1226

Y ERSINIA-RELATED ARTHRITIS IN THE PACIFIC NORTHWEST

DENYS K. FORD, ELIZABETH HENDERSON, GEORGE E. PRICE, and HOWARD B. STEIN

Serologic evidence of Yersinia enterocolitica in- fection was sought by agglutination testing in serum sam- ples from several populations, including Haida Indians, Red Cross blood donors, and Caucasian patients with rheumatoid arthritis, ankylosing spondylitis, and Reiter’s syndrome. No evidence was found to indicate that yersi- nial infection was etiologically related to Haida spondy- litis or Reiter’s syndrome. Four of 28 patients with acute arthritis were diagnosed from serologic evidence as having Y ersinia-related arthritis.

Arthritis following Yersinia enterocolitica in- fection has been well described in Scandinavia (1-4) but not in North America. The arthritis can be associated with erythema nodosum ( 5 ) or with Reiter’s syndrome (6) , though frequently it occurs without either. Sacroiliitis and spondylitis are recognized sequelae, and the pre- disposition of HLA-B27 individuals to arthritis follow- ing yersinial infection is established (7). In 1975 a study

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

Supported by the Canadian Arthritis and Rheumatism Society and by Federal Health Grant No. 610-1055-28.

Denys K. Ford, M.D.: Professor of Medicine; Elizabeth Hen- derson, BSc.: Research Assistant; George E. Price, M.D.: Associate Professor of Medicine; Howard B. Stein, M.D.: Clinical Assistant Professor of Medicine.

Address reprint requests to Denys K. Ford, M.D., Division of Rheumatology, Department of Medicine, 700 West 10th Avenue, Vancouver, British Columbia, Canada V5Z 1M9.

Submitted for publication February 15. 1977; accepted March 15. 1977.

was initiated in Vancouver, British Columbia, to answer three questions. Was acute yersinial arthritis common? Was yersinial infection a possible inciting cause of spondylitis in the predisposed Haida Indian population (8), which lives in a geographic terrain somewhat similar to Scandinavia? Was infection with Yersinia enterocoli- tica a precipitating cause of Reiter’s syndrome, espe- cially in those patients presenting with nonepidemic diarrhea? The study was based on serologic evidence of agglutinating antibody to the six most frequently en- countered antigenic types of Yersinia enterocolitica.

MATERIALS AND METHODS Serum Samples. The Haida Indian sera were collected

in the Queen Charlotte Islands during the initial population sur- vey in 1962, and again in 1975 when blood was collected for HLA typing (9). Sera were obtained from Red Cross blood donors in Vancouver, both during 1973 and 1975. Sera from Caucasian patients with rheumatoid arthritis, Reiter’s syn- drome, spondylitis, and “acute arthritis” were taken in Van- couver from those under the care of the rheumatologists of the Division of Rheumatology of the University of British Columbia Medical School at the Arthritis Centre in Van- couver. Patients with acute arthritis were selected for this study when acute arthritis was not characteristic of the usual specific types of acute arthritis, such as septic arthritis, rheu- matic fever, Reiter’s syndrome, or gout. These patients were seen between September 1975 and May 1976. All sera were stored at -2OOC before testing.

Origin of Yersinia Enterocolitica Serotypes and Refer- ence Antisera. 0-types 3, 6, 30, and 9 were acquired from Dr. S. Toma, Director of the National Reference Service for Yersinia, Ontario Ministry of Health, Box 9000 Ter-

Arthritis and Rheumatism, Vol. 20, No. 6 (July-August 1977)

YERSINIA-RELATED ARTHRITIS 1227

minal A, Toronto, Ontario, Canada, M5W 1R5. Dr. Toma also supplied human reference type-specific sera for all of the six types studied. 0-types 4, 32, 5, and 8 were acquired from the Division of Bacteriology, Vancouver General Hos- pital, Department of Pathology; these types are the ones that have been sporadically isolated in British Columbia in recent years (10).

Yersinia Agglutination Techniques. Two methods were employed, that of Winblad et a1 (1 1) and a microtiter method developed in the author’s laboratory. The tube agglutination method of Winblad was employed to cross-check the micro- titer technique. As Table 2 shows, a close correlation was observed.

To prepare antigen for the microtiter technique, frozen stock of Yersinia enterocolitica was grown at 24°C for 48 hours on trypticase soy agar. A suspension of organisms was obtained by washing the plates with sterile phosphate-buffered saline. Then I % sterile methylene blue, to a final concen- tration of 0.02%, was added to the suspension, which was kept at room temperature for 1 hour. The dyed suspension was washed three times and diluted to approximately 15.0 X 108 organism per milliliter with merthiolate-buffered saline (MBS) at pH 7.0. This stock antigen was frozen in 100-ml aliquots at -20°C until used within 6 weeks.

All sera, inactivated by heating at 56°C for 30 minutes, were initially diluted 1:lO with MBS. A two-fold, duplicate, serial dilution was prepared with an automatic Minidiluter in MBS, starting at a dilution of 1:20. Each microtiter well contained 0.1 ml of serum dilution, except for control wells, and 0.1 ml of antigen suspension. The microtiter plates (Cooke-lucite acrylic round-bottom type) were covered with plate-sealing tape (Cooke pre-cut acetate sealers), and the tape was perforated over each well. The plates were incubated for 2 hours at 37”C, then at 24°C overnight.

The microtiter agglutination plates were read from the bottom by comparing the control well with the wells containing sera. Agglutination-negative wells showed a large blue button of antigen in the bottom of the well, in contrast to positive wells in which no button was visible.

Agglutination Tests for Brucella Abortus. Because of a recognized cross-agglutination between Brucellae and Y enterocolitica type 0 9 (12), positive sera were sent to the British Columbia Provincial Health Laboratory for the dem- onstration of Brucella agglutinins, but none was found.

RESULTS

Table 1 summarizes the results of the agglutina- tion tests and shows that agglutination titers of 1 / 160 or greater were rare. Moreover, in none of the patient groups was there any increased incidence of elevated agglutination titers. In particular, sera collected from the Indians in both 1962 and 1975 and sera from pa- tients with Reiter’s syndrome provided no evidence that infection with Y enterocolitica, of the serotypes studied, was related t o either Haida Indian spondylitis or to Reiter’s syndrome. However only 2 of the latter patients started their disease with diarrhea.

Table 2 summarizes the data on the 4 patients who were considered to have Y ersinia-related arthritis; it also compares the microtiter and tube agglutination methods.

Patient ST, a 19-year-old recent high-school graduate, complained of abdominal pain and anorexia in August 1975. Three weeks later he had generalized arthralgias with pain and swelling of the left knee. On admission to the Vancouver General Hospital an ill- defined mass was felt in the left iliac fossa, which his rheumatologist (GEP) thought to be enlarged internal iliac lymph nodes. Synovial fluid from the left knee was sterile on culture and had a leukocyte count of 9300 cells/mm3. The Westergren ESR was 70 mm/hour. He had no evidence of urethritis or mucocutaneous lesions suggestive of Reiter’s syndrome. His histocompatibility type was HLA-Al, HLA-B 12, 27. The arthritis of the left knee subsided in about 6 weeks, but the right knee became swollen for a week or 2 as it improved. At follow-up examinations, 4 and 14 months after the onset of his symptoms, he had no arthritis, felt entirely well, and was at work. This patient had a significantly ele- vated agglutination titer to Y enterocolitica serotype 8 , which fell over the succeeding 4 months (Table 2).

Patient JF, a 20-year-old technician working at the Canadian Red Cross blood bank, complained of rather bizarre neurologic symptoms in December 1975, for which she was admitted to the Vancouver General Hospital by a neurologist, who could find no ex- planation for the symptoms. During the admission she complained of acute pain and swelling of the left knee and a rheumatologist (GEP) was consulted. The syno- vial aspirate contained 5700 leukocytes/mm3 and was sterile on culture. Her sedimentation rate was 39 (West- ergren) and her antinuclear factor test was negative. An elevated agglutination titer against Y enterocolitica, type 9, was found; as Table 2 shows, it fell to negative in 2 months. The arthritis in her left knee subsided in 3 to 4 weeks, but she then complained of transient pain and swelling of the right ankle which was observed to be swollen. When seen in follow-up on February 4, 1976, and again in December 1976, she had no arthritis, but had complained of variable arthralgias with transient swelling of joints during the interval between the two latter examinations. This patient’s histocompatibility type was HLA-A 2, 3 HLA- B 7, 14.

Two young Chinese men were referred to one of. us (HBS) and were found t o have a similar clinical syndrome which differed from the previous two cases. One, a 31-year-old resident in anesthesiology, had an episode of lumbar spinal stiffness in January 1975.

1228 FORD ET AL

Table 1. Agglutination of Y enterocolitica by Sera from Different Groups of Patients

Serotypes 4.32; 5; and 8 Serotypes 3 and 6,30 Serotype 9

Patient Category

No. of Sera No. of Sera No. of Sera with with with

Titer 1/160 Titer 1/160 Titer 1/160 No. of No. of No. of Sera 4,32 5 8 Sera 3 6.30 Sera 9

Red X 1973 Red X 1975 RA Haida 1962 Haida 1975 Haida spondylitis Caucasian spondylitis Reiter’s syndrome Acute arthritis

Total

3 0 - - - o - - 0 20 2 5 - 1 - 20 1 -

3 0 - - - 20 - - 20 30 - 1 1 o - - 0 2 5 - - - 20 - - 20 20 I - - 20 - 2 20 2 0 - - - 20 - - 20 2 2 - - - o - - 22 28 - - I 12 - 1 28

230 1 2 2 112 1 3 150 3 _ _ _ _ _ _ _ ~ ~ _ _ _ _ ~ ~

Agglutination was performed by the microtiter method.

During this time he had been in South Africa and had experienced a mild episode of loose bowel movements. In October 1975 he again noticed mild, intermittent diarrhea, followed a month later by pain and stiffness in the base of the cervical spine, the area between the

scapulae, the left buttock, the knees, and the thumbs. Tenderness was elicited over (25-6, the left sacroiliac joint, the flexor tendon of the right thumb, both tibia1 tuberosities, and the medial aspect of the left knee. Only the right thumb was swollen. The range of movement of

Table 2. Data on 4 Patients Diagnosed as Having Yersinia-Related Arthritis

Y enterocolitica Agglutination Data

Titer

Sero- Micro- HLA- Rheumatic Patient GI Symptom Date type titer Tube B27 Manifestations

ST Caucasian Abdominal 9/17/75 8 160 320 + Arthritisin both male age 19 pain 9/30/75 8 160 160 knees

10/16/75 .8 80 80 11/27/75 8 40 40

2/4/76 8 20 20

J F Caucasian None 12/11/75 9 640 1280 0 Arthritis in left knee female age 20 2/4/76 9 20 40 and right ankle

A K L Chinese Mild, transient, 1/15/76 6,30 160 160 + Spinal pain, male age 31 recurrent 9/29/76 6,30 20 20 “tendinitis.”

diarrhea 1/10/77 6,30 ND 20 arihralgia

K E Chinese Single episode 3/4/76 9 160 ND + Spinal pain, male age 25 of diarrhea 6/1/76 9 20 ND “tendinitis,” arthritis

at onset of right sterno- clavicular joint and right temporoman- dibular joint

Y ERSINIA-RELATED A RTH RITlS 1229

the spine was normal. He was found to have an ESR of 106 mm/hour and probable left sacroiliitis on his X rays. The latex fixation was negative. A diagnosis of early ankylosing spondylitis or one of its variants was made, and he was treated effectively with phenylbuta- zone.

However, in 1976 pain and tenderness persisted in the low back, neck, and knees and started in the medial aspects of both ankles and in the left heel. A dactylitis developed in the right thumb. Symptoms were partially relieved by 50 mg of indomethacin qid, and the ESR fell to 15 mm/hour. He continued to have mild, intermittent diarrhea. There were no genitourinary or mucocutaneous symptoms at any time. His Y enterocoli- tica titers are shown in Table 2, and his histocompatibil- ity type was HLA-A2 and 11, HLA-B27 and 35.

The other Chinese man, a 26-year-old automo- tive mechanic, had a 2-week episode of two to four watery stools daily in November 1975. About 1 month later he complained of pain in the upper lateral aspect of the left tibia just below the knee, in the posterior aspect of the left thigh, and in the lumbar spine. He stated that his knees were “swollen” and he had to use crutches until the pain was relieved by phenylbutazone. Because of persisting pain, however, he was referred to one of us (HBS) in March 1976. Examination revealed soft tissue tenderness in the regions of the right scapula and left iliac crest, and an area of tenderness and swelling just below the left tibial plateau laterally. Repeated ESR determinations ranged between 61 and 90 mm/hour, but had fallen to 19 mm/hour by March 1976. He was seen again in May 1976, when he was noted to have a low- grade arthritis in the right sternoclavicular and right temporomandibular joints, a dactylitis of the left little toe, muscle tenderness in both buttocks and the area between the scapulae, and localized tenderness over the right patella and left tibial tuberosity. There was also tenderness and a mild decrease of range of movement in the lumbar spine. The sedimentation rate, latex fixation, and sacroiliac radiographs remained normal. He im- proved with naproxen. At no time did he have gen- itourinary or mucocutaneous lesions suggesting Reiter’s syndrome. His Y enterocolitica agglutination titers are shown in Table 2. His histocompatibility type was HLA- A W 24 and 33, HLA-Bl5 and 27.

DISCUSSION This study provides no evidence that Yersinia

enterocolitica infection might be related to the preva- lence of spondylitis in the Haida Indians. The data,

however, do not exclude such a relationship, because yersinial agglutination titers usually fall within a few months after infection, as in the 4 patients in the present study thought to have yersinial arthritis. However the data do suggest that yersinial infections are not endemic in the Haida Indian population, at least during 1962 and again in 1975.

In the the Pacific Northwest, there are occasional patients with Reiter’s syndrome in whom the precipi- tating event appears to be diarrhea. These patients have sometimes recently vacationed in Mexico, but there is usually no indication that shigella dysentery is involved. The present study does not support the veiw that the diarrhea in these patients could be due to Yersinia en- terocolitica infection.

There is clearly no proof that the 4 patients diag- nosed as having Yersinia-related arthritis did, in fact, have their arthritis caused by a preceding yersinial in- fection. However high initial agglutinin titers in all 4 patients, and corresponding decreases in the ensuing few months, do support this diagnosis quite strongly. The fact that 4 of 28 patients with “acute undiagnosed ar- thritis” were found to have serologic evidence of recent yersinial infection indicates that Yersinia-related arthri- tis may be a relatively common entity in this part of the world.

ACKNOWLEDGMENTS The authors are grateful to Dr. S. Toma for his help in

supplying Yersinia serotypes and human type-specific refer- ence antisera; he also provided advice on the methodology used in this study. The authors are also grateful to the Tissue Typing and Bacteriology Laboratories of the Department of Pathology of the Vancouver General Hospital, and to the British Columbia Provincial Health Laboratory.

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