1350 ARTHRITIS & RHEUMATISM Volume 36 Number 10, October 1993, pp 135G1352 0 1593, American College of Rheumatology

VIEWPOINT

SYNOVIAL LYMPHOCYTES CAN INDICATE SPECIFIC MICROBIOLOGIC CAUSES OF

RHEUMATOID ARTHRITIS

DENYS K . FORD

In 1979, a study of patients with reactive arthri- tis (ReA) was initiated, in which synovial fluid lympho- cytes were cultured in the presence of crude antigens derived from organisms related clinically to the pre- cipitation of ReA. The antigenic preparations were crude because purification might have resulted in the loss of relevant antigens. It was immediately found that the 3H-thymidine uptake response was maximal from lymphocytes exposed to the specific antigen that was etiologically implicated in the individual case of ReA. The findings applied to both enteric and sexually acquired ReA (1-3); usually, simultaneously measured peripheral blood lymphocyte responses were signifi- cantly lower or even absent. These observations have been confirmed in studies from England, Finland, and Germany (4-6).

The discriminatory capability of these lympho- cytes derived from the site of disease enables them to distinguish between the different enteric pathogens causing ReA (7). It can be concluded from these results that synovial lymphocytes from patients with ReA can indicate the cause of the ReA by their responses to appropriate microbiologic antigen stimu- lation in vitro.

Since 1986, intrasynovial chlamydial antigen (8,9), DNA (lo), and RNA (11) have been found in patients with sexually acquired ReA; similarly, in patients with enteric ReA, salmonella (12), yersinia

From the Division of Rheumatology, Department of Medi- cine, University of British Columbia, Vancouver, British Columbia, Canada.

Denys K. Ford, MD: Emeritus Professor of Medicine. Address reprint requests to Denys K. Ford, MD, The

Arthritis Center, 895 West 10 Avenue, Vancouver, British Columbia V5Z 1L7, Canada.

Submitted for publication January 27, 1993; accepted in revised form April 7 , 1993.

(13), and shigella (14) antigens have been observed in the synovium. It therefore seems likely that the inflam- matory lesion in the joint in ReA is the result of antigen-specific synovial lymphocytes reacting to intra- synovial homologous microbiologic antigen (7).

In 1984, it was reported that synovial lympho- cytes from some patients with persistent or recurrent knee synovitis would respond to stimulation with the same enteric or chlamydiahreaplasma antigens that cause specific responses in ReA, even though these patients did not have ReA (15). Subsequently, intra- synovial chlamydial antigen was found in 5 of 15 women with seronegative sligoarthritis (16), a disease that is in many ways analogous to ReA. More recently, synovial lymphocytes from patients with adult oligo- arthritis have shown specific responses to stimulation by chlamydial antigen, and this finding was associated with the presence of chlamydial antigen in the syno- vium (17). Additionally, a study of boys with pauci- articular juvenile chronic iirthritis (18) has revealed specific synovial lymphocyte proliferation in response to chlamydial antigen in 6 cases and in response to yersinial antigen in 11 cases.

None of the patients in the above investigations had reactive arthritis by the usual criteria. These observations therefore see.m to indicate that both chlamydia and yersinia are etiologically related to oligoarthritis in adults and to pauciarticular arthritis in boys, and consequently, that these agents can cause forms of arthritis other than ReA. Thus, the data suggest that not only can the same clinical syndrome be caused by multiple microbiologic agents (19), but that the same agent can cause different clinical types of arthritis (20). Moreover, it would also seem that inves- tigation of the response of synovial lymphocytes to

VIEWPOINT: SYNOVIAL LYMPHOCYTE RESPONSES IN RA 1351

microbiologic antigen stimulation is helpful in studying types of arthritis other than ReA.

In distinction to ReA, rheumatoid arthritis (RA) has had no known clinical associations or circumstan- tial evidence to suggest microbiologic causation. How- ever, the recognition that arthritis is often a complica- tion of rubella, parvovirus, Ross River fever, and borrelia infections suggests that a number of micro- biologic agents might conceivably be involved. During the last 10 years, therefore, the response of synovial lymphocytes to stimulation with a variety of microbio- logic antigens has been examined in patients with “rheu- matoid arthritis.” In the majority of cases, lymphocytes were tested against chlamydia, ureaplasma, salmonella, and candida, as well as the viral antigens of rubella, mumps, adenovirus, cytomegalovirus (CMV), influenza, parainfluenza, herpes type 1 , and respiratory syncytial viruses; other enteric and viral antigens were used in certain cases.

Particular attention was given to cases in which significant stimulation in response to one particular antigen was shown to be consistent on repeated test- ing. Whenever possible, attempts were made to obtain corroborative evidence from virus isolation, or the demonstration of intrasynovial antigen, or intrasyno- vial agent-specific nucleotide sequences. However, due to the sophistication and expense of the tech- niques required, this was possible only occasionally, through collaborative arrangements. The following summarizes the most suggestive findings, which rep- resent -15% of the total cases studied.

In 5 cases, rubella antigen elicited significant responses and in 3 of these patients, rubella virus was isolated despite the absence of any history of recent rubella infection (21,22). In 1 of these consistent rubella responders, 16 repeated observations, employ- ing a total of 22 microbiologic antigens, were made over 7 years, and not only was intrasynovial rubella virus isolated, but the patient was found to have a defective immune response to rubella virus (23). An- other patient from whom rubella virus was isolated had RA with rheumatoid nodules.

In 6 cases, the maximal synovial fluid lympho- cyte reaction was consistently found in response to adenovirus, and in 1 of the 6, adenoviral nucleotide sequences were demonstrable in a synovial biopsy specimen (24).

In 3 cases, chlamydial antigen caused repeated maximal stimulation. One of these patients had rheu- matoid factor and radiographic bone erosions, and synovectomy showed intrasynovial chlamydia1 anti-

gen (25); another of the 3 also had rheumatoid factor in high titer.

In 8 cases, the synovial lymphocytes responded maximally to CMV antigen on 2 or more occasions (26). One patient had RA with rheumatoid factor and bone erosions, and each of 6 tests over 13 months gave maximal responses to CMV. His synovial, but not blood, lymphocytes responded to CMV stimulation in vitro, with a significant increase in T4 DR+ cells. It was not possible to correlate the synovial lymphocyte responses with the demonstration of CMV virus, an- tigen, or DNA, since the expertise for performance of such tests was not available in the given setting. However, a recent report from Germany describes the demonstration of CMV DNA in synovial tissue of patients with RA; only in patients with both RA and intrasynovial CMV DNA was the titer of CMV- specific antibodies in synovial fluid higher than that in serum (27). Additionally, this same group reported in 1992 that intrasynovial B 19 parvovirus DNA was found in some patients with RA (28).

Two other cases presented suggestive findings. One RA patient had 9 tests over 6 years, each resulting in maximal responses to mumps antigen, although his blood lymphocytes never responded to mumps (29). Another patient had 3 tests, with a maximal response to salmonella antigen shown on each occasion.

In summary, the above-described investigative approach, employing the relatively simple and micro- biologically restricted techniques that were available, seemed to show that, in -15% of “rheumatoid arthri- tis” patients, synovial fluid lymphocyte responses suggested that the pathogenesis of their disease was related to a particular microbiologic agent. It might thus be that the use of this methodology, extended to include a greater number of microbiologic antigens, could prove as informative in RA as it is in ReA. The recent developments of molecular biology now enable us to manufacture individual antigens of specific infec- tive agents. If diseases such as RA are due to aberrant immune responses to particular antigens of specific infective agents, then it is possible that we will soon be able to correct specific defects. The development of therapies with this objective may be a more attractive approach than the use of treatments based on essen- tially “blind” attacks on the patient’s overall immune system.

REFERENCES 1 . Ford DK, da Roza DM, Shah P, Wenman WM: Cell-mediated

immune responses of synovial mononuclear cells in Reiter’s

1352 FORD

syndrome against ureaplasmal and chlamydial antigens. J Rheu- matol7:751-755, 1980

2. Ford DK, da Roza DM, Schulzer M: The specificity of synovial mononuclear cell responses to microbiological antigens in Rei- ter’s syndrome. J Rheumatol 9561-567, 1982

3. Ford DK, da Roza DM, Schulzer M: Lymphocytes from the site of disease but not blood lymphocytes indicate the cause of arthritis. Ann Rheum Dis 44:701-710, 1985

4. Hermann E, Fleischer B, Mayet WJ, Poralla T, Meyer zum Buschenfelde KH: Response of synovial fluid T cell clones to Yersinia enterocolitica antigens in patients with reactive yer- sinia arthritis. Clin Exp Immunol 75:365-370, 1989

5. Gaston JSH, Life PF, Granfors K, Merilahti-Palo R, Bailey L, Consalvey S, Toivanen A, Bacon PA: Synovial T lymphocyte recognition of organisms that trigger reactive arthritis. Clin Exp Immunol76:348-353, 1989

6. Sieper J , Kingsley G, Palacios-Boix A, Pitzalis C, Treharne J, Hughes R , Keat A, Panayi GS: Synovial T lymphocyte-specific immune response to Chlamydia trachomatis in Reiter’s disease. Arthritis Rheum 34588-598, 1991

7. Ford DK: Lymphocytes from the site of disease in reactive arthritis indicate antigen-specific immunopathology . J Infect Dis

8. Keat AC, Thomas B, Dixey J , Osborn M, Sonnex C, Taylor- Robinson D: Chlamydia trachomatis and reactive arthritis: the missing link. Lancet I:72-74, 1987

9. Schumacher HR Jr, Magge S, Cherian PV, Sleckman J, Roth- fuss S, Clayburne G, Sieck M: Light and electron microscopic studies on the synovial membrane inReiter’s syndrome: immuno- cytochemical identification of chlamydial antigen in patients with early disease. Arthritis Rheum 31:937-946, 1988

10. Taylor-Robinson D, Gilroy CB, Thomas BJ, Keat ACS: Detec- tion of Chlamydia trachomatis DNA in joints of reactive arthri- tis patients by polymerase chain reaction. Lancet 340:81-82, 1992

11. Rahman MU, Cheema MA, Schumacher HR, Hudson AP: Molecular evidence for the presence of chlamydia in the syno- vium of patients with Reiter’s syndrome. Arthritis Rheum

12. Granfors K, Jalkanen S, Lindberg AA, Maki-Ikola 0, von Essen R, Lahesmaa-Rantala R, Isomaki H, Saario R, Arnold WJ, Toivanen A: Salmonella lipopolysaccharide in synovial cells from patients with reactive arthritis. Lancet 335:685-688, 1990

13. Granfors K, Jalkanen S, von Essen R, Lahesmaa-Rantala R, Isomaki 0, Pekkola-Heino K, Merilahti-Palo R, Saario R, Isomaki H, Toivanen A: Yersinia antigens in synovial fluid cells from patients with reactive arthritis, N Engl J Med 320:216-221, 1989

14. Granfors K , Jalkanen S, Toivanen P, Koski J, Lindberg AA: Bacterial lipopolysaccharide in synovial fluid cells in shigella triggered reactive arthritis (letter). J Rheumatol 19500, 1992

15. Ford DK, da Roza DM, Ward RH: Arthritis confined to knee

164: 1032-1 033, 199 I

35:521-529, 1992

joints: synovial lymphocyte responses to microbial antigens correlate with distribution of HLA. Arthritis Rheum 27: 1157- 1164, 1984

16. Taylor-Robinson D, Dixey .I, Thomas B, Osborn MF, Furr FM, Keat AC: Evidence that Chlamydia trachomatis causes seroneg- ative arthritis in women. A m Rheum Dis 47:295-299, 1988

17. Sieper J, Braun J, Brandt J, Miksits K, Heesemann J, Laitko S, Sorenson H, Distler A, Kingsley G: Pathogenetic role of Chla- mydia, Yersinia, and Borrelma in undifferentiated oligoarthritis. J Rheumatol 19:12361242, 1!J92

18. Sieper J, Braun J, Doring E,, Wu P, Heesemann J, Treharne J, Kingsley G: Aetiological role of bacteria associated with reac- tive arthritis in pauciarticular juvenile chronic arthritis. Ann Rheum Dis 51:120&1214, 1992

19. Ford DK: One syndrome: many infectious agents. J Rheumatol 14:650-652, 1987

20. Tingle AJ: One infectious agent: many syndromes. J Rheumatol 14:653-655, 1987

21. Ford DK, da Roza DM, Reid GD, Chantler JK, Tingle AJ: Synovial mononuclear cell responses to rubella antigen in rheumatoid arthritis and unexplained persistent knee arthritis. J Rheumatol9:420-423, 1982

22. Chantler JK, da Roza DM, Bonnie ME, Reid GD, Ford DK: Sequential studies on synovial lymphocyte stimulation by ru- bella antigen, and rubella virus isolation in an adult with persistent arthritis. Ann Rheum Dis 44:564568, 1985

23. Ford DK, Reid GD, Tingle AJ, Mitchell L , Schulzer M: Sequential follow up observations of a patient with rubella associated persistent arthritis. Ann Rheum Dis 51 :407-410, 1992

24. Ford DK, Stein HB, Schulzer M, Bateman ED, Hogg JC, Hayashi S: Lymphocytes from the site of disease suggest adenovirus is one cause of persistent or recurrent inflammatory arthritis. J Rheumatol 20:31CL313, 1993

25. Ford DK, Reid GD, Magge S, Schumacher HR: Synovial lymphocyte response to chlamydial stimulation associated with intrasynovial chlamydial antigen in a patient with “rheumatoid arthritis.” Arthritis Rheum 31:914-917, 1988

26. Ford DK, da Roza DM, Schulzer M, Reid GD, Denegri JF: Persistent synovial lymphocyte responses to cytomegalovirus antigen in some patients with rheumatoid arthritis. Arthritis Rheum 30:700-704, 1987

27. Einsele H, Steidle M, Muller CA, Fritz P, Zacher J, Schmidt H, Saal JG: Demonstration of cytomegalovirus (CMV) DNA and anti-CMV response in the synovial membrane and serum of patients with rheumatoid arthritis. J Rheumatol 19:677-682, I992

28. Saal JG, Steidle M, Einsele H, Muller CA, Fritz P, Zacher J: Persistence of B19 parvovirus in synovial membranes of pa- tients with rheumatoid arthritxs. Rheumatol Int 12:147-151, 1992

29. Ford DK, Stein HB, Schulzer M: Persistent synovial lympho- cyte responses to mumps and adenovirus antigens. J Rheumatol 15:1717-1719, 1988