Antibody activity in ankylosing spondylitis sera to two sites on HLA B27.1 at the MHC groove region (within sequence 65-85), and to a Klebsiella pneumoniae nitrogenase reductase peptide (within sequence 181-199).

74 overlapping peptides of varying lengths from Klebsiella pneumoniae nitrogenase reductase (residues 181-199) and from the HLA B27.1 molecule (residues 65-85) were synthesized and tested by ELISA against sera from HLA B27+ ankylosing spondylitis (AS) patients, and sera from HLA B27+ and HLA B27- healthy first-degree relatives. Antibody activity in AS sera to Klebsiella peptides of four to eight amino acids was maximal with the peptide NSRQTDR. Activity to HLA B27 peptides was maximal with the peptide KAKAQTDR (named epitope I). These peptides overlap with, but are proximal to the NH2 terminus from QTDRED, which is homologous in HLA B27.1 and K. pneumoniae nitrogenase reductase. A second weaker reactive site was noted in the HLA B27.1 peptides, proximal to the COOH terminus from the homologous sequence, namely peptide REDLRTLL (named epitope II). Little activity was seen against peptides that included the entire homologous sequence. Sera from 50 AS patients showed higher total Ig activity against peptides KAKAQTDR (p less than 0.001) and NSRQTDR (p less than 0.02) than did sera from 22 B27+ and 22 B27- healthy controls. These data indicate that AS patient sera contain antibodies that bind to K. pneumoniae nitrogenase peptides and HLA B27.1 peptides, and that there are at least two epitopes on HLA B27.1 in the alpha 1 domain, at the MHC groove region, that are autoantigenic in AS patients. Epitope I may be a site for crossreactivity between HLA B27 and Klebsiella.

Acute anterior uveitis and faecal carriage of gram-negative bacteria.

In a prospective study a high recovery of faecal Klebsiella was obtained in patients with acute anterior uveitis, who bear HLA-B27 or other HLA-B7 CREG antigens.

Seasonal variation of acute anterior uveitis: differences between HLA-B27 positive and HLA-B27 negative disease.

One hundred and seventy-five consecutive patients with acute anterior uveitis (AAU) were examined over a 24-month period. There was a significantly increased incidence of AAU during the months August to December (p less than 0.05). This increase was confined predominantly to the HLA-B27 negative group of patients (p less than 0.01). There was no significant monthly difference in incidence between males and females, between patients with first or recurrent attacks, or between patients with and without arthritis. These results suggest that seasonal environmental factors may play a role in the production of HLA-B27 negative AAU.

Serum immunoglobulins in acute anterior uveitis.

Serum levels of immunoglobulin A, G, and M were examined in 99 patients with acute anterior uveitis (AAU). The mean level of serum IgA was raised (p less than 0.001) in AAU patients when compared with healthy control subjects. The levels of serum IgG and IgM were not significantly different from those in the control group. The raised levels of serum IgA were found to occur predominantly in the HLA-B27 positive group of patients (p less than 0.001) and were highest in HLA-B27 positive patients with sacroiliitis or associated spondylarthritic diseases (p less than 0.001). The HLA-B27 negative group of AAU patients did not have a significantly raised mean serum IgA. The raised level of serum IgA in HLA-B27 positive AAU patients suggests that there has been a response to an environmental or infectious agent(s) acting across a mucosal tissue in these patients. This agent could be responsible for the initiation of the acute ocular inflammation.

A search for gram-negative enteric micro-organisms in acute anterior uveitis: association of klebsiella with recent onset of disease, HLA-B27, and B7 CREG.

Faecal samples obtained from patients with acute anterior uveitis (AAU) and healthy controls unconnected with hospitals were examined for the presence of Gram-negative micro-organisms reported to be associated with AAU. There was an increased recovery of Klebsiella spp. from AAU patients seen in the first and in the second week after onset of symptoms when compared with patients presenting three to four weeks after onset of symptoms (p less than 0.025 and p less than 0.05 respectively) or with healthy control subjects (p less than 0.005 and p less than 0.05 respectively). By the third to fourth week there was no difference in klebsiella recovery between AAU patients and controls. The increased faecal recovery of klebsiella in the first two weeks was predominantly in HLA-B27 positive patients or patients possessing antigens which cross-react with B27, namely, HLA-B7 CREG. The patients with faecal cultures positive for klebsiella had a higher mean ESR than patients with negative faecal cultures (p less than 0.05). Although there was an increase in recovery of faecal klebsiella from AAU patients with spondylarthritis when compared with AAU patients without arthritis, the difference was not statistically significant. These results suggest that some klebsiella micro-organisms may play a role in the aetiopathogenesis of AAU associated with HLA-B27 or HLA-B7 CREG.

HLA-B27 and the immune response to enterobacterial antigens in ankylosing spondylitis.

Total serum immunoglobulins and class specific serum antibodies to Klebsiella pneumoniae, Salmonella typhimurium, Yersinia enterocolitica and Pseudomonas aeruginosa were measured in 107 patients with ankylosing spondylitis (AS) and 110 healthy tissue typed controls by enzyme linked immunosorbent assay (ELISA). The specificity of this technique was confirmed by the use of specific bacterial murine antisera and by cross-absorption of human sera by specific bacteria. Total serum IgA in AS patients correlated with both erythrocyte sedimentation rate (ESR) (P less than 0.001) and C-reactive protein (P less than 0.05) and was significantly elevated compared to healthy individuals (P less than 0.001). A significant elevation of IgA antibodies to K. pneumoniae was detected in the serum of AS patients with active disease when compared to healthy controls (P less than 0.01). These studies support the involvement of an enterobacterial micro-organism in the pathogenesis of AS and further relate to the role of HLA-B27 in this disease.

IgA antibodies to Klebsiella pneumoniae in ankylosing spondylitis.

Serum IgA antibodies to Klebsiella pneumoniae were measured in 65 patients with ankylosing spondylitis (AS) during different phases of disease activity and compared with the antibody level in 21 psoriatic arthritis (PsA) patients, 43 rheumatoid arthritis (RA) patients and 57 healthy controls. The mean IgA antibody to Klebsiella in AS patients with an erythrocyte sedimentation rate (ESR) greater than or equal to 15 mm/h was significantly higher than the antibody level in patients with an ESR less than 15 mm/h (p less than 0.02) and tended to increase with rising ESR. There was a significant difference in anti-Klebsiella antibody levels between AS patients with an elevated ESR and antibody levels in PsA patients (p less than 0.001), RA patients (p less than 0.001) and healthy controls (p less than 0.005). There was no difference between healthy controls and patients with PsA, RA or AS patients with a low ESR. The IgA anti-Klebsiella antibody was specifically absorbed out from sera with inactivated klebsiella pneumoniae organisms. Antibody levels to Candida albicans and Escherichia coli did not differ in patients vis-à-vis control subjects. The mean serum anti-Klebsiella IgA level was found to be higher in patients who were either clinically active or had positive faeval cultures, when compared with patients with inactive disease and negative cultures, but these differences were not statistically significant, although when both parameters were examined together a significant additive effect was detected (p less than 0.001). It is concluded that patient with AS exhibit a specific elevation of serum IgA antibody to Klebsiella antigen.

Yersinia enterocolitica biotype I. Diarrhoea and episodes of HLA B27 related ocular and rheumatic inflammatory disease in South-East England.

Yersinia enterocolitica biotype I were isolated from faeces of 16% of 56 consecutive patients with diarrhoea or gastrointestinal symptoms and 2.8% of 109 healthy controls (p less than 0.01). Similar Yersinia biotypes were isolated from 4% of samples from 86 rheumatoid arthritis patients and 4.5% of samples from 140 ankylosing spondylitis patients examined regularly over an 8-month period. These results suggest that Yersinia enterocolitica biotype I are regular but infrequent inhabitants of the human gastrointestinal tract in south-east England. The increased isolation rate of these microorganisms from patients with enteric disease and from patients with exacerbations of HLA B27-related arthritic and ocular inflammatory disease justifies further investigations.

Autoantibodies to cartilage and type II collagen in relapsing polychondritis and other rheumatic diseases.

Cartilage antibodies were demonstrated by indirect immunofluorescence (IFL) on human fetal cartilage in 6 out of 9 patients with relapsing polychondritis (RPC), in 4 out of 260 patients with rheumatoid arthritis (RA), and in only 1 out of 1016 patients with other disorders. The antibodies were specific for cartilage and evenly stained the whole cartilage matrix. They were predominantly of IgG class and varied in titres from 1:1 to 1:320. Follow-up studies in the RPC patients indicated that higher titres were present during the early acute phase of the disease. Five of the 6 positive cases had developed the disease within the past 12 months, and the 3 negative cases had had the disease for 3 to 7 years when tested. The RA cases showing positive cartilage IFL had no clinical evidence of RPC. Sequential measurements in 2 of the 4 cases showed that these antibodies became detectable some years after the onset of arthritis. Absorption studies with human type II collagen and purified porcine proteoglycan failed to remove the cartilage IFL. Antibodies to human native type II collagen were measured by an enzyme-linked immunosorbent assay. The highest levels were found in the RA sera which also displayed cartilage IFL, but the 2 tests gave discordant results. RPC sera showed the same antibody levels by this method, as did cartilage-IFL-negative RA sera, though both groups had higher mean levels than health controls. The findings that cartilage antibodies are detected in the majority of cases of RPC and only rarely in other diseases suggests these antibodies may play an important role in the pathogenesis of cartilage destruction in RPC.

Association of inflammation with raised serum IgA in ankylosing spondylitis.

Serum immunoglobulins were measured in 122 patients with ankylosing spondylitis (AS) during various phases of disease activity and compared to those in 58 healthy subjects. The mean serum IgA was 38% higher in patients (306.9 mg/dl) than in controls (222.7 mg/dl) (P < 0.005), but there was no significant difference in IgG and IgM levels. Increased IgA was associated with laboratory parameters of active inflammatory disease. The mean IgA in patients having an erythrocyte sedimentation rate (ESR) equal to or greater than 15 mm/h was 369 mg/dl, 65% higher than in controls (P < 0.001), whereas there was no significant difference between controls and patients with an ESR of less than 15 mm/h. The mean IgA in patients having a C-reactive protein (CRP) level equal to greater than 15 micrograms/ml (15 mg/l) was 387.8 mg/dl, 74% higher than in controls (P < 0.001), and again there was no significant difference between controls and patients with CRP levels less than 15 micrograms/ml. (SI conversion: g/l = mg/dl x 0.01). It is suggested that selective increase of serum IgA occurs predominantly during phases of active inflammatory disease in AS, and this finding is compatible with the concept of a microbial triggering agent acting across an IgA secreting organ such as the gut.

A double-blind cross-over trial of fenoprofen and phenylbutazone in ankylosing spondylitis.

Fenoprofen, 600 mg, three times daily, was compared with phenylbutazone, 100 mg, three times daily, in 30 patients suffering from ankylosing spondylitis in a double-blind cross-over study. Assessments were made after an initial washout period and after each month-long treatment period. Phenylbutazone significantly improved morning stiffness, finger-to-floor distance, chest expansion, overall joint pain, spinal pain, the physician's assessment of disease activity and ESR. Only chest expansion was significantly improved by fenoprofen, and phenylbutazone was significantly better than fenoprofen in its effects on finger-to-floor distance, morning stiffness, overall joint pain, spinal pain and the physician's assessment of disease activity. Side-effects were of a minor nature apart from one patient who developed rectal bleeding on phenylbutazone which recurred on rechallenging.

Increased incidence of faecal Klebsiella pneumoniae in patients with HLA B7 CREG antigen and men with rheumatoid arthritis.

In a study of the carriage of faecal Klebsiella pneumoniae in 106 patients with rheumatoid arthritis the incidence of carriage was higher in men (28%) than women (14%) (p < 0.001) and klebsiellae were isolated on two or more occasions from a higher proportion of men than women (p < 0.002). The incidence of carriage was increased among patients with rheumatoid arthritis who had B7 cross-reacting (B7 CREG) antigens (32% v 13%--p < 0.001). Carriage of klebsiellae was not associated with clinical disease activity, raised erythrocyte sedimentation rate, drug treatment, or the presence of HLA Dw4 or DRw4 or both. Thus the carriage and prevalence of faecal Klebsiella pneumoniae appear to be partly determined by the sex and HLA state of the host.

Levamisole in rheumatoid arthritis -- a double-blind study.

Levamisole was used in a double blind trial in 24 patients with severe rheumatoid arthritis (RA). Each patient received either levamisole 150 mg daily, or placebo for a period of 6 months in addition to nonsteroidal antiinflammatory therapy. Ten patients, 8 of whom were taking levamisole, failed to complete the trial. Clinically 3 or 4 patients on levamisole who completed the study showed improvement whereas 5 were considered improved on placebo. The high incidence of side effects, (rashes, gastrointestinal upset, stomatitis and depression) in the levamisole treated group indicates that this drug, in the dose used, was too toxic for the management of severe RA. A much lower incidence of side effects is reported with recent recommendations using much lower daily or even weekly dosage.

Ankylosing spondylitis, HLA-B27 and Klebsiella. I. Cross-reactivity studies with rabbit antisera.

Sera from rabbits immunized with HLA-B27 lymphocytes showed increased activity against klebsiellal enterobacter antigens using immunodiffusion, bacterial agglutination (P less than 0.025), haemagglutination (P less than 0.001) and radiobinding assays (P less than 0.001). Immunoprecipitin lines were also produced by these antilymphocyte sera against extracts from Yersinia enterocolitica and Shigella sonnci microorganisms. Rabbit anti-klebsiella sera had lymphocytotoxic activity against HLA-B27 lymphocytes obtained from patients with ankylosing spondylitis (P less than 0.001). These results suggest partial cross-reactivity between some antigens found in several Gram-negative microorganisms and HLA-B27 lymphocytes.