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Annals of the Rheumatic Diseases 1992; 51: 572-575
572
Table 2 Neutrophil activating peptide llinterleukin 8 (NAP-IIIL-8) concentrations in the media of mononuclear cells culturedfor 24 hours in the presence ofdifferent concentrations of lipopolysaccharide (LPS). ' Results are given as the geometric mean (-SD; +SD)
LETTERS TO THE EDITOR
LIPS
NAP-IIIL-8 (nmolll)
(pg/ml) 10 1 01 0 01 0
Normal production of neutrophil activating peptide I/interleukin 8 in monocytes from subjects with previous yersinia triggered reactive arthritis
I
II
III
IV
V
17 4(6 2;48 2)
16-7(6-6;41-9) 10-1 (45;222) 6-2(3-5;10-7) 4-4(2-2;8-6)
15-6(6-9;34-6) 98 (45;21 1)
16 7(6 1;45 9) 97 (36;258) 6-7(2-8;15 8) 5 7(2 7,11-9) 3 5 (0 9;1 1-9)
15 6(5 2;46 3) 106 (34;31 6) 7 2(2-0;25-1) 6 4(1-9;20 9) 46(0;24-3)
11l0(3-8;31-3) 7 7(3-0;19 7) 5 2(2-1;12-2) 3 6 (0;14 8)
2-2 (0;8-9)
5-8(3-0;114)
4-6(2-5;8-2) 3-2 (0-8;10 6)
*For explanation of groups see table 1.
colitica (0:3 or 0:9). At the time of this study the subjects had recovered completely from yersinia infection/arthritis, did not use antiinflammatory drugs, and were free from signs and symptoms of infection. Blood samples from two subjects with previous yersinia arthritis (one HLA-B27 positive, the other HLA-B27 negative), one subject with previous yersinia enteritis, and two controls (one HLA-B27 positive, the other HLA-B27 negative) without a history of yersinia infection were taken and studied concurrently on a given day. In three series of experiments, group II and group III subjects (see table 1) were not available for study. Buffy coat cells were prepared from peripheral blood anticoagulated with heparin (10 U/ml). Mononuclear cells were separated by dextran sedimentation and Ficoll-Isopaque density gradient centrifugation.' The purified cells were washed three times with Hanks's balanced salt solution and then suspended in RPMI 1640 medium supplemented with 1-25% (vol/vol) pyrogen-free albumin solution (40 mg/ml; Finnish Red Cross Blood Transfusion Service, Helsinki), 1 mM HEPES buffer, 2 mM L-glutamine, and antibiotics. Samples (I ml) containing 1 x 106 monocytes were cultured in 24-well tissue culture plates (Costar, Cambridge MA, USA; No 3424) for 24 hours at 37°C in 5% C02 and 95% air in the presence of 0 to 10 ig/ml Escherichia coli 026:B6 lipopolysaccharide (Sigma Chemical Company, St Louis, MO, USA). The culture supernatants were then collected and stored at 60°C before analysis for NAP-1/IL-8 content. Concentrations ofNAP- 1/IL-8 in the culture supernatants were determined by a microtitre plate assay for elastase release from human peripheral blood buffy coat neutrophils.'0 In brief, 100 RI portions of a neutrophil suspension (107 cells/ml) treated for 10 minutes with S ig/ml cytochalasin B were dispensed into the wells containing 125 nmol of elastase substrate
SIR: Ankylosing spondylitis and reactive arthritis, a form of sterile joint inflammation triggered by an infection elsewhere in the body, belong to a family of seronegative spondyloarthropathies. Reactive arthritis can follow enteric infections caused by salmonella, shigella, campylobacter, or Yersinia enterocolitica, urogenital infection caused by chlamydia, and, possibly also, infections caused byBorrelia burgdorferi, among others. ' About 80% of patients with reactive arthritis carry the HLAB27 antigen. The mechanism of this disease is not known, but non-specific inflammatory reactions of the host with increased generation of inflammatory mediators or increased responsiveness to them may play a part.2 For instance, subjects with previous yersinia triggered reactive arthritis show enhanced neutrophil chemotaxis3 and increased oxygen radical production.4 Neutrophil activating peptide 1/ interleukin 8 (NAP-1/IL-8) is a newly characterised chemotactic cytokine, produced by stimulated mononuclear phagocytes and a variety of tissue cells.5 Production of NAP-l/ IL-8 may be induced by microbial antigens, which were recently found in the inflamed joints of patients with reactive arthritis triggered by chlamydia,6 yersinia,7 or salmonella.t To find out whether subjects susceptible to the development of reactive arthritis show aberrant production of cytokines we compared NAP-1/IL-8 production by monocytes of subjects with previous yersinia arthritis, uncomplicated yersinia enteritis, and without a history of yersinia infection. Subjects were allocated to five groups (I-V, table 1) on the basis of HLA-B27, previous yersinia triggered reactive arthritis (yersinia arthritis), and previous uncomplicated yersinia enteritis. Twenty one subjects with previous yersinia arthritis were selected from a follow up patient group,9 nine subjects with previous non-complicated yersinia enteritis had been treated at the Helsinki University Central Hospital, and 24 subjects without a history of yersinia infection were healthy laboratory and hospital personnel. Diagnosis of yersinia infection was based on a stool culture positive for the organism or a raised agglutination antibody titre (>1/160) for Yersinia entero-
(N-methoxysuccinyl-ala-ala-pro-val-7-amido4-methylcoumarin; Bachem, Budendorf, Switzerland) and the test sample in 150 ,ul phosphate buffered saline containing 2 5 mg/ ml of bovine serum albumin (Fluka AG, Buchs, Switzerland). For each plate, background and NAP-1/IL-8 controls (0-3, 1, 3,
10, 30, 100 nmol/l) were included. The assay was performed at room temperature using a Titertek Fluoroscan (Elflab, Helsinki, Finland), and the titres in test samples were determined from an NAP-1/IL-8 standard curve. The frequency distributions of NAP-1/IL-8 values were significantly skewed, but could be normalised by logarithmic transformation, and therefore the data are expressed as geometric means (SD). To evaluate the responsiveness of the cells, differentials were determined by subtracting the control value in the absence of lipopolysaccharide from the values in the presence of lipopolysaccharide. The significance of the difference between the groups was evaluated by Student's t test. The results showed that monocyte and lymphocyte counts were similar in the five subject groups (table 1). In all cases low levels of NAP-1/IL-8 production were seen in the absence of lipopolysaccharide and the yields increased markedly in parallel with the lipopolysaccharide concentration, reaching a maximum on exposure to 10 [sg/ml lipopolysaccharide (table 2). No significant difference was obtained in the yield of NAP-1/IL-8, in the presence and absence of lipopolysaccharide, among groups I to V (table 2; figure). The differentials at each lipopolysaccharide concentration among the five groups were also similar (data not shown). In patients with reactive arthritis consequent upon chlamydia, yersinia, or salmonella, antigens of the triggering microbe are detected in the inflamed joint."8 In two cases yersinia 5r *
4
.
6 --f 00
-32 cs
-U-w
gO
I
a@ Table I Characteristics of the subject groups"' and differential counts of mononuclear cells after Ficoll-Isopaque centrifugatton Characteristics
I
II
III
IV
V
Number of subjects Men/women Mean age in years (range) Mean period in years (range) since yersinia infection Mean (SD) differential count (%)
12 7/5 40 (26-49)
9 2/7 56 (48-70)
9 1/8 43 (26-29)
12 2/10 44 (29-63)
12 3/9 43 (35-47)
15 (10-20)
16 (14-19)
6 (2-14)
-
-
25 (5) 27 (7) 26 (6) 23 (5) 27 (6) Monocytes 71 (8) 73 (7) 74 (6) 72 (7) Lymphocytes 71(6) 'I = HLA-B27 positive subjects with previous yersinia arthritis; II= HLA-B27 negative subjects with previous yersinia arthritis; III= subjects with previous yersinia infection without extraintestinal manifestations (two of these were HLA-B27 positive); IV=HLA-B27 positive subjects without a history of yersinia infection; V= HLA-B27 negative subjects without a history of yersinia infection
0
*-
03
.-
a
0 .
11
III
IV
V
Concentrations (nmolll) ofneutrophil activating peptide l/interleukin 8 (NAP-IIIL-8) in the media of mononuclear cells culturedfor 24 hours in the presence of 10 tg/ml lipopolysaccharide. Geometric means and SD values are indicated by horizontal lines. I-V denotes thefive groups described in table 1.
Downloaded from http://ard.bmj.com/ on May 30, 2015 - Published by group.bmj.com
573
Letters to the editor
antigen was detected as long as three and 17 years after yersinia infection,7 suggesting that the microbial structures can persist in the tissues. The antigens are found in mesenteric and cervical lymph nodes and in the skin," and, during the acute phase of infection, in peripheral blood cells of almost every patient, including patients who will not develop reactive arthritis.'2 Thus the presence of antigens in the blood provides an explanation for extensive antigen dissemination, but not for the development of reactive arthritis and other clinically significant extraintestinal manifestations. Possibly, extraintestinal symptoms derive from inflammatory hyperreactivity of the patient to the antigenic stimulus. It has been reported that neutrophils of HLA-B27 positive subjects without a history of yersinia infection and of patients with previous yersinia reactive arthritis show enhanced neutrophil migration in response to a chemotactic stimulus in vitro3 and in vivo,3 as do patients with ankylosing spondylitis, at least in vitro."' Furthermore, neutrophils from patients who have a history of severe actue yersinia triggered reactive arthritis,'5 or with sequelae,4 show increased generation of oxygen radicals in vitro. NAP-l/ IL-8 stimulates neutrophil chemotaxis and oxygen radical production5 and might thereby contribute to the neutrophil hyperactivity. In conclusion, the results show that both control and lipopolysaccharide induced NAP1/IL-8 production by monocytes was similar in subjects with past yersinia arthritis or enteritis and unaffected subjects, and did not differ between HLA-B27 positive and negative subjects. This seems to rule out an aberrant function of monocytes, at least for the synthesis and release of NAP-1/IL-8, one of their major products, in the triggering of reactive arthritis. We thank Heidi Muhlethaler, Paula Rahikainen, and Eine Virolainen for technical help. The study was supported by grants from the Yrjo Jahnsson Foundation, Helsinki and the Finnish Cultural Fund, Helsinki, Finland. H REPO M RISTOLA MARJATTA LEIRISALO-REPO Department of Bacteriology and Immunology Second Department of Medicine University of Helsinki Helsinki, Finland
A WALZ M BAGGIOLINI Theodor-Kocher Institute
University of Bern Bern, Switzerland
Correspondence to: Dr Heikki Repo, Department of Bacteriology and Immunology, University of Helsinki, Haartmaninkatu 3, SF-00290 Helsinki, Finland.
1 Arnett F C. The Lyme spirochete: another cause of Reiter's syndrome? Arthritis Rheum 1989; 32: 1082-4. 2 Repo H, Ristola M, Leirisalo-Repo M. Enhanced inflammatory reactivity in the pathogenesis of spondyloarthropathies. Autoimmunity 1990; 7: 245-54. 3 Leirisalo M, Repo H, Tiilikainen A, Kosunen T U, Laitinen 0. Chemotaxis in yersinia arthritis. HLA-B27 positive neutrophils show high stimulated motility in vitro. Arthritis Rheum 1980; 23: 1036-44. 4 Repo H, Koivuranta-Vaara P, Leirisalo-Repo M. Polymorphonuclear leucocyte function and previous yersinia arthritis: correlation of enhanced superoxide production with late manifestations. Ann Rheum Dis 1988; 47: 452-7. 5 Baggiolini M, Walz A, Kunkel S L. Neutrophilactivating peptide-1/interleukin 8, a novel cytokine that activates neutrophils. J Clin Invest 1989; 84: 1045-9. 6 Keat A, Thomas B, Dixey J, Osborn M, Sonnex
C, Taylor-Robinson D. Chlamydia trachomatis and reactive arthritis: the missing link. Lancet 1987; i: 72-4. 7 Granfors K, Jalkanen S, von Essen R, et al. Yersinia antigens in synovial-fluid cells from patients with reactive arthritis. N Engl J Med 1989; 320: 2 16-2 1. 8 Granfors K, Jalkanen S, Lindberg A A, et al. Salmonella lipopolysaccharide in synovial cells from patients with reactive arthritis. Lancet 1990; 335:685-8. 9 Leirisalo-Repo M, Suoranta H. Ten-year followup study of patients with yersinia arthritis. Arthritis Rheum 1988; 31: 533-7. 10 Walz A, Peveri P, Aschauer H, Baggiolini M. Purification and amino acid sequencing of NAF, a novel neutrophil-activating factor produced by monocytes. Biochem Biophys Res Commun 1987; 149: 755-61. 11 Hoogkamp-Korstanje J A A, de Koning J, Samsom J P. Incidence of human infection with Yersinia enterocolitica serotypes 03, 08, and 09 and the use of indirect immunofluorescence in diagnosis. J Infect Dis 1986; 153: 138-41. 12 Granfors K, Jalkanen S, Lahesmaa-Rantala R, Saario R, Mottonen T, Toivanen A. Bacterial antigens in peripheral blood cells in yersiniatriggered reactive arthritis [abstract]. Scand J Rheumatol Suppl 1990; 85: 45. 13 Koivuranta-Vaara. P, Repo H, Leirisalo M, Kiistala U, Osterman T, Vapaatalo H. Enhanced neutrophil migration in vivo in HLA-B27 positive subjects. Ann Rheum Dis 1984;43: 181-5. 14 Pease C T, Fordham J N, Currey H L F. Polymorphonuclear cell motility, ankylosing spondylitis, and HLA-B27. Ann Rheum Dis 1984; 43: 279-84. 15 Koivuranta-Vaara P, Repo H, Leirisalo-Repo M. Polymorphonuclear leucocyte function and previous yersinia arthritis: enhanced chemokinetic migration and oxygen radical production correlate with the severity of the acute disease. Ann Rheum Dis 1987; 46: 307-13.
Hand radiography: an indicator of upper cervical disease in rheumatoid arthritis
Sir: One of the most dangerous complications of rheumatoid arthritis is upper cervical disease, which can cause sudden deaths and serious neurological problems. In previous surveys, reported prevalences of atlantoaxial subluxations range between 19 and 71% according to the patient selection and radiological techniques used.' Although direct radiographic investigations can show atlantoaxial subluxations, computed tomography (CT) and magnetic resonance imaging are the best procedures for eliciting the myelopathy and bone soft tissue pathologies in this region." As these methods are expensive, however, the question then has to be asked: which patients with rheumatoid arthritis should be evaluated by CT or magnetic resonance imaging? Conlon et al were the first group reporting a relation between atlantoaxial subluxations and severe peripheral joint destruction.2 Later, reports from Stevens et al ' and Rasker and Cosh3 supported this view. We attempted to determine if the CT findings correlate with hand radiographic findings or not. We studied 40 patients chosen randomly from 138 outpatients at Ankara Hospital, diagnosed as having rheumatoid arthritis according to the 1987 revised criteria of the American Rheumatism Association.8 Anteroposterior and lateral radiographs were obtained and then we carried out CT of the craniocervical junction in the axial and coronal planes with the patient's neck in maximum flexion and neutral position by using a third generation scanner. We noticed not only atlantoaxial subluxations but also erosions of the odontoid process or atlas arcus, thickness of the ligaments, distension of the synovial cavities, and ligament
ruptures.
Of the 40 patients studied, 12 had completely normal or slightly abnormal (periarticular soft tissue swelling, periarticular osteoporosis, slight joint space narrowing) hand radiographs. In this group there was no evidence of upper cervical disease or atlantoaxial subluxations in CT scans, except in one patient who had a slightly thickened transverse ligament. In the remaining group of 28 patients, who had erosions and marked joint space narrowing in hand radiographs, we found CT abnormalities of all kinds in 25 and atlantoaxial subluxations in 19 patients. As expected, atlantoaxial subluxations were associated with severe and mutilating abnormalities in the hand radiographs. We suggest that ifthe hand radiographs are normal, upper cervical spine disease should not be expected in rheumatoid arthritis and there is no need for sophisticated examination of this region. M NAFIZ AKMAN
GULAY DINQER
8 cadde 85 sokak 22/6 Emek 06510 Ankara
Turkey
1 Stevens J C, Cartlidge N E F, Saunders M, Appleby A, Hall M, Shaw D A. Atlanto-axial subluxation and cervical myelopathy in rheumatoid arthritis. Q J Med 1971; 159: 391-408. 2 Conlon P W, Isdale I C, Rose B S. Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis 1966; 25: 120-6. 3 Rasker J J, Cosh J A. Radiological study of cervical spine and hand in patients with rheumatoid arthritis of 15 years' duration: an assessment of the effects of corticosteroid treatment. Ann Rheum Dis 1978; 37: 529-35. 4 Daniels D L, Williams A L, Haughton V M. Computed tomography of the articulations and ligaments at the occipito-atlanto-axial region. Radiology 1983; 146: 709-16. 5 Castor W R, Miller J D R, Russell A S, Chiu P L, Grace M, Hanson J. Computed tomography of the craniocervical junction in rheumatoid arthritis. J ComputAssist Tomogr 1983; 7: 31-6. 6 Toolanen G, Larsson S E, Fagerlund M. Medullary compression in rheumatoid atlanto-axial subluxation evaluated by computerised tomography. Spine 1986; 11: 191-4. 7 Reynolds H, Carter S W, Murtagh F R, Rechtine G R. Cervical rheumatoid arthritis: value of flexion and extension views in imaging. Radiology 1987; 164: 215-8. 8 Arnett F C, Edworthy S M, Bloch D A, et al. The American Rheumatism Association 1987 revised criteria for classification of rheumatoid arthritis. Arthritis Rheum 1988; 31: 315-24.
Positive antinuclear antibodies in
malignancies
Sir: I read with interest the recent case report of a patient with Raynaud's phenomenon and positive antinuclear antibodies in a malignancy.' I would like to report two additional cases of malignancies, which were associated with Raynaud's phenomenon and a high titre of antinuclear antibodies, and make some comments on the subject. CASE I
A 61 year old man presented for rheumatology evaluation with a six month history of arthralgias in both hands and a six week history of severe Raynaud's phenomenon. Eight months earlier he had been admitted to hospital because of hemiparesis of his left arm and leg, which lasted a couple of days with fever of 39- 5C. He was checked thoroughly in a neurological and a medical clinic, but no underlying cause of the prolonged neurological deficit and the fever was found. Finally, he was suspected to have an unknown vasculitis and given high dose steroids, which relieved his symptoms. Antinuclear antibodies were negative at that time. When he was referred to
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Normal production of neutrophil activating peptide 1/interleukin 8 in monocytes from subjects with previous yersinia triggered reactive arthritis. H Repo, M Ristola, M Leirisalo-Repo, A Walz and M Baggiolini Ann Rheum Dis 1992 51: 572-573
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Annals of the Rheumatic Diseases 1992; 51: 572-575
572
Table 2 Neutrophil activating peptide llinterleukin 8 (NAP-IIIL-8) concentrations in the media of mononuclear cells culturedfor 24 hours in the presence ofdifferent concentrations of lipopolysaccharide (LPS). ' Results are given as the geometric mean (-SD; +SD)
LETTERS TO THE EDITOR
LIPS
NAP-IIIL-8 (nmolll)
(pg/ml) 10 1 01 0 01 0
Normal production of neutrophil activating peptide I/interleukin 8 in monocytes from subjects with previous yersinia triggered reactive arthritis
I
II
III
IV
V
17 4(6 2;48 2)
16-7(6-6;41-9) 10-1 (45;222) 6-2(3-5;10-7) 4-4(2-2;8-6)
15-6(6-9;34-6) 98 (45;21 1)
16 7(6 1;45 9) 97 (36;258) 6-7(2-8;15 8) 5 7(2 7,11-9) 3 5 (0 9;1 1-9)
15 6(5 2;46 3) 106 (34;31 6) 7 2(2-0;25-1) 6 4(1-9;20 9) 46(0;24-3)
11l0(3-8;31-3) 7 7(3-0;19 7) 5 2(2-1;12-2) 3 6 (0;14 8)
2-2 (0;8-9)
5-8(3-0;114)
4-6(2-5;8-2) 3-2 (0-8;10 6)
*For explanation of groups see table 1.
colitica (0:3 or 0:9). At the time of this study the subjects had recovered completely from yersinia infection/arthritis, did not use antiinflammatory drugs, and were free from signs and symptoms of infection. Blood samples from two subjects with previous yersinia arthritis (one HLA-B27 positive, the other HLA-B27 negative), one subject with previous yersinia enteritis, and two controls (one HLA-B27 positive, the other HLA-B27 negative) without a history of yersinia infection were taken and studied concurrently on a given day. In three series of experiments, group II and group III subjects (see table 1) were not available for study. Buffy coat cells were prepared from peripheral blood anticoagulated with heparin (10 U/ml). Mononuclear cells were separated by dextran sedimentation and Ficoll-Isopaque density gradient centrifugation.' The purified cells were washed three times with Hanks's balanced salt solution and then suspended in RPMI 1640 medium supplemented with 1-25% (vol/vol) pyrogen-free albumin solution (40 mg/ml; Finnish Red Cross Blood Transfusion Service, Helsinki), 1 mM HEPES buffer, 2 mM L-glutamine, and antibiotics. Samples (I ml) containing 1 x 106 monocytes were cultured in 24-well tissue culture plates (Costar, Cambridge MA, USA; No 3424) for 24 hours at 37°C in 5% C02 and 95% air in the presence of 0 to 10 ig/ml Escherichia coli 026:B6 lipopolysaccharide (Sigma Chemical Company, St Louis, MO, USA). The culture supernatants were then collected and stored at 60°C before analysis for NAP-1/IL-8 content. Concentrations ofNAP- 1/IL-8 in the culture supernatants were determined by a microtitre plate assay for elastase release from human peripheral blood buffy coat neutrophils.'0 In brief, 100 RI portions of a neutrophil suspension (107 cells/ml) treated for 10 minutes with S ig/ml cytochalasin B were dispensed into the wells containing 125 nmol of elastase substrate
SIR: Ankylosing spondylitis and reactive arthritis, a form of sterile joint inflammation triggered by an infection elsewhere in the body, belong to a family of seronegative spondyloarthropathies. Reactive arthritis can follow enteric infections caused by salmonella, shigella, campylobacter, or Yersinia enterocolitica, urogenital infection caused by chlamydia, and, possibly also, infections caused byBorrelia burgdorferi, among others. ' About 80% of patients with reactive arthritis carry the HLAB27 antigen. The mechanism of this disease is not known, but non-specific inflammatory reactions of the host with increased generation of inflammatory mediators or increased responsiveness to them may play a part.2 For instance, subjects with previous yersinia triggered reactive arthritis show enhanced neutrophil chemotaxis3 and increased oxygen radical production.4 Neutrophil activating peptide 1/ interleukin 8 (NAP-1/IL-8) is a newly characterised chemotactic cytokine, produced by stimulated mononuclear phagocytes and a variety of tissue cells.5 Production of NAP-l/ IL-8 may be induced by microbial antigens, which were recently found in the inflamed joints of patients with reactive arthritis triggered by chlamydia,6 yersinia,7 or salmonella.t To find out whether subjects susceptible to the development of reactive arthritis show aberrant production of cytokines we compared NAP-1/IL-8 production by monocytes of subjects with previous yersinia arthritis, uncomplicated yersinia enteritis, and without a history of yersinia infection. Subjects were allocated to five groups (I-V, table 1) on the basis of HLA-B27, previous yersinia triggered reactive arthritis (yersinia arthritis), and previous uncomplicated yersinia enteritis. Twenty one subjects with previous yersinia arthritis were selected from a follow up patient group,9 nine subjects with previous non-complicated yersinia enteritis had been treated at the Helsinki University Central Hospital, and 24 subjects without a history of yersinia infection were healthy laboratory and hospital personnel. Diagnosis of yersinia infection was based on a stool culture positive for the organism or a raised agglutination antibody titre (>1/160) for Yersinia entero-
(N-methoxysuccinyl-ala-ala-pro-val-7-amido4-methylcoumarin; Bachem, Budendorf, Switzerland) and the test sample in 150 ,ul phosphate buffered saline containing 2 5 mg/ ml of bovine serum albumin (Fluka AG, Buchs, Switzerland). For each plate, background and NAP-1/IL-8 controls (0-3, 1, 3,
10, 30, 100 nmol/l) were included. The assay was performed at room temperature using a Titertek Fluoroscan (Elflab, Helsinki, Finland), and the titres in test samples were determined from an NAP-1/IL-8 standard curve. The frequency distributions of NAP-1/IL-8 values were significantly skewed, but could be normalised by logarithmic transformation, and therefore the data are expressed as geometric means (SD). To evaluate the responsiveness of the cells, differentials were determined by subtracting the control value in the absence of lipopolysaccharide from the values in the presence of lipopolysaccharide. The significance of the difference between the groups was evaluated by Student's t test. The results showed that monocyte and lymphocyte counts were similar in the five subject groups (table 1). In all cases low levels of NAP-1/IL-8 production were seen in the absence of lipopolysaccharide and the yields increased markedly in parallel with the lipopolysaccharide concentration, reaching a maximum on exposure to 10 [sg/ml lipopolysaccharide (table 2). No significant difference was obtained in the yield of NAP-1/IL-8, in the presence and absence of lipopolysaccharide, among groups I to V (table 2; figure). The differentials at each lipopolysaccharide concentration among the five groups were also similar (data not shown). In patients with reactive arthritis consequent upon chlamydia, yersinia, or salmonella, antigens of the triggering microbe are detected in the inflamed joint."8 In two cases yersinia 5r *
4
.
6 --f 00
-32 cs
-U-w
gO
I
a@ Table I Characteristics of the subject groups"' and differential counts of mononuclear cells after Ficoll-Isopaque centrifugatton Characteristics
I
II
III
IV
V
Number of subjects Men/women Mean age in years (range) Mean period in years (range) since yersinia infection Mean (SD) differential count (%)
12 7/5 40 (26-49)
9 2/7 56 (48-70)
9 1/8 43 (26-29)
12 2/10 44 (29-63)
12 3/9 43 (35-47)
15 (10-20)
16 (14-19)
6 (2-14)
-
-
25 (5) 27 (7) 26 (6) 23 (5) 27 (6) Monocytes 71 (8) 73 (7) 74 (6) 72 (7) Lymphocytes 71(6) 'I = HLA-B27 positive subjects with previous yersinia arthritis; II= HLA-B27 negative subjects with previous yersinia arthritis; III= subjects with previous yersinia infection without extraintestinal manifestations (two of these were HLA-B27 positive); IV=HLA-B27 positive subjects without a history of yersinia infection; V= HLA-B27 negative subjects without a history of yersinia infection
0
*-
03
.-
a
0 .
11
III
IV
V
Concentrations (nmolll) ofneutrophil activating peptide l/interleukin 8 (NAP-IIIL-8) in the media of mononuclear cells culturedfor 24 hours in the presence of 10 tg/ml lipopolysaccharide. Geometric means and SD values are indicated by horizontal lines. I-V denotes thefive groups described in table 1.
Downloaded from http://ard.bmj.com/ on May 30, 2015 - Published by group.bmj.com
573
Letters to the editor
antigen was detected as long as three and 17 years after yersinia infection,7 suggesting that the microbial structures can persist in the tissues. The antigens are found in mesenteric and cervical lymph nodes and in the skin," and, during the acute phase of infection, in peripheral blood cells of almost every patient, including patients who will not develop reactive arthritis.'2 Thus the presence of antigens in the blood provides an explanation for extensive antigen dissemination, but not for the development of reactive arthritis and other clinically significant extraintestinal manifestations. Possibly, extraintestinal symptoms derive from inflammatory hyperreactivity of the patient to the antigenic stimulus. It has been reported that neutrophils of HLA-B27 positive subjects without a history of yersinia infection and of patients with previous yersinia reactive arthritis show enhanced neutrophil migration in response to a chemotactic stimulus in vitro3 and in vivo,3 as do patients with ankylosing spondylitis, at least in vitro."' Furthermore, neutrophils from patients who have a history of severe actue yersinia triggered reactive arthritis,'5 or with sequelae,4 show increased generation of oxygen radicals in vitro. NAP-l/ IL-8 stimulates neutrophil chemotaxis and oxygen radical production5 and might thereby contribute to the neutrophil hyperactivity. In conclusion, the results show that both control and lipopolysaccharide induced NAP1/IL-8 production by monocytes was similar in subjects with past yersinia arthritis or enteritis and unaffected subjects, and did not differ between HLA-B27 positive and negative subjects. This seems to rule out an aberrant function of monocytes, at least for the synthesis and release of NAP-1/IL-8, one of their major products, in the triggering of reactive arthritis. We thank Heidi Muhlethaler, Paula Rahikainen, and Eine Virolainen for technical help. The study was supported by grants from the Yrjo Jahnsson Foundation, Helsinki and the Finnish Cultural Fund, Helsinki, Finland. H REPO M RISTOLA MARJATTA LEIRISALO-REPO Department of Bacteriology and Immunology Second Department of Medicine University of Helsinki Helsinki, Finland
A WALZ M BAGGIOLINI Theodor-Kocher Institute
University of Bern Bern, Switzerland
Correspondence to: Dr Heikki Repo, Department of Bacteriology and Immunology, University of Helsinki, Haartmaninkatu 3, SF-00290 Helsinki, Finland.
1 Arnett F C. The Lyme spirochete: another cause of Reiter's syndrome? Arthritis Rheum 1989; 32: 1082-4. 2 Repo H, Ristola M, Leirisalo-Repo M. Enhanced inflammatory reactivity in the pathogenesis of spondyloarthropathies. Autoimmunity 1990; 7: 245-54. 3 Leirisalo M, Repo H, Tiilikainen A, Kosunen T U, Laitinen 0. Chemotaxis in yersinia arthritis. HLA-B27 positive neutrophils show high stimulated motility in vitro. Arthritis Rheum 1980; 23: 1036-44. 4 Repo H, Koivuranta-Vaara P, Leirisalo-Repo M. Polymorphonuclear leucocyte function and previous yersinia arthritis: correlation of enhanced superoxide production with late manifestations. Ann Rheum Dis 1988; 47: 452-7. 5 Baggiolini M, Walz A, Kunkel S L. Neutrophilactivating peptide-1/interleukin 8, a novel cytokine that activates neutrophils. J Clin Invest 1989; 84: 1045-9. 6 Keat A, Thomas B, Dixey J, Osborn M, Sonnex
C, Taylor-Robinson D. Chlamydia trachomatis and reactive arthritis: the missing link. Lancet 1987; i: 72-4. 7 Granfors K, Jalkanen S, von Essen R, et al. Yersinia antigens in synovial-fluid cells from patients with reactive arthritis. N Engl J Med 1989; 320: 2 16-2 1. 8 Granfors K, Jalkanen S, Lindberg A A, et al. Salmonella lipopolysaccharide in synovial cells from patients with reactive arthritis. Lancet 1990; 335:685-8. 9 Leirisalo-Repo M, Suoranta H. Ten-year followup study of patients with yersinia arthritis. Arthritis Rheum 1988; 31: 533-7. 10 Walz A, Peveri P, Aschauer H, Baggiolini M. Purification and amino acid sequencing of NAF, a novel neutrophil-activating factor produced by monocytes. Biochem Biophys Res Commun 1987; 149: 755-61. 11 Hoogkamp-Korstanje J A A, de Koning J, Samsom J P. Incidence of human infection with Yersinia enterocolitica serotypes 03, 08, and 09 and the use of indirect immunofluorescence in diagnosis. J Infect Dis 1986; 153: 138-41. 12 Granfors K, Jalkanen S, Lahesmaa-Rantala R, Saario R, Mottonen T, Toivanen A. Bacterial antigens in peripheral blood cells in yersiniatriggered reactive arthritis [abstract]. Scand J Rheumatol Suppl 1990; 85: 45. 13 Koivuranta-Vaara. P, Repo H, Leirisalo M, Kiistala U, Osterman T, Vapaatalo H. Enhanced neutrophil migration in vivo in HLA-B27 positive subjects. Ann Rheum Dis 1984;43: 181-5. 14 Pease C T, Fordham J N, Currey H L F. Polymorphonuclear cell motility, ankylosing spondylitis, and HLA-B27. Ann Rheum Dis 1984; 43: 279-84. 15 Koivuranta-Vaara P, Repo H, Leirisalo-Repo M. Polymorphonuclear leucocyte function and previous yersinia arthritis: enhanced chemokinetic migration and oxygen radical production correlate with the severity of the acute disease. Ann Rheum Dis 1987; 46: 307-13.
Hand radiography: an indicator of upper cervical disease in rheumatoid arthritis
Sir: One of the most dangerous complications of rheumatoid arthritis is upper cervical disease, which can cause sudden deaths and serious neurological problems. In previous surveys, reported prevalences of atlantoaxial subluxations range between 19 and 71% according to the patient selection and radiological techniques used.' Although direct radiographic investigations can show atlantoaxial subluxations, computed tomography (CT) and magnetic resonance imaging are the best procedures for eliciting the myelopathy and bone soft tissue pathologies in this region." As these methods are expensive, however, the question then has to be asked: which patients with rheumatoid arthritis should be evaluated by CT or magnetic resonance imaging? Conlon et al were the first group reporting a relation between atlantoaxial subluxations and severe peripheral joint destruction.2 Later, reports from Stevens et al ' and Rasker and Cosh3 supported this view. We attempted to determine if the CT findings correlate with hand radiographic findings or not. We studied 40 patients chosen randomly from 138 outpatients at Ankara Hospital, diagnosed as having rheumatoid arthritis according to the 1987 revised criteria of the American Rheumatism Association.8 Anteroposterior and lateral radiographs were obtained and then we carried out CT of the craniocervical junction in the axial and coronal planes with the patient's neck in maximum flexion and neutral position by using a third generation scanner. We noticed not only atlantoaxial subluxations but also erosions of the odontoid process or atlas arcus, thickness of the ligaments, distension of the synovial cavities, and ligament
ruptures.
Of the 40 patients studied, 12 had completely normal or slightly abnormal (periarticular soft tissue swelling, periarticular osteoporosis, slight joint space narrowing) hand radiographs. In this group there was no evidence of upper cervical disease or atlantoaxial subluxations in CT scans, except in one patient who had a slightly thickened transverse ligament. In the remaining group of 28 patients, who had erosions and marked joint space narrowing in hand radiographs, we found CT abnormalities of all kinds in 25 and atlantoaxial subluxations in 19 patients. As expected, atlantoaxial subluxations were associated with severe and mutilating abnormalities in the hand radiographs. We suggest that ifthe hand radiographs are normal, upper cervical spine disease should not be expected in rheumatoid arthritis and there is no need for sophisticated examination of this region. M NAFIZ AKMAN
GULAY DINQER
8 cadde 85 sokak 22/6 Emek 06510 Ankara
Turkey
1 Stevens J C, Cartlidge N E F, Saunders M, Appleby A, Hall M, Shaw D A. Atlanto-axial subluxation and cervical myelopathy in rheumatoid arthritis. Q J Med 1971; 159: 391-408. 2 Conlon P W, Isdale I C, Rose B S. Rheumatoid arthritis of the cervical spine. An analysis of 333 cases. Ann Rheum Dis 1966; 25: 120-6. 3 Rasker J J, Cosh J A. Radiological study of cervical spine and hand in patients with rheumatoid arthritis of 15 years' duration: an assessment of the effects of corticosteroid treatment. Ann Rheum Dis 1978; 37: 529-35. 4 Daniels D L, Williams A L, Haughton V M. Computed tomography of the articulations and ligaments at the occipito-atlanto-axial region. Radiology 1983; 146: 709-16. 5 Castor W R, Miller J D R, Russell A S, Chiu P L, Grace M, Hanson J. Computed tomography of the craniocervical junction in rheumatoid arthritis. J ComputAssist Tomogr 1983; 7: 31-6. 6 Toolanen G, Larsson S E, Fagerlund M. Medullary compression in rheumatoid atlanto-axial subluxation evaluated by computerised tomography. Spine 1986; 11: 191-4. 7 Reynolds H, Carter S W, Murtagh F R, Rechtine G R. Cervical rheumatoid arthritis: value of flexion and extension views in imaging. Radiology 1987; 164: 215-8. 8 Arnett F C, Edworthy S M, Bloch D A, et al. The American Rheumatism Association 1987 revised criteria for classification of rheumatoid arthritis. Arthritis Rheum 1988; 31: 315-24.
Positive antinuclear antibodies in
malignancies
Sir: I read with interest the recent case report of a patient with Raynaud's phenomenon and positive antinuclear antibodies in a malignancy.' I would like to report two additional cases of malignancies, which were associated with Raynaud's phenomenon and a high titre of antinuclear antibodies, and make some comments on the subject. CASE I
A 61 year old man presented for rheumatology evaluation with a six month history of arthralgias in both hands and a six week history of severe Raynaud's phenomenon. Eight months earlier he had been admitted to hospital because of hemiparesis of his left arm and leg, which lasted a couple of days with fever of 39- 5C. He was checked thoroughly in a neurological and a medical clinic, but no underlying cause of the prolonged neurological deficit and the fever was found. Finally, he was suspected to have an unknown vasculitis and given high dose steroids, which relieved his symptoms. Antinuclear antibodies were negative at that time. When he was referred to
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Normal production of neutrophil activating peptide 1/interleukin 8 in monocytes from subjects with previous yersinia triggered reactive arthritis. H Repo, M Ristola, M Leirisalo-Repo, A Walz and M Baggiolini Ann Rheum Dis 1992 51: 572-573
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