Protracted anemia associated with chronic, relapsing systemic inflammation induced by arthropathic peptidoglycan-polysaccharide polymers in rats.

Mild hypoproliferative anemia with abnormal iron metabolism frequently accompanies chronic inflammation and infection in humans. To determine whether anemia is associated with chronic relapsing arthritis induced by bacterial cell wall polymers, serial determinations of the hematocrit were measured in rats injected intraperitoneally with sonicated peptidoglycan-polysaccharide fragments from group A streptococci. Acute anemia peaked 5 to 10 days after injection, and chronic, spontaneously relapsing anemia persisted for 309 days. 51Cr labeling demonstrated decreased erythrocyte survival, i.e., a half-life of 8.4 days in cell wall-injected rats versus 11.8 days in controls. Erythrocytes were mildly microcytic, and leukocyte counts were elevated during early spontaneous reactivation of arthritis, 15 days after injection of peptidoglycan-polysaccharide. Bone marrow myeloid/erythroid precursor ratios were elevated in arthritic rats (P less than 0.0001). Purified peptidoglycan produced an acute anemia lasting 10 days, while injection of group A streptococcal polysaccharide and mutanolysin-digested cell wall did not affect the hematocrit. The minimal effective dose of peptidoglycan-polysaccharide was 5 micrograms of rhamnose per g (body weight). Serum iron and transferrin levels were decreased in cell wall-injected rats (P less than 0.005) and were closely correlated with hematocrit values and joint inflammatory scores. Stainable iron was increased in the liver, spleen, and mesenteric lymph nodes and unchanged in the bone marrow of cell wall-injected rats. Anemia accompanying chronic, relapsing systemic inflammation induced by peptidoglycan-polysaccharide polymers appears to be an excellent animal model of the anemia of chronic disease.

Immunosuppressive macrophages induced by arthropathic peptidoglycan-polysaccharide polymers from bacterial cell walls.

Rats injected with peptidoglycan-polysaccharide polymers derived from group A streptococcal cell walls (PG-APS) develop a chronic, remittant, erosive synovitis. Spleen cells from injected rats failed to proliferate when stimulated in vitro by Con A or PHA, unless nylon wool adherent cells were first removed. The suppression could also be reversed by removing phagocytic cells which had ingested carbonyl iron. Cells from control rats were suppressed in vitro by co-culture with unfractionated or nylon wool-adherent cells from PG-APS injected rats, and the suppressor activity was still expressed after exposure of the suppressor cells to 3,000 rad of irradiation. Addition of catalase and indomethacin to cultures only partially reversed the suppression. T lymphocytes from rats given a single arthropathic dose of PG-APS remained suppressed for at least 86 days after injection. Cells from rats given a low, non-arthropathic dose of PG-APS did not become suppressed. Cells from the Buffalo rat, which is resistant to development of PG-APS-induced chronic arthritis, showed less suppression than cells from the susceptible Lewis and Sprague-Dawley rat strains.

Lipopolysaccharide induces recurrence of arthritis in rat joints previously injured by peptidoglycan-polysaccharide.

Rat ankle joints injected intraarticularly with 5 micrograms of group A streptococcal peptidoglycan-polysaccharide (PG-APS) developed an acute course of arthritis. Recurrence of arthritis was induced in 100% of these joints by intravenous injection of as little as 10 micrograms of Salmonella typhimurium lipopolysaccharide (LPS) 3 wk after intraarticular injection. This reaction was similar in athymic and euthymic rats. Buffalo rats were less susceptible than Lewis or Sprague-Dawley rats. Neisseria gonorrhoeae, Yersinia enterocolitica, and Escherichia coli LPS, and S. typhimurium Re mutant LPS, were also active. Re mutant LPS activity was greatly reduced by mixing with polymyxin B. E. coli lipid A was weakly active. An acute synovitis of much less incidence, severity, and duration was seen in contralateral joints injected initially with saline, and in ankle joints of naive, previously uninjected rats after intravenous LPS injection. The intravenous injection of the muramidase mutanolysin on day 0 or 7 after intraarticular PG-APS injection prevented LPS-induced recurrence of arthritis. These studies suggest that the phlogistic activities of lipid A and peptidoglycan might interact in an inflammatory disease process, and that LPS may play a role in recurrent episodes of rheumatoid arthritis or reactive arthritis.

Effect of acetylation on arthropathic activity of group A streptococcal peptidoglycan-polysaccharide fragments.

Purified group A streptococcal peptidoglycan-polysaccharide (PG-PS) fragments were either de-O-acylated, or acetylated and then de-O-acylated to yield N-acetylated PG-PS. Native PG-PS was poorly degraded, N-acetylated PG-PS was extensively degraded, and de-O-acylated PG-PS was only slightly degraded by hen egg white lysozyme. N-acetylated PG-PS was also extensively degraded by human lysozyme and partially degraded by rat serum or rat liver extract. After a single intraperitoneal injection of rats with a sterile, aqueous suspension, all PG-PS preparations induced acute arthritis. The acute arthritis induced by N-acetylated PG-PS was significantly more severe than that induced by native PG-PS; that induced by de-O-acylated PG-PS was of intermediate severity. After the acute reaction, rats injected with native PG-PS developed chronic relapsing erosive synovitis which remained severe for the duration of the experiment (83 days). In contrast, joint inflammation induced by N-acetylated PG-PS resolved within 6 weeks with little evidence of recurrent disease. Chronic arthritis induced by de-O-acylated PG-PS was of intermediate severity. In another assay of arthropathic activity, the arthritis in all rat ankle joints, which had been injected directly with native PG-PS, could be reactivated 3 weeks later by the intravenous injection of a small dose of PG. In contrast, only 50% of the joints initially injected with de-O-acylated PG-PS and none of the joints injected with N-acetylated PG-PS could be reactivated. These studies support the concepts that the resistance of PG-PS to muralytic digestion is crucial for chronic arthropathic activity and that the nature and degree of PG acetylation are important molecular determinants of the phlogistic activities of PG-PS polymers.

Comparison of in vivo degradation of 125I-labeled peptidoglycan-polysaccharide fragments from group A and group D streptococci.

The in vivo degradation and persistence of 125I-labeled peptidoglycan-polysaccharide (PG-PS) fragments from the cell walls of group A and D streptococci were compared by group after intraperitoneal injection into rats. The quantity of PG-PS in the livers and spleens of group D PG-PS-injected rats was less than the quantity in rats injected with group A PG-PS throughout the course of the experiment. Gel filtration analyses of liver and spleen homogenates indicated that group A PG-PS was relatively resistant to degradation, whereas group D PG-PS was extensively degraded to yield a heterogeneous mixture of fragments of lower molecular weight. There was no significant difference in the content of group A PG-PS versus that of group D in joints or blood samples. Analysis of fragment sizes in these tissues also indicated more extensive degradation of group D PG-PS. However, the majority of group A PG-PS in blood samples and joints was a lower molecular weight than that found in the livers or spleens. We conclude that group A PG-PS undergoes a significant but low level of degradation and that group D PG-PS is much less persistent and more extensively degraded than group A PG-PS is in vivo. These differences in PG-PS catabolism may account, in part, for the capacity of group A PG-PS to induce chronic, recurrent arthritis of longer duration than that induced by group D PG-PS.

Localized gut-associated lymphoid tissue hemorrhage induced by intravenous peptidoglycan-polysaccharide polymers.

A hemorrhage into gut-associated lymphoid tissue developed as early as 3 min after the intravenous injection of group A streptococcal peptidoglycan-polysaccharide polymers into rats. Extravasated erythrocytes were specifically located in the lamina propria and organized lymphoid follicles of the intestines and mesenteric lymph nodes and did not occur in the lungs, kidneys, liver, spleen, adrenal glands, or submandibular and popliteal lymph nodes, as determined by gross and histologic observations and measurement of radiolabeled erythrocytes. Petechial hemorrhage was preferentially located within the intestine to the distal ileum, Peyer's patches, and lymphoid aggregates of the colon. The hemorrhage was transient and occurred in a dose-dependent fashion. It was maximal 5 min after injection and resolved completely by 3 days. A unique feature of this altered vascular permeability was the absence of polymorphonuclear leukocytic infiltration, edema, vasculitis, and tissue necrosis.

Comparison of inflammatory reactions induced by intraarticular injection of bacterial cell wall polymers.

Cell wall polymers isolated from group A streptococci, as well as lipopolysaccharide from Salmonella typhimurium and synthetic muramyl dipeptide, were injected into the ankle joints of rats. The inflammatory responses were assessed by gross and histologic examination, and edema was measured by accumulation of radiolabeled albumin in the limbs. The isolated group-specific polysaccharide induced extensive edema of the articular and periarticular tissue immediately after injection, and this resolved in 24 hours. The peptidoglycan moiety did not produce early edema, but induced an acute exudative reaction followed by a proliferative synovitis which resolved after 5 days. Reactions induced by covalently bound complexes of peptidoglycan and the group-specific polysaccharide (PG-APS) varied, depending on the size of the complex. Small fragments, derived from mutanolysin digestion, caused both an acute edematous reaction and transient arthritis. Larger fragments did not cause the immediate edematous reaction, but induced an acute arthritis that appeared within 24 hours and evolved into a chronic process. Episodes of recurrent inflammation, a distinctive feature of joint inflammation induced by systemic injection of PG-APS polymers, were not observed following intraarticular injection of any of the cell wall polymers. The relative susceptibility of different rat strains to arthritis induced by intraarticular injection paralleled the responses to systemic injection of PG-APS. These results demonstrate that variations in arthropathogenicity are due, in part, to inherent differences in the phlogistic activities of different cell wall polymers, and that the genetic control of susceptibility involves regulation of the inflammatory responses rather than the quantity of cell wall distributed to the joint.

Arthropathic properties of cell wall polymers from normal flora bacteria.

Peptidoglycan-polysaccharide (PG-PS) fragments were purified from cell walls of group D streptococci (Streptococcus faecium, strains ATCC 9790 and F-24) with a protocol which minimizes autolytic activity and tested for ability to induce arthritis in rats. PG-PS fragments from cell walls of other normal flora bacteria (Peptostreptococcus productus, and Propionibacterium acnes), group A streptococci, and pseudomurein-PS fragments from cell walls of Methanobacterium formicicum, were similarly purified and tested. Upon intraarticular injection into rat ankles, all PG-PS polymers induced acute inflammation; pseudomurein-PS fragments were approximately five times less active than the PG-PS preparations. After intraperitoneal injection, P. acnes PG-PS induced a minimal acute arthritis, Peptostreptococcus productus PG-PS induced a moderately severe acute joint inflammation followed by a mild chronic arthritis, and both group A and group D streptococcal PG-PS induced severe acute arthritis which evolved into chronic, erosive joint disease; pseudomurein-PS fragments were without effect, consistent with a crucial role for the PG moiety of PG-PS. Chronic arthritis induced by group D streptococcal PG-PS subsided after 60 days, whereas that induced by group A streptococcal PG-PS was still active after 128 days. The arthropathic properties of this modest number of common normal flora bacteria suggest that different PG-PS structures derived from the normal flora have the potential to induce a wide range of responses, from transient acute to chronic erosive joint disease.

Reactivation of streptococcal cell wall-induced arthritis by homologous and heterologous cell wall polymers.

Joint inflammation initially induced by intraarticular injection of an aqueous suspension of peptidoglycan-polysaccharide (PG-PS) fragments isolated from Streptococcus pyogenes was reactivated by systemic injection of a normally subarthropathic dose of homologous or heterologous cell wall polymers, including muramyl dipeptide and lipopolysaccharide. Reactivation was not correlated with the severity of the initial inflammatory reaction. Results of studies utilizing 125I-labeled PG-PS fragments suggested that reactivation was associated with increased localization of PG-PS fragments in the joint following reinjection. These results indicate that the initial injury of the joint by S pyogenes PG-PS fragments increases the susceptibility of the joint to subsequent injury. Furthermore, once the inflammatory reaction is initiated, it can be perpetuated by a variety of ubiquitous cell wall polymers derived from normal flora as well as from pathogenic bacteria.

Inflammation induced by bacterial cell wall fragments in the rat air pouch. Comparison of rat strains and measurement of arachidonic acid metabolites.

Streptococcal cell wall fragments, suspended in phosphate-buffered saline, were injected into a preformed subcutaneous air pouch in rats. The advantage of the air pouch model is the capacity for quantitation of exudative, cellular, and proliferative responses and soluble mediators. Accumulation of pouch fluid containing many leukocytes occurred during the first 3 days. Granulation tissue separable from the surrounding subcutaneous tissue developed by 6 days. Immunofluorescence and immunoperoxidase staining showed the presence of cell walls in inflammatory cells both in pouch fluid and in pouch tissue. Histologic features of this inflammation included an acute exudative phase with a predominantly neutrophil infiltration followed by a chronic phase characterized by fibroblast proliferation, formation of blood vessels, and infiltration with mononuclear cells. The lining of the pouch before injection of cell wall developed morphologic features of synovial membrane, which became more evident during the chronic phase of induced inflammation. Outbred Sprague-Dawley and inbred Lewis rats developed more pouch fluid, cell numbers in the pouch fluid, and granulation tissue than inbred Buffalo rats. The arachidonic acid metabolites, prostaglandin E2 and leukotriene B4, were measured in the pouch fluid, and more of each was produced in the Lewis than in the Buffalo strain. These measurements of inflammation are consistent with the relative susceptibility of these strains to cell-wall-induced arthritis. This model of inflammation can be used in the examination of the regulatory mechanisms of evolving chronic inflammation.

Measurement of streptococcal cell wall in tissues of rats resistant or susceptible to cell wall-induced chronic erosive arthritis.

The quantity of streptococcal cell wall localized in the joints of rats of strains which are either susceptible (Sprague-Dawley, LEW/N, M520/N) or resistant (Buffalo, WKY/N, F344/N) to cell wall-induced chronic erosive arthritis was measured after intraperitoneal injection of group A streptococcal cell wall fragments. Susceptibility or resistance was not associated with a difference in the amount of cell wall localized in limbs or other tissues. It is concluded that although localization of cell wall in joint tissue is essential for development of arthritis, the relative resistance of certain rat strains reflects genetic regulation of inflammatory response rather than a quantitative difference in localization of cell wall in joints.

Granulomatous enterocolitis induced in rats by purified bacterial cell wall fragments.

This study was designed to determine if poorly biodegradable bacterial cell wall components can produce chronic intestinal inflammation. A sterile aqueous suspension of sonically disrupted group A or group D streptococcal cell wall fragments was injected intramurally into the small intestine and cecum of 100 rats. Gross findings in rats killed at intervals of 1 day to 6 mo included intestinal thickening, adhesions, and mesenteric contraction. Acute histologic inflammation subsided by 2 wk, but chronic granulomatous inflammation persisted for 6 mo in the rats injected with group A streptococcal cell wall fragments and 3 mo in the rats injected with group D streptococcal cell wall fragments. Ninety-six control rats identically injected with human serum albumin or phosphate-buffered saline demonstrated mild acute inflammation that resolved, with only 1 rat having chronic intestinal inflammation. Granulomas in the intestine, mesentery, and mesenteric lymph nodes developed in 46% of the rats injected with group A fragments and 45% of the rats injected with group D streptococcal cell wall fragments, compared with 20% of the controls injected with albumin and 4% of the controls injected with phosphate-buffered saline. Group A streptococcal antigen was detected by immunofluorescence at the site of inflammation for 4 mo, and possible reactivation of acute inflammation was seen up to 6 mo after injection. We conclude that bacterial cell wall fragments are capable of producing chronic granulomatous inflammation in the intestinal wall if present in appropriate particle size and concentration. We speculate that cell walls from the enteric microflora may leak across a permeable mucosa in chronic inflammatory bowel disease to initiate and sustain local and systemic inflammation.

Treatment of experimental erosive arthritis in rats by injection of the muralytic enzyme mutanolysin.

A single intravenous injection into rats of 0.4 mg of the muralytic enzyme mutanolysin, given as long as 3 d after an arthropathic dose of peptidoglycan-polysaccharide polymers derived from group A streptococci (PG-APS), resulted in a complete resolution of acute arthritis and the prevention of chronic joint disease. When administration of mutanolysin was delayed until 14 d after the injection of PG-APS, a great reduction in the severity of chronic inflammation was still observed. Quantitation of the amount of PG-APS present in the limbs, spleen, and liver by a solid phase enzyme-linked immunoassay indicated that the tissues of mutanolysin-treated rats contained as much PG-APS as tissues of PBS-treated control rats. In addition, rats treated with mutanolysin immediately after receiving an intraperitoneal injection of PG-APS developed a transient limb edema similar to that seen in rats after the injection of PG-APS digested to a small fragment size in vitro with mutanolysin. We hypothesize that mutanolysin acts in vivo by degrading PG-APS to small fragments that persist but are no longer arthropathic.

Microangiographic studies of experimental erosive synovitis in rats.

Chronic remittent erosive synovitis, which is clinically, radiologically and pathologically similar to rheumatoid arthritis in man, can be produced in rats by systemic injection of cell wall fragments isolated from Group A streptococci. Because of our desire to study the synovial microvasculature in this experimental model, we developed a reliable microangiographic technique to document these changes. This paper describes the first reported microangiographic studies of rat joints and discusses the microvascular changes that parallel the previously reported radiographic and histologic findings. As the arthritis progresses, as judged by clinical and radiographic parameters, early synovial hypervascularity associated with developing hyperplastic synovium gives way to a more obliterative hypovascular pattern associated with chronic erosions, periosteal reaction, and fibrous ankylosis. Microangiography offers an additional and helpful modality by which to investigate synovial microvascular morphology as well as the pathophysiology of joint destruction during erosive synovitis.

Measurement of bacterial cell wall in tissues by solid-phase radioimmunoassay: correlation of distribution and persistence with experimental arthritis in rats.

We have developed sensitive and specific solid-phase radioimmunoassays to quantitate the distribution and persistence of bacterial antigen in rats developing arthritis in response to a single injection of streptococcal cell wall material. Three separate assays were specific for either the A polysaccharide (N-acetyl-D-glucosamine), A-variant polysaccharide (polyrhamnose), or peptidoglycan (D-ala-D-ala) moieties of the streptococcal cell wall. Antigen was detected in all tissues surveyed, although the greatest amount was in the liver and spleen. By using three fractions of cell wall separated by size, we have shown that the development of arthritis correlates with the degree of cell wall deposited and persisting in the joints. Further statistical analyses suggested differences in metabolism by different tissues and differential metabolism of different antigenic epitopes in some cases.

Relationship of complement to experimental arthritis induced in rats with streptococcal cell walls.

Experimental arthritis developed in rats injected intraperitoneally with aqueous suspensions of peptidoglycan-polysaccharide complexes (PG-APS) isolated from group A streptococcal cell walls. Reduction of serum complement by pretreatment with cobra venom factor (COV) reduced acute joint inflammation over the first 3 days following injection of PG-APs. Thereafter, the course of the disease was not different in the COV-treated rats. The serum levels of complement were depressed below detectable levels by 24 hr in rats injected only with cell walls, but rebounded to normal levels or above 3 days after injection. In rats injected with COV before cell walls, the complement levels also increased 3 days after injection of cell walls, in contrast to sustained depressed levels in rat injected only with COV. The correlation between severity of joint inflammation and serum complement levels at day 3 was positive in COV-treated rats. The quantity of cell wall per joint at day 3 correlated with the severity of joint disease. However, COV treatment did not alter the amount of cell wall localized in joint tissue. Therefore, although complement does appear to have a role in early joint inflammation, its effect is not upon the transport of cell wall into joint tissue.

Arthropathic properties related to the molecular weight of peptidoglycan-polysaccharide polymers of streptococcal cell walls.

The covalently bound polymers of peptidoglycan and group-specific polysaccharide (PG-APS) were isolated from the cell walls of group A streptococci. Arthritis was induced in rats with a single intraperitoneal injection of an aqueous suspension of PG-APS fragments derived by sonication. The joint lesions induced with this polydisperse suspension followed a bimodal pattern consisting of an acute phase, which reached a peak 5 days after injection and then receded, followed by a chronic, remittent, erosive arthritis lasting several months. The relative severities of the acute and chronic phases could be manipulated by selection of the size of PG-APS fragments. The fragments of PG-APS obtained by sonic treatment were resolved on the basis of size into three major populations by sucrose gradient or differential centrifugation. Based upon light scattering and gel filtration, the average molecular weight of the largest family of fragments was estimated to be about 500 x 10(6), the intermediate fragments were 50 x 10(6) daltons, and the predominant size in the smallest population was 5.3 x 10(6) daltons. The larger fragments induced negligible acute inflammation, but chronic disease became apparent 5 to 9 weeks after injection. The smallest fragments induced the most severe acute inflammation, with relatively little late, chronic joint disease. The particles of intermediate size induced moderate acute inflammation and the most severe chronic, erosive joint lesions. A single injection of fragments of the isolated peptidoglycan moiety of the PG-APS induced only a moderate acute inflammation of joints, with no apparent capacity to maintain the injury and induce chronic disease.

Cell-mediated immune response during experimental arthritis induced in rats with streptococcal cell walls.

Chronic, remittent, erosive arthritis was produced in rats by a single intraperitoneal injection of an aqueous suspension of cell wall fragments isolated from group A streptococci. Arthritis could be induced in rats which had been immunologically compromised by neonatal thymectomy. Delayed hypersensitivity to cell wall peptidoglycan could not be elicited in these rats, although progressive joint disease was obvious by clinical and radiological measurements. A delayed skin test was elicited with peptidoglycan in non-thymectomized rats at 6 to 14 days after injection of low doses of cell wall fragments. Between 2 to 4 weeks after cell wall injection the skin test could not be elicited and these rats could not be sensitized again with peptidoglycan. After a high dose of cell wall the skin test could not be elicited at any time. These non-thymectomized rats which had been injected with cell walls remained hyporesponsive to peptidoglycan for at least 3 months. Lymphocytes from non-thymectomized cell wall-injected rats also showed a non-specific depression of lymphocyte response to phytohaemagglutinin in vitro, but this function was recovered between 2 to 4 weeks after cell wall injection. We conclude that cell-mediated immunity against bacterial cell wall antigens is not a pathogenetic factor in this experimental model of arthritis.

The relation of experimental arthritis to the distribution of streptococcal cell wall fragments.

The intraperitoneal injection of peptidoglycan-carbohydrate fragments from Group A streptococci produces a chronic, polyarticular, erosive synovitis in rats. The cell wall material accumulates rapidly in the liver, spleen, and lymph nodes, where it causes little injury. At the same time, selective localization and persistence of the material in the synovial and periarticular tissues occurs. Its presence in the joint is associated with acute and recurrent inflammation with focal synotivitis, pannus formation, joint destruction, and ankylosis. Cell wall fragments become localized in the synovial and periarticular tissues at a time when there are leukocytes in the bloodstream, which appear to contain the material. During this early phase vascular lesions appear in the synovium and in periarticular tissues with collections of fibrin, neutrophils, macrophages, and cell wall fragments near the venules and capillaries. Recurrent episodes of inflammation and joint injury, associated with persistent cell wall antigen within macrophages, were observed over a period of 90 days.

Modulation of the susceptibility of inbred and outbred rats to arthritis induced by cell walls of group A streptococci.

Inbred Buffalo rats were resistant to the induction of experimental arthritis induced by systemic injection of cell wall fragments in a crude whole-cell sonic extract of group A streptococci. This was in contrast to the susceptibility of outbred Sprague-Dawley and certain other inbred strains. Preliminary breeding studies indicated that genetic control of resistance of susceptibility is multigenic. When Buffalo rats were infected with a saline suspension of isolated cell wall fragments, chronic remittent arthritis developed. Suspension of isolated cell wall fragments, chronic remittent arthritis developed. Suspension of the isolated cell walls in the supernatant fraction of group A streptococci solubilized by sonication eliminated the arthropathogenicity in Buffalo rats. Thus, a component separable from the cell wall fraction can modulate the arthropathogenicity of cell walls in rats, but the effect depends upon the genetic background of the rat. The antibody response of Buffalo rats to the polysaccharide antigen of cell walls was also affected by the supernatant fraction of sonicated group A streptococci.