS cells transfected with HLA-A2 and pp65 complementary DNA. We analyzed the phenotype of virus-specific cells within PBMCs and SFMCs in three donors. The SFMC virus-specific T cells were more highly activated than those in PBMCs, as evidenced by expression of high levels of CD69 and HLA-DR. A greater proportion of SFMCs were CD38+, CD62L low, CD45RO bright, CD45RA dim, CD57+ and CD28- when compared with PBMCs. DISCUSSION: This work shows that T cells specific for certain epitopes from viral proteins are present at very high frequencies (up to 15.5% of CD8+ T cells) within SFMCs taken from patients with inflammatory joint disease. This enrichment does not reflect a generalized enrichment for the 'memory pool' of T cells; we did not find enrichment of T cells specific for the GILGFVFTL epitope from influenza A or for the FLRGRAYGL epitope from the EBV latent protein EBNA3A, whereas we found clear enrichment of T cells specific for the GLCTLVAML epitope from the EBV lytic protein BMLF1 and for the RAKFKQLL epitope from the EBV lytic protein BZLF1. The enrichment might reflect preferential recruitment of subpopulations of virus-specific T cells, perhaps based on expression of selectins, chemokine receptors or integrins. Alternatively, T cells specific for certain viral epitopes may be stimulated to proliferate within the joint, by viral antigens themselves or by cross-reactive self-antigens. Finally, it is theoretically possible that subpopulations of T cells within the joint are preferentially protected from apoptotic cell death. Whatever the explanation, the virus-specific T cells are present at high frequency, are activated and are able to secrete proinflammatory cytokines. They could potentially interact with synoviocytes and contribute to the maintenance of inflammation within joints in many different forms of inflammatory arthritis.

Surgery for rheumatoid arthritis of the elbow: a comparison of radial-head excision and synovectomy with total elbow replacement.

The results of total elbow replacement (TER) in 45 elbows of 38 patients with rheumatoid arthritis were compared with results of radial head excision with synovectomy (RHES) in 45 age-matched patients treated in the same unit. The groups were similar with respect to duration of disease and preoperative clinical status, although pain was of longer duration and slightly more severe in the TER group. Failure was defined as the onset of moderate or severe pain after surgery or revision surgery for any reason. Reduction in pain was greater after TER than after RHES (P < .05). Recurrence of pain was common after RHES but was not seen after TER. Movement increased by a similar amount in each group. Complications were more frequent and more serious after TER (4 dislocations, 4 ulnar nerve dysfunctions, 1 significant wound breakdown) than after RHES (2 ulnar nerve dysfunctions, 1 transient wound discharge). Complications after TER were most common in patients who had previous RHES. On survival analysis, TER results were better than RHES results in each successive year. Cumulative survival rates at 10 years were 85% for TER and 69% for RHES, but the difference in rates was not statistically significant. In the medium term, TER relieves pain more reliably than RHES and its use is justified despite the greater risk of complications. In view of the paucity of long-term results for TER, RHES may retain a role in younger patients or in those whose symptoms are related mainly to the radiohumeral joint.

Synovectomy of the elbow and radial head excision in rheumatoid arthritis. Predictive factors and long-term outcome.

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50 degrees in supination-pronation and 11 degrees in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

Acute pneumonitis associated with low dose methotrexate treatment for rheumatoid arthritis: report of five cases and review of published reports.

BACKGROUND: Low dose methotrexate has become established in the treatment of refractory rheumatoid arthritis. Until recently it has been considered that the use of a low dose regimen (< 20 mg/week) would avoid the pulmonary toxicity associated with the higher doses prescribed in malignant disease. Although initial experience with low dose methotrexate was encouraging, an increasing number of cases of an acute, life threatening pneumonitis are being reported in patients with refractory rheumatoid arthritis. PATIENTS: Since 1984 43 patients with refractory rheumatoid arthritis have been established on low dose methotrexate in the Oxford Health District. Five of these patients have subsequently developed acute methotrexate induced pneumonitis. The clinical and radiological features of these cases are described and previous reports reviewed. RESULTS: Five patients having low dose methotrexate treatment developed acute pneumonitis. Presentation was subacute and dominated by constitutional features. Respiratory symptoms developed insidiously but progressed rapidly with increasing dyspnoea associated with severe hypoxia. Chest radiographs were non-specific, showing diffuse interstitial infiltration and alveolar shadowing. Microbiological investigation gave negative results. In all cases methotrexate was discontinued and high dose corticosteroids started, with rapid clinical and radiological improvement. After withdrawal of steroid both clinical and radiological resolution was maintained at follow up. CONCLUSION: Acute pneumonitis is an uncommon but serious adverse effect of low dose methotrexate treatment for refractory rheumatoid arthritis. The initial presentation is non-specific and a high index of suspicion is required as respiratory failure may develop rapidly. Management depends on exclusion of infection, withdrawal of methotrexate, and high dose corticosteroid treatment. Full supportive treatment is indicated as the prognosis in such patients is good.

Scleroderma with bilateral synovial fistulae.

Synovial fistulae developed in an elderly man with rapidly progressive scleroderma. We describe this case and review the literature on synovial fistulae.

Coexisting rheumatoid arthritis and ankylosing spondylitis.

Since the second publication by some of the present authors in which 10 patients with coexisting rheumatoid arthritis (RA) and ankylosing spondylitis (AS) were described, 7 new cases have been found. For accuracy, all cases of the original study still available were reexamined. Of the total of 17 cases, 13 were male and 4 female. All had positive tests for rheumatoid factor and 6 had subcutaneous nodules. The male predominance and the frequency of nodules are consistent with other publications. In addition, our study demonstrates the strong association of each of these 2 diseases with its genetic marker: the antigen HLA-DR4 was present in 8 of 12 cases tested and the antigen HLA-B27 was present in 16 of the 17 cases. The coexistence of these 2 classical rheumatological entities in the same patient appears to occur by chance and is probably often overlooked.

Indications of vascular endothelial cell dysfunction in systemic lupus erythematosus.

Fibrinolytic and other factors have been measured in 73 patients with systemic lupus erythematosus or related conditions to determine whether clinical thrombosis, a common feature of these disorders, is associated with defective fibrinolysis. Twenty five of 72 (35%) patients, compared with two of 22 (9%) controls, showed a low level of plasminogen activator activity in response to venous occlusion, suggesting decreased fibrinolytic potential. In addition, mean plasma levels of von Willebrand factor antigen and fibronectin were markedly raised in the patients (mean (SD) 384.5 (277)% and 727 (436) mg/l respectively) compared with healthy controls (100 (50)% and 306 (65) mg/l). These data suggest a degree of endothelial cell dysfunction. No clear correlation was found between a history of thrombosis and any plasma factor measured, except for prolongation of clotting tests suggestive of the 'lupus anticoagulant'.

A review of 100 patients with ankylosing spondylitis with particular reference to socio-economic effects.

One hundred patients with ankylosing spondylitis of at least 5 years' duration were interviewed and examined. In addition to musculoskeletal symptoms, 11 subjects had evidence of a variety of neurological complaints. Nine were unemployed and only nine of the remainder felt the disease had seriously affected their employment. One third of patients had been off work for more than 2 months in the course of the disease but frequently due to associated illness. Most patients did not experience disability with household activities but peripheral joint involvement or serious spinal stiffness increased this risk. Symptoms referrable to athletic pursuits may have first drawn attention to the disease in some individuals and sporting activities were curtailed at a younger age than in controls. Driving caused difficulties in up to 50% of subjects due to poor all-round vision. Cervical spine fractures occurred in two patients.

Dupuytren's contracture and alcohol.

Reported alcohol consumption was quantified and scored by a validated questionnaire administered by an interviewer to 64 patients (10 female) with Dupuytren's contracture (DC) before hand surgery and to 89 controls (44 female) admitted for other hand or foot surgery. Serum urate (SUA), gamma-glutamyl transferase (GGT), and mean red cell volume (MCV) were measured on admission. Thirteen of 54 men with DC reported current daily alcohol intake of 40 g or more compared with one of 45 male controls (p = 0.0001). Two of 10 women with DC (but none of 44 controls) admitted consuming at least 40 g alcohol daily (p = 0.03). MCV was higher in men (but not women) with DC than in controls (p less than 0.0005). Current alcohol consumption score of patients with DC correlated with SUA (r = 0.308, p less than 0.05), MCV (r = 0.44, p less than 0.01), and GGT (r = 0.54, p much less than 0.001) on admission. DC among men is strongly associated with heavy drinking, reflected both in self reporting and haematological data.

MacIntosh arthroplasty for the rheumatoid knee: a 10-year follow up.

The results of 75 MacIntosh arthroplasties performed for rheumatoid arthritis of the knee in 63 patients were reviewed at least 10 years after surgery. Forty-two knees in 35 patients were available for assessment. Eleven arthroplasties had been revised to total knee replacement without difficulty because of pain or poor function. The remaining 31 knees in 25 patients gave good or excellent results in 22 cases, fair in eight, and poor in one. Seven patients could not be traced, and 21 patients representing 26 knees had died. At least half these knees had given satisfactory results immediately before death judged by review of the case notes. The difficulty of comparing functional status with the preoperative state because of progressive multiarticular disease was highlighted. Although greater angular deformities preoperatively reduced the chance of success in the medium term, late failure of the arthroplasty after five years was very rare. Approximately two-thirds of all the arthroplasties performed gave satisfactory results at 10-year follow up or until the time of death.

Spinal movements in ankylosing spondylitis and the effect of treatment.

Fourteen male patients with ankylosing spondylitis, admitted for a 2-week period of inpatient treatment, had their spinal mobility assessed on admission and at the end of treatment by clinical measures and a three-dimensional radiographic technique. The patients were given injections of low-dose corticotrophin (ACTH) or placebo under a double-blind protocol. Initially all the patients had restricted movements compared with normal. After treatment all showed some improvement of mobility but no additional benefit accrued from ACTH. Clinical measures of mobility must be interpreted with care as the changes in these measurements were not closely reflected in the lumbar movements measured radiographically. Changes seen in plain radiographs were of little predictive value for improvements in mobility.

Corticosteroid prescribing in rheumatoid arthritis--the fiction and the fact.

The results of a postal questionnaire to consultant rheumatologists (80% response rate) suggest that most comply with current teaching regarding the indications for systemic corticosteroids in articular rheumatoid arthritis (RA). They are prescribed as a last resort and most frequently in the elderly. However, a review of 100 consecutive RA out-patients revealed 24 patients currently taking corticosteroids at a mean prednisolone dosage of 5.6 mg daily. Only two had been prescribed these drugs for extra-articular problems. In 11 cases the treatment was not initiated by a rheumatologist. The discrepancies between the two surveys are discussed.

Comparison of reconstructive orthopaedic surgery in patients with seropositive and seronegative rheumatoid arthritis.

The longitudinal orthopaedic history of 107 unselected patients with rheumatoid arthritis undergoing reconstructive surgery was studied to define the relationship between serology and surgery. Using strict criteria 85 patients were seropositive and 22 seronegative. Age, disease duration, number of reconstructive orthopaedic operations, and second-line or corticosteroid drug treatment were similar in seropositive and seronegative patients. Users of steroids and/or second-line drugs had a similar number of operations to non-users. However, patients undergoing only hip or knee surgery used steroids more often in the pre-operative disease than those only having other operations (p less than 0.05). This may reflect more-aggressive disease or the direct effect of steroids. The expected proportions of seropositive and seronegative patients together with their similar surgical and treatment patterns do not suggest that they have different diseases.

Rapid development of gouty tophi after diuretic therapy.

Increasing attention has been drawn to the role played by diuretics in the pathogenesis of gout, particularly in the elderly. We describe an elderly woman presenting acutely with tophus formation mimicking infection, in whom diuretic therapy was responsible for her disease. Her presentation with acutely inflamed tophi without any history of joint involvement, only 3 months after starting treatment, was highly unusual.