close

Вход

Забыли?

вход по аккаунту

?

Synovial lymphocyte responses to microbiologic antigen stimulation indicate the etiology of undifferentiated and reactive arthritis and possibly of rheumatoid arthritisComment on the article by Schnarr et al.

код для вставкиСкачать
ARTHRITIS & RHEUMATISM
Vol. 46, No. 8, August 2002, pp 2252–2264
© 2002, American College of Rheumatology
LETTERS
months after the diagnosis of type II MC, despite mildly
positive cryoglobulins and rheumatoid factor (RF), she had
purpura, diffuse bullous lesions, and urticaria.
Patient 3 was a 68-year-old woman who was HCV
negative and had been unresponsive to plasmapheresis and
prednisone. Five months after the diagnosis of type II MC, she
presented with diffuse purpura, ulcerative skin lesions on her
lower limbs, and a severe, primarily sensorial polyneuropathy.
Patient 4, a 68-year-old woman, had previously been
treated with prednisone. Forty-eight months after the diagnosis of type II MC, her clinical picture was characterized by
development of a CD20⫹ B cell non-Hodgkin’s lymphoma
(small lymphocytic lymphoma according to the revised
European-American lymphoma classification), with superficial
lymphadenopathies and bone marrow involvement (⬍10% of
marrow infiltrated), Coombs-negative hemolytic anemia, and
grade IV neutropenia (according to World Health Organization grading).
Rituximab was administered intravenously in a dose of
375 mg/m2 on days 1, 8, 15, and 22. No other cytotoxic,
immunosuppressive, or steroid drugs were allowed in association with use of rituximab. Response was evaluated by assessing the modifications of clinical signs, symptoms, and the main
immunologic pattern.
Each patient’s clinical and laboratory features before
and after rituximab treatment are summarized in Tables 1–4.
Patient 4 had a complete remission of the clinical manifestations and normalization of laboratory values. Patients 1, 2, and
3 demonstrated good partial responses, as defined by ⬎50%
reduction in clinical and laboratory signs of disease. The
duration of response ranged from 3 to 13 months. Depletion of
CD20⫹ B cells and reduction of serum IgG and RF levels were
observed in all 4 patients. In patients 3 and 4, the disappearance of the serum monoclonal component IgM␬ was shown by
immunofixation. Normalization of complement levels was inconsistent, and disappearance of cryoglobulins was seen in
patients 1 (transient disappearance only) and 4.
DOI 10.1002/art.10345
Rituximab for the treatment of type II mixed
cryoglobulinemia
To the Editor:
Rituximab is a human/mouse chimeric monoclonal
antibody (IgG1␬) that reacts specifically with CD20 antigen (a
transmembrane protein present during different steps in the
maturation of B lymphocytes, from early pre B to mature
lymphocyte), inducing complement-dependent cytotoxicity
and antibody-dependent cellular cytotoxicity. The marked and
systemic B cell depletion observed in non-Hodgkin’s lymphoma patients treated with rituximab has recently led to use
of this agent in autoimmune diseases, with the aim of inhibiting
production of antibodies reacting against normal cells and
tissues. Preliminary published results appeared encouraging,
because rituximab showed activity in some cases of cold
agglutinin disease (1–3), warm antibody hemolytic anemia (2),
idiopathic thrombocytopenic purpura (4–6), paraproteinemic
polyneuropathy (7), and myasthenia gravis (8).
Type II mixed cryoglobulinemia (MC) is a systemic
vasculitis strictly associated with hepatitis C virus (HCV)
infection and is generally sustained by proliferation of nonneoplastic oligoclonal B cells (9,10). Based on the hypothesis
that rituximab could act on proliferating B cells and thus on
systemic autoimmune manifestations, we used the drug in 4
patients with symptomatic type II MC who were unresponsive
to previous treatments. The main clinical features of these
patients, before treatment with rituximab, are described below.
Patient 1 (previously described; see ref. 11) was a
58-year-old man who had formerly been treated with
interferon-␣ (IFN␣), cyclophosphamide, prednisone, danazol,
and plasmapheresis. Forty-six months after the diagnosis of
type II MC, the patient still had diffuse purpura, arthralgias,
fever, moderate anemia, and chronic renal failure.
Patient 2 was a 67-year-old woman previously treated
with prednisone and plasmapheresis. One hundred eight
Table 1. Clinical and laboratory features of patient 1 before and after rituximab treatment (375 mg/m2)*
Months after
RTX therapy
Baseline
1
2
3
4
5
6
12, LF
Main features of type
II MC
Purpura
Arthralgia
RF,
units/ml
Cryo,
mg/dl
IgM,
gm/liter
IgA,
gm/liter
IgG,
gm/liter
C3,
mg/dl
C4,
mg/dl
CD20,
⫻109/liter
CD19,
⫻109/liter
⫹⫹⫹
⫹
⫹
⫹
⫹⫹
⫹⫹
⫹⫹⫹
⫹⫹⫹
9
2
2
2
5
8
9
9
868
159
71
132
604
296
944
427
90
⬍50
Neg
150
90
137
169
319
1.7
1.1
0.8
1
1.4
1.3
1.6
1.4
0.7
0.8
0.6
0.7
0.7
0.7
0.8
0.9
2.9
4.7
3
4.5
4.9
4.3
5.2
3
72
88
80
85
88
112
92
96
8
4
4
2
3
2
3
2
0.032
0.002
0.002
0.002
0.020
NA
NA
NA
0.032
0.002
0.001
0.001
0.020
NA
NA
NA
* The patient was a 58-year-old, hepatitis C virus–positive man. Purpura was scored as follows: ⫹⫹⫹ ⫽ diffuse and persistent involvement of the
trunk and lower limbs; ⫹⫹ ⫽ diffuse and persistent involvement of the lower limbs; ⫹ ⫽ spare and fluctuating involvement of the lower limbs.
Arthralgia was graded according to a patient-scored (range 0–10) visual analog scale. Rheumatoid factor (RF) normal range 0–14; C3 normal range
90–180; C4 normal range 10–40. MC ⫽ type II mixed cryoglobulinemia; Cryo ⫽ cryoglobulins; RTX ⫽ rituximab; Neg ⫽ negative; NA ⫽ data not
available; LF ⫽ last followup.
2252
LETTERS
2253
Table 2. Clinical and laboratory features of patient 2 before and after rituximab treatment (375 mg/m2)*
Months after
RTX therapy
Baseline
1
2
3
4
5
6
13, LF
Main features of type II MC
Purpura
Urticaria
Bullae
RF,
units/ml
Cryo,
mg/dl
IgM,
gm/liter
IgA,
gm/liter
IgG,
gm/liter
C3,
mg/dl
C4,
mg/dl
CD20,
⫻109/liter
CD19,
⫻109/liter
⫹⫹
0
0
0
0
0
⫹
0
⫹⫹
0
0
0
0
0
0
0
⫹⫹
0
0
0
0
0
0
0
42
48
51
20
64
50
40
40
⬍50
⬍50
⬍50
⬍50
⬍50
⬍50
⬍50
⬍50
1
1
0.9
0.6
0.8
0.8
0.9
0.9
1.5
1.5
1.4
1.4
1.4
1.4
1.2
2.2
7
7.3
7.5
6.4
6.9
7.5
9.4
9.4
114
127
108
128
128
104
100
98
2
4
4
6
6
6
8
4
0.145
0.010
0.008
0.007
0.006
0.009
0.150
NA
0.120
0.005
0.004
0.001
0.001
0.009
0.150
NA
* The patient was a 67-year-old, hepatitis C virus–positive woman. Purpura, urticaria, and bullae were scored as follows: ⫹⫹⫹ ⫽ diffuse and
persistent involvement of the trunk and lower limbs; ⫹⫹ ⫽ diffuse and persistent involvement of the lower limbs; ⫹ ⫽ spare and fluctuating
involvement of the lower limbs. Rheumatoid factor (RF) normal range 0–14; C3 normal range 90–180; C4 normal range 10–40. See Table 1 for
definitions.
In patient 1, the therapeutic regimen was interrupted
after the second infusion of rituximab because of the development of acute left-sided amaurosis with a documented thrombosis of the retinal artery. A symmetric panniculitis at the
elbows and knees, which spontaneously resolved after 1 month,
was recorded for patient 2 on day 60. No other acute or
delayed relevant side effects or infectious complications occurred.
In this preliminary experience, rituximab treatment
proved effective in all 4 type II MC patients whose clinical
manifestations had been unresponsive to conventional treatments. Clinical improvement was accompanied by improvement in disease-related laboratory values. In particular, the
reduction in the levels of IgM and RF and the disappearance
of the monoclonal component of IgM␬ in 2 patients, in
conjunction with the concomitant depletion of B cells from the
peripheral blood, indicate that rituximab inhibited type II
MC–related B cell proliferation and pathogenic autoantibody
production. Rituximab therapy, although not targeted to the
key infectious trigger of type II MC, effectively treated mani-
festations of the disease, presumably by blocking the crucial
pathobiologic events (RF and immunocomplex production)
linked to the infection. This fact may be relevant in type II MC
patients, in whom HCV eradication may not be achieved
because of inefficacy of or contraindications to treatment with
antiviral agents.
Data for patients with non-Hodgkin’s lymphomas and
autoimmune diseases indicate that use of rituximab is associated with low toxicity and, in particular, absence of infectious
complications. This is important, because infection, the most
common cause of death in type II MC, is commonly associated
with use of steroids and cytotoxic drugs. Administration of
rituximab was not associated with arterial or venous thrombosis in a large series of patients (12). However, the thrombotic
event observed in patient 1 could have been related to factors
predisposing to type II MC (e.g., vasculitis, hyperviscosity).
Thus, use of rituximab should be carefully supervised in
patients with type II MC, especially if additional risk factors for
vascular events are present.
In conclusion, these preliminary results suggest that
Table 3. Clinical and laboratory features of patient 3 before and after rituximab treatment (375 mg/m2)*
Main features of type II MC
Months after
RTX therapy
Neuropathy
Purpura
Skin ulcers
RF,
units/ml
Cryo,
mg/dl
IgM,
gm/liter
IgA,
gm/liter
IgG,
gm/liter
C3,
mg/dl
C4,
mg/dl
CD20,
⫻109/liter
CD19,
⫻109/liter
Baseline
1
2
3
4
5, RTX ⫻ 4
6
7
8
9
10
11, LF
8
4
4
4
4
4
4
4
3
3
3
3
⫹⫹⫹
0
0
0
⫹
⫹⫹
⫹⫹
⫹⫹
⫹⫹
⫹⫹
⫹⫹
⫹⫹
⫹⫹
⫹⫹
⫹
⫹
0
0
0
0
0
0
0
⫹
79
34
21
⬍15
16
⬍15
⬍15
⬍15
⬍15
47
40
⬍15
1,500
1,200
1,100
3,900
NA
NA
1,613
1,421
NA
2,924
1,324
NA
14
10
7
5
7
6
2
1.7
0.4
2.3
2.4
2.9
1.6
1.2
0.9
0.8
0.9
0.9
0.9
0.9
0.9
0.9
1.1
1
7.4
3.4
3.4
3.4
4.8
5
2.7
1.9
3.3
3.3
3.3
3.2
107
179
140
143
145
149
168
154
167
155
134
148
2
6
7
10
10
10
11
11
14
13
12
10
0.053
0.007
0.001
0.007
0.020
0.001
NA
0.001
0.010
0.056
NA
NA
0.026
0.007
0.002
0.015
0.020
0.001
NA
0.001
0.010
0.056
NA
NA
* The patient was a 68-year-old, hepatitis C virus–negative woman. Neuropathic symptoms (pain and paresthesias) were graded according to a
patient-scored (range 0–10) visual analog scale. Purpura and ulcers were scored as follows: ⫹⫹⫹ ⫽ diffuse and persistent involvement of the trunk
and lower limbs; ⫹⫹ ⫽ diffuse and persistent involvement of the lower limbs; ⫹ ⫽ spare and fluctuating involvement of the lower limbs. Rheumatoid
factor (RF) normal range 0–14; C3 normal range 90–180; C4 normal range 10–40. RTX ⫻ 4 ⫽ 4 infusions. See Table 1 for additional definitions.
2254
LETTERS
Table 4. Clinical and laboratory features of patient 4 before and after rituximab treatment (375 mg/m2)*
Months after
RTX therapy
Baseline
1
2
3
4
5, LF
Main features of type II MC
AHA, grade
Neutropenia, grade
RF,
units/ml
Cryo,
mg/dl
IgM,
gm/liter
IgA,
gm/liter
IgG,
gm/liter
C3,
mg/dl
C4,
mg/dl
CD20,
⫻109/liter
CD19,
⫻109/liter
1
0
0
0
0
0
IV
0
0
0
0
0
101
40
33
21
15
15
446
293
45
Neg
Neg
Neg
8
5.1
2.2
2.1
1.7
1.7
1.9
1
0.8
0.8
0.8
0.8
10
8
7
8
7.1
7.1
240
133
138
134
127
119
6
10
13
19
18
20
0.060
0.006
0.001
0.006
NA
0.020
0.043
0.001
0.002
0.006
NA
0.020
* The patient was a 68-year-old, hepatitis C virus–positive woman. Anemia and neutropenia were graded according to World Health Organization
classification. Rheumatoid factor (RF) normal range 0–14; C3 normal range 90–180; C4 normal range 10–40. AHA ⫽ autoimmune hemolytic
anemia. See Table 1 for definitions.
rituximab may represent an important alternative for the
treatment of patients with type II MC. Rituximab could be the
ideal replacement for corticosteroids and conventional cytotoxic drugs, which increase the risk of infection and oncogenic
events. Moreover, rituximab could also be the ideal drug for
use in association with classic antiviral therapy (i.e., IFN␣,
ribavirin).
We wish to thank Roche Diagnostics S.p.A. (Monza, Italy) for
kindly supplying rituximab and Professor Angelo Giumanini for editing.
Francesco Zaja, MD
Salvatore De Vita, MD
Domenico Russo, MD
Angela Michelutti
Renato Fanin, MD
Gianfranco Ferraccioli, MD
Policlinico Universitario
Udine, Italy
Michele Baccarani, MD
Policlinico S. Orsola
Bologna, Italy
1. Berentsen S, Tjonnfjord GE, Gjertsen BT, Hammerstrom J,
Langholm R, Sorbo JH, et al. Rituxan (rituximab) therapy for
chronic cold agglutinin disease [abstract]. Blood 2000;96:3156a.
2. Lee E, Zamkoff KW, Gentile TC, Zimrin A. Rituxan in the
treatment of auto-immune haemolytic anemia (AIHA) [abstract].
Blood 2000;96:2560a.
3. Zaja F, Russo D, Fuga G, Michelutti T, Sperotto A, Fanin R, et al.
Rituximab in a case of cold agglutinin disease. Br J Haematol
2001;115:232–3.
4. Perotta A, Sunnemberg JS, Ratanatharathorn V, Hook C, Attas L,
Dawson D, et al. Rituxan in the treatment of chronic idiopathic
thrombocytopenia purpura (ITP) [abstract]. Blood 1999;94:94a.
5. Ratanatharathorn V, Carson E, Reynolds C, Ayash LJ, Levine J,
Yanik G, et al. Anti-CD20 chimeric monoclonal antibody treatment of refractory immune-mediated thrombocytopenia in a patient with chronic graft-versus-host disease. Ann Intern Med
2000;133:275–9.
6. Saleh MN, Gutheil J, Moore M, Feinberg B, Bunch P, Butler J, et
al. A pilot study of anti-CD20 MoAb rituximab in patients with
refractory immune thrombocytopenic purpura (ITP) [abstract].
Blood 2000;96:1086a.
7. Levine TD, Pestronk A. IgM antibody-related polyneuropathies:
B-cell depletion chemotherapy using rituximab. Neurology 1999;
52:1701–4.
8. Zaja F, Russo D, Fuga G, Perella G, Baccarani M. Rituximab for
myasthenia gravis developing after bone marrow transplant. Neurology 2000;55:1062–3.
9. De Vita S, De Re V, Gasparotto D, Ballare M, Pivetta B,
Ferraccioli G, et al. Oligoclonal non-neoplastic B cell expansion is
the key feature of type II mixed cryoglobulinemia: clinical and
molecular findings do not support a bone marrow pathologic
diagnosis of indolent B cell lymphoma. Arthritis Rheum 2000;43:
94–102.
10. Langford CA. Treatment of polyarteritis nodosa, microscopic
polyangiitis, and Churg-Strauss syndrome: where do we stand?
Arthritis Rheum 2001;44:508–12.
11. Zaja F, Russo D, Fuga G, Patriarca F, Ermacora A, Baccarani M.
Rituximab for the treatment of type II mixed cryoglobulinemia.
Haematologica 1999;84:1157–8.
12. McLaughlin P, Grillo-Lopez AJ, Link BK, Levy R, Czuczman MS,
Williams ME, et al. Rituximab chimeric anti-CD20 monoclonal
antibody therapy for relapsed indolent lymphoma: half of patients
respond to a four-dose treatment program. J Clin Oncol 1998;16:
2825–33.
DOI 10.1002/art.10351
Reply
To the Editor:
The letter by Zaja and colleagues raises some important points with regard to cryoglobulinemic vasculitis and its
management. Since the discovery of HCV, it has become
apparent that the vast majority of cases once identified as
essential mixed cryoglobulinemia are associated with chronic
HCV infection (1). Although the mechanisms involved in the
development of cryoglobulinemic vasculitis continue to be
actively investigated, current evidence suggests that in the
setting of HCV infection, stimulation of B cells leads to the
production of IgM RF that complexes with HCV antigens and
polyclonal HCV-specific IgG. The deposition of these immune
complexes in blood vessel walls triggers inflammation, resulting in the clinical features of cryoglobulinemic vasculitis.
Treatment of HCV-related cryoglobulinemic vasculitis
has primarily focused on elimination of HCV and on measures
that interfere with the immune mechanisms responsible for
blood vessel damage. For patients with HCV, combined treatment with IFN␣ and ribavirin has resulted in an overall
sustained response rate of 40–45% (2,3). IFN␣ has been
shown to be beneficial in HCV-related cryoglobulinemic vasculitis, with clinical response and reduction in the level of
LETTERS
circulating cryoglobulins being related to suppression of viremia (4).
In the largest prospective, randomized, controlled trial
to date, involving 65 patients with HCV-related cryoglobulinemic vasculitis, complete response was observed in
53% of those who received IFN␣ plus methylprednisolone,
53% who received IFN␣ alone, 17% who received methylprednisolone alone, and 7% who received no treatment (5). Although the rate of relapse following discontinuation of treatment was delayed in patients who received combined therapy,
the addition of methylprednisolone to IFN␣ was found to be of
limited benefit overall. Long-term remission was observed in
33% of patients treated with combined therapy, compared with
25% of those treated with IFN␣ alone, and HCV RNA levels
increased in almost 40% of methylprednisolone-treated patients. This prior experience supports that IFN␣ plus ribavirin
should remain the first line of treatment for HCV-related
cryoglobulinemic vasculitis, because it provides the best opportunity for viral clearance and resultant improvement of disease. The reality, however, is that ⬍50% of patients may have
a sustained response to this regimen, or patients may be unable
to receive or tolerate IFN␣ plus ribavirin because of side
effects. For such individuals, there is a great need to identify
other therapeutic options.
In their letter, Zaja and coworkers describe their
experience with 4 patients with type II mixed cryoglobulinemia
who were treated with rituximab. Rituximab is a chimeric
monoclonal antibody that binds to the CD20 antigen on B
cells, resulting in B cell death. Such a mechanism is intriguing
in the setting of HCV-related cryoglobulinemic vasculitis,
because it would theoretically deplete the population of B cells
that are producing the pathogenic RF that is driving the
immune complex disease.
The experience of Zaja et al must be viewed with both
caution and interest. Regarding safety, rituximab can be
associated with infusion reactions, and, although such reactions were not described, 1 patient had amaurosis and 1 had
panniculitis, both of which were unclearly associated with the
medication. The 4 individuals treated by Zaja and associates
had very diverse clinical pictures. Of the 3 with HCV-related
cryoglobulinemic vasculitis, only 1 was previously treated with
IFN␣ and ribavirin. One patient had a B cell non-Hodgkin’s
lymphoma, which is the primary indication for rituximab.
Although a complete response of her hemolytic anemia and
neutropenia was observed with treatment, these are not features of cryoglobulinemic vasculitis and were likely related to
lymphoma. The 3 other patients, who had more characteristic
manifestations of cryoglobulinemic vasculitis, had a partial
response.
Based upon this experience, it is difficult to draw any
conclusions regarding the safety or possible efficacy of rituximab in cryoglobulinemic vasculitis. However, the mechanism
of action of rituximab does support the need for a standardized
study, which is currently being conducted at the National
Institutes of Health. Until such time when further information
becomes available, management of cryoglobulinemic vasculitis
should continue to focus on identification of any underlying
disease processes and, in the setting of HCV infection, providing treatment when possible with IFN␣ and ribavirin.
2255
Carol A. Langford, MD, MHS
National Institute of Allergy and Infectious Diseases
National Institutes of Health
Bethesda, MD
1. Agnello V, Chung RT, Kaplan LM. A role for hepatitis C virus
infection in type II cryoglobulinemia. N Engl J Med 1992;327:
1490–5.
2. Poynard T, Marcellin P, Lee SS, Niederau C, Minuk GS, Ideo G, et
al, International Hepatitis Interventional Therapy Group (IHIT).
Randomised trial of interferon alpha2b plus ribavirin for 48 weeks
or for 24 weeks versus interferon alpha2b plus placebo for 48 weeks
for treatment of chronic infection with hepatitis C virus. Lancet
1998;352:1426–32.
3. McHutchison JG, Gordon SC, Schiff ER, Shiffman ML, Lee WM,
Rustgi VK, et al, Hepatitis Interventional Therapy Group. Interferon alfa-2b alone or in combination with ribavirin as initial
treatment for chronic hepatitis C. N Engl J Med 1998;339:1485–92.
4. Misiani R, Bellavita P, Fenili D, Vicari O, Marchesi D, Sironi PL,
et al. Interferon alfa-2a therapy in cryoglobulinemia associated with
hepatitis C virus. N Engl J Med 1994;330:751–6.
5. Dammacco F, Sansonno D, Han JH, Shyamala V, Cornacchiulo V,
Iacobelli AR, et al. Natural interferon-alpha versus its combination
with 6-methyl-prednisolone in the therapy of type II mixed cryoglobulinemia: a long-term, randomized, controlled study. Blood
1994;84:3336–43.
DOI 10.1002/art.10374
Anti–tumor necrosis factor therapy and Listeria
monocytogenes infection: report of two cases
To the Editor:
The tumor necrosis factor (TNF)–blocking agents infliximab and etanercept have recently been approved by the
US Food and Drug Administration and the respective European licensing institutions for treatment of rheumatoid arthritis (RA) refractory to other medical therapy (1–3). Tolerability
and therapeutic efficacy of both infliximab and etanercept are
good, and the number of patients treated with these drugs is
increasing steadily (4,5). Animal studies, however, have shown
that TNF is not only a key mediator of inflammation but also
plays an essential role in the defense against infection (6). Mice
treated with TNF-blocking agents became exquisitely sensitive
to infections with pathogens such as cryptosporidia, mycobacteria, fungi, Leishmania, and Listeria, which require an intact
Th1 response for recovery (7).
Increased susceptibility to such infections may also be
relevant to humans receiving TNF-blocking therapy. In December 2000, the manufacturers of infliximab reported that 33
cases of active tuberculosis were potentially associated with use
of this anti-TNF antibody. Moreover, 2 patients with Crohn’s
disease developed listeriosis and invasive pulmonary aspergillosis, respectively, while receiving infliximab (8,9).
We now report 2 cases of Listeria monocytogenes
infection, 1 of which was fatal, in 2 patients who were receiving
infliximab together with other immunosuppressive diseasemodifying antirheumatic drugs (DMARDs). Patient 1 was a
60-year-old woman with a history of severe RA since 1984. Her
therapy included methotrexate, cyclosporin A, and repeated
2256
prednisolone pulses because of ongoing, highly active arthritis.
In April 2000, she began receiving infliximab at a dosage of 10
mg/kg every 4 weeks. RA activity was well controlled with this
therapy until September 2000 (14 days after receiving the sixth
infusion of infliximab), when she was admitted to the hospital
because of anemia, fever, and abdominal pain. A gastric ulcer,
without evidence of acute hemorrhage, and acute cholecystitis
were diagnosed, together with a pulmonary infiltrate. Laboratory tests revealed anemia and the following values: hemoglobin 6.2 gm/dl, white blood cell count (WBC) 4.2/nl with a left
shift in the differential, platelet count 70/nl, lactate dehydrogenase (LDH) 552 units/liter, aspartate aminotransferase
(AST) 82 units/liter, alanine aminotransferase (ALT) 49 units/
liter, creatinine 1.9 mg/dl, and C-reactive protein 254 mg/liter.
Cholecystectomy was performed, and the patient was
immediately given antibiotic therapy with cefriaxone, metronidazole, and fluconazole. After surgery, she did not regain
consciousness appropriately and continued to require respiratory support despite discontinuation of all sedative drugs. The
leukocyte count increased to 11.5/nl, and C-reactive protein
decreased slightly to 163 mg/dl. A cerebral computed tomography (CT) scan was performed and showed severe brain
edema with small spots of subarachnoidal hemorrhage, which
was initially interpreted as acute sinus vein thrombosis. Subsequently, the patient developed multi-organ failure and brainstem herniation due to the massive brain edema and died 2
days later, despite maximum supportive care. Unexpectedly,
both a swab culture from the gallbladder obtained during
surgery and a blood culture obtained 1 day later grew L
monocytogenes.
Patient 2 was a 62-year-old woman with a diagnosis of
RA since 1992. Until July 2000, her therapy included methotrexate together with cyclosporin A. Because of highly active
arthritis, cyclosporin A was switched to infliximab, 200 mg
intravenously, which was planned to be given at weeks 0, 2, 6,
and 10 and at 8-week intervals thereafter. The arthritis improved after the first dose of infliximab. However, 14 days after
the second dose, the patient developed cholecystitis and was
admitted to the surgical department for cholecystectomy.
After surgery, she developed signs indicating an intracerebral process, including hemiparesis, aphasia, and fever. A
cerebral CT scan showed a mass lesion (4 cm in diameter) in
the left frontal lobe, with circular contrast enhancement.
Laboratory tests showed the following values: WBC 13.3/nl,
C-reactive protein 126 mg/liter, AST 85 units/liter, ALT 48
units/liter, and LDH 516 units/liter. Two days later, blood
cultures turned positive for L monocytogenes, and therapy with
ampicillin and gentamicin was started. Fever and the elevated
parameters of inflammation responded adequately, and it was
decided that neurosurgical intervention would not be helpful.
Antibiotic therapy was continued for a total of 18 weeks.
Improvement of the neurologic symptoms was slow; however,
repeated cerebral CT scans 5 months after the initial diagnosis
revealed a marked reduction in the size of the brain lesion,
with no perifocal contrast enhancement.
The common features in these 2 cases of systemic
listeriosis are striking and include cholecystitis and involvement of the central nervous system (CNS), with meningoencephalitis and brain abscess, respectively. Several cases of
localized Listeria infection, the majority in the form of monarthritis, have been reported in patients receiving immunosup-
LETTERS
pressive therapy, usually methotrexate (for review, see ref. 10).
Pregnant women, patients receiving chronic immunosuppressive therapy, or organ transplant recipients (i.e., patients with
a more or less pronounced T cell defect) are known to be at
risk for listeriosis. Both of our patients were severely immunocompromised, because they had received immunosuppressive disease-modifying therapy with methotrexate, cyclosporin
A, and corticosteroids for an extended period of time before
TNF-blocking therapy with infliximab was initiated. Both
patients subsequently developed cholecystitis, bacteremia, and
CNS infection from L monocytogenes. It should be noted that
neither patient had a major infection during long-term therapy
with conventional immunosuppressive DMARDs (before infliximab treatment was started), and Listeria infections developed in both patients shortly after initiation of TNF-blocking
therapy. Therefore, it can be hypothesized that the newly
administered anti-TNF antibody therapy blocked the critical
step required for appropriate defense against L monocytogenes
infection, resulting in systemic infection.
Increased susceptibility to Listeria in humans might
have been predicted from in vivo experiments using infectious
agents in animals pretreated with TNF-blocking drugs. In these
experiments, immunity against Listeria was shown to depend
on appropriate secretion of TNF (7,11), most likely because in
this particular infection, TNF is essential for macrophage
activation (12,13).
The occurrence of severe infections associated with
TNF-blocking drugs does not necessarily preclude their use,
because these agents are clearly beneficial for patients with
chronic inflammatory disease refractory to other therapies.
Rather, we suggest routinely advising patients receiving TNFblocking agents not to eat soft cheese or other nonpasteurized
dairy products, which are known to harbor Listeria (14). All
physicians treating patients who receive TNF-blocking drugs
should be highly suspicious about atypical pathogens, including
Listeria, once signs of infection occur in their patients. Antibiotic susceptibility of Listeria is restricted to ampicillin, carbapenems, aminoglycosides, and trimethoprim-sulfamethoxazole.
However, these agents are not used as first-line empiric
therapy for fever in the immunocompromised host. Therefore,
infection with Listeria must be aggressively sought and ruled
out in such cases. Empiric antibiotic coverage for Listeria may
be appropriate in high-risk cases and should be mandatory if
signs of CNS involvement are present.
T. Glück, MD
H.-J. Linde, MD
J. Schölmerich, MD
U. Müller-Ladner, MD
University of Regensburg
Regensburg, Germany
C. Fiehn, MD
University of Heidelberg
Heidelberg, Germany
P. Bohland, MD
Diakoniekrankenhaus Mannheim
Mannheim, Germany
1. Maini R, St Clair EW, Breedveld F, Furst D, Kalden J, Weisman
M, et al for the ATTRACT Study Group. Infliximab (chimeric
anti-tumour necrosis factor alpha monoclonal antibody) versus
LETTERS
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
placebo in rheumatoid arthritis patients receiving concomitant
methotrexate: a randomised phase III trial. Lancet 1999;354:
1932–9.
Weinblatt ME, Kremer JM, Bankhurst AD, Bulpitt KJ, Fleischmann RM, Fox RI, et al. A trial of etanercept, a recombinant
tumor necrosis factor receptor: Fc fusion protein, in patients with
rheumatoid arthritis receiving methotrexate. N Engl J Med 1999;
340:253–9.
Feldman N, Maini RN. Anti-TNF therapy of rheumatoid arthritis:
what have we learned? Annu Rev Immunol 2001;19:193–6.
Kremer JM. Combination therapy with biologic agents in rheumatoid arthritis: perils and promise. Arthritis Rheum 1998;41:
1548–51.
Markham A, Lamb HM. Infliximab: a review of its use in the
management of rheumatoid arthritis. Drugs 2000;59:1341–59.
Echtenacher B, Falk W, Männel DN, Krammer PH. Requirement
of endogenous tumor necrosis factor/cachectin for recovery from
experimental peritonitis. J Immunol 1990;145:3762–6.
Nakane A, Minagawa T, Kato K. Endogenous tumor necrosis
factor (cachectin) is essential to host resistance against Listeria
monocytogenes infection. Infect Immun 1988;56:2563–9.
Morelli J, Wilson FA. Does administration of infliximab increase
susceptibility to listeriosis? Am J Gastroenterol 2000;95:841–2.
Warris A, Bjorneklett A, Gaustad P. Invasive pulmonary aspergillosis associated with infliximab therapy. N Engl J Med 2001;344:
1099–100.
Polnau U, Braun MG, van der Boom H, Becker-Capeller D.
Listerienarthritis bei chronischer polyarthritis unter low-doseprednisolon- und methotrexat-therapie. Z Rheumatol 2001;60:
41–6.
Nishikawa S, Miura T, Sasaki S, Nakane A. The protective role of
endogenous cytokines in host resistance against an intragastric
infection with Listeria monocytogenes in mice. FEMS Immunol
Med Microbiol 1996;31:291–8.
Roll JT, Young KM, Kurtz RS, Czuprynski CJ. Human rTNF
alpha augments anti-bacterial resistance in mice: potentiation of
its effect by recombinant human rIL-1 alpha. Immunology 1990;
69:316–22.
Kato K, Nakane A, Minagawa T, Kasai N, Yamamoto K, Sato N,
et al. Human tumor necrosis factor increases the resistance against
Listeria infection in mice. Med Microbiol Immunol 1989;178:
337–46.
Rudol M, Scherer S. High incidence of Listeria monocytogenes in
European red smear cheese. Int J Food Microbiol 2001;63:91–8.
2257
suggestion about counseling patients receiving TNF inhibitors
to limit potential exposure to Listeria by avoiding nonpasteurized dairy products makes some sense in this regard.
It is also possible that long-term intermittent use of
trimethoprim-sulfamethoxazole (TMP-SMX), often used for
prophylaxis of Pneumocystis carinii pneumonia (4), might have
the additional benefit of avoidance of Listeria infections. It is
unlikely that the effects of TMP-SMX would result in significant toxicity because this agent is now widely used with
methotrexate without additional toxicity when treating patients
with Wegener’s granulomatosis (5). Long-term observations in
patients receiving TNF inhibitors and TMP-SMX would be
needed in order to provide insight about whether this strategy
is safe and effective. Because of the relative infrequency of
Listeria infections, very large numbers of patients, as can be
found only in large clinical data bases, will be needed to
provide these answers.
In the meantime, clinicians using biotechnology agents
must remain vigilant for reports of opportunistic infections, as
described in the letter by Glück et al, while being willing to
incorporate new and creative strategies, when appropriate, to
avoid them. The inhibition of TNF has resulted in significant
gains in the fight against RA, and continued, expanded use of
these agents is both likely and appropriate.
Joel M. Kremer, MD
The Center for Rheumatology
Albany, NY
1. Keane J, Gershon S, Wise RP, Mirabile-Levens E, Kasznica J,
Schwieterman WD, et al. Tuberculosis associated with infliximab, a
tumor necrosis factor alpha-neutralizing agent. N Engl J Med
2001;345:1098–104.
2. Kremer JM. Combination therapy with biologic agents in rheumatoid arthritis: perils and promise. Arthritis Rheum 1998;41:1548–51.
3. Cohn DL, O’Brien RJ. Targeted tuberculin testing and treatment of
latent tuberculosis infection. Am J Resp Crit Care Med 2000;161:
S221–S247.
4. Ognibene FP, Shelhamer JH, Hoffman GS, Kerr GS, Reda D,
Fauci AS, et al. Pneumocystis carinii pneumonia: a major complication of immunosuppressive therapy in patients with Wegener’s
granulomatosis. Am J Respir Crit Care Med 1995;151:795–9.
5. Hoffman GS. Treatment of Wegener’s granulomatosis: time to
change the standard of care? Arthritis Rheum 1997;40:2099–104.
DOI 10.1002/art.10371
Reply
To the Editor:
Dr. Glück and colleagues should be commended for
their careful report of 2 cases of L monocytogenes infection in
patients with RA receiving infliximab. As use of new biotechnology treatments expands, the medical community is likely to
see other reports of this kind (1).
The fact that their letter is based on an editorial
authored and published in 1998 (2) speaks to the need for a
centralized collection system for reporting toxicities associated
with the use of these new agents. One of the challenges faced
by clinicians using new drugs is to increase awareness of
toxicity issues that inevitably emerge with expanded clinical
use, while seeking to develop creative strategies to avoid these
newly reported untoward events. Recent directives to perform
targeted tuberculin skin testing in patients at risk (3) have thus
been applied to the use of infliximab. The authors’ empiric
DOI 10.1002/art.10348
Bullous skin lesions following infliximab infusion in a
patient with rheumatoid arthritis
To the Editor:
Infliximab, a chimeric monoclonal antibody to tumor
necrosis factor ␣ (TNF␣), is a treatment option for patients
with rheumatoid arthritis (RA) (1). Infliximab has been associated with a variety of side effects, including hypersensitivity
reactions, serum sickness–like reactions, and the development
of a lupus-like syndrome with autoantibodies. However, to our
knowledge, development of bullous skin lesions in patients
treated with infliximab has not been reported.
Recently, a 72-year-old white man with RA presented
to our emergency department with severe pain and blistering
skin lesions. These symptoms occurred 1 day after the patient
received his fourth dose of infliximab for the treatment of
2258
Figure 1. Large bulla on the right medial thigh, containing strawcolored fluid, with surrounding erythema.
severe RA. Physical examination revealed huge (10–15 cm)
flaccid bullae over the left elbow and right thigh that contained
straw-colored fluid (Figure 1).
Serologic testing revealed positive (2.0 units) antinuclear antibodies (ANA) (⬍1.0 unit is considered negative), but
antibodies to Sm, Ro, La, Jo-1, Scl-70, RNP, and doublestranded DNA (dsDNA) were not detected. The total complement level was reduced (15 units/ml, normal range 30–75), as
was the level of C3 (54 mg/dl, normal range 75–175). Human
antichimeric antibodies (Prometheus Laboratories, San Diego,
CA) were positive (2.57 ␮g/ml, reference ⬍1.69), and chimeric
anti-TNF antibodies were also positive (2.25 ␮g/ml, reference
⬍1.4).
Although the bullous skin lesions had some features in
common with pemphigus vulgaris and bullous pemphigoid,
light microscopy and direct immunofluorescence of the skin
biopsy specimens revealed features that were not typical of
either (e.g., discontinuous granular IgM deposition in the
basement membrane zone was seen).
Based on the temporal relationship between the infliximab infusion and development of the bullae, an infliximabinduced bullous skin reaction was diagnosed, and treatment
was initiated with prednisone, 60 mg/day, with tapering to the
patient’s baseline prednisone dose over a 2-week period. No
further bullae developed after initiation of higher-dose prednisone, and the patient recovered completely.
The US Food and Drug Administration recently reported on the safety of TNF␣ antagonists (2). Infliximab rarely
has been associated with cases of demyelinating disease,
seizures, and intestinal perforation. Granulomatous infections
such as tuberculosis (3) and histoplasmosis have been reported
more frequently; other reported infections include listeriosis
and Pneumocystis carinii pneumonia.
Cutaneous adverse events have included rash, edema,
urticaria, and rare cases of lupus-like illnesses and rashes
compatible with subacute cutaneous and discoid lupus, associated with increases in autoantibody titers (4). Low titers of
autoantibodies developed in ⬍10% of patients, and druginduced lupus developed in ⬍1% in a long-term safety evaluation of infliximab (4). Antibodies to dsDNA of the IgM class
are induced by infliximab in 5–7% of patients (5).
LETTERS
The safety of and adverse events associated with
infliximab have been reviewed by combining data from 453
patients in 9 clinical trials (6). Human antichimeric antibodies
(HACA) developed in 13% of patients with Crohn’s disease.
Of note, patients receiving immunosuppressive treatment with
methotrexate, azathioprine, or 6-mercaptopurine were less
likely to develop HACA responses. Infusion reactions were
positively correlated with the presence of HACA (6).
This report does not definitely show that infliximab was
the cause of the patient’s bullous skin eruption. However, the
close temporal relationship between the infusion and the
observed reaction does signal a potential causal association.
Bullous skin lesions have been described in patients with lupus,
but the immunofluorescence studies in this case were not
typical of lupus (7). Our patient had developed positive ANA
and HACA, but whether these played any role in the pathogenesis of the skin eruption is speculative. In addition, while
the patient was receiving low-dose prednisone and hydroxychloroquine, he was not receiving methotrexate because of
hepatotoxicity caused by this drug. Lack of use of a potent
immunosuppressive medication in conjunction with infliximab
may have been a predisposing factor in this case.
Continued vigilance for similar adverse reactions is
indicated. Whether concomitant therapy with agents such as
methotrexate must always be prescribed with infliximab is not
known, but it would seem prudent to pursue this therapy
whenever possible and indicated.
Peter D. Kent, MD
John M. Davis III, MD
Mark D. P. Davis, MD
Eric L. Matteson, MD, MPH
Mayo Clinic
Rochester, MN
1. Taylor PC. Anti-tumor necrosis factor therapies. Curr Opin Rheumatol 2001;13:164–9.
2. Arthritis Advisory Committee. Safety update on the TNF-alpha
antagonists. Open session of the Food and Drug Administration
Center for Biologics Evaluation and Research; 2001 Aug 17;
Gaithersburg (MD). Online at http:www.fda.gov/ohrms/dockets/ac/
01/transcripts/3779t2_01.pdf.
3. Keane J, Gershon S, Wise RP, Mirabile-Levens E, Kasznica J,
Schwieterman WD, et al. Tuberculosis associated with infliximab, a
tumor necrosis factor alpha-neutralizing agent. N Engl J Med
2001;345:1098–104.
4. Shaible TF. Long-term safety of infliximab. Can J Gastroenterol
2000;14 Suppl C:29C–32C.
5. Charles PJ, Smeenk RJ, De Jong J, Feldmann M, Maini RN.
Assessment of antibodies to double-stranded DNA induced in
rheumatoid arthritis patients following treatment with infliximab, a
monoclonal antibody to tumor necrosis factor alpha: findings in
open-label and randomized placebo-controlled trials. Arthritis
Rheum 2000;43:2383–90.
6. Hanauer SB. Safety of infliximab in clinical trials. Aliment Pharmacol Ther 1999;13 Suppl 4:16–22.
7. Chan LS, Lapiere J, Chen M, Traczyk T, Mancini AJ, Paller AS, et
al. Bullous systemic lupus erythematosus with autoantibodies recognizing multiple skin basement membrane components, bullous
pemphigoid antigen 1, laminin-5, laminin-6, and type VII collagen.
Arch Dermatol 1999;135:569–73.
LETTERS
2259
DOI 10.1002/art.10353
DOI 10.1002/art.10377
Reply
Synovial lymphocyte responses to microbiologic
antigen stimulation indicate the etiology of
undifferentiated and reactive arthritis, and possibly of
rheumatoid arthritis: comment on the article by
Schnarr et al
To the Editor:
Infliximab-induced ANA and anti-dsDNA antibodies
of the IgM class, usually in low titer, are only rarely associated
with a lupus-like illness (1). For example, from among a group
of 156 RA patients exposed to infliximab in clinical trials, we
documented 1 who developed fever, a nonspecific rash, and
pleuropericarditis and who, interestingly enough, developed
both IgG and IgM anti-dsDNA antibodies in high titer.
Another patient, who developed a lupus-like, erythematous
rash, was ANA positive but had no anti-dsDNA antibodies (2).
The striking reduction in complement in the patient
with the bullous eruption described by Kent et al would
implicate immune complexes in the pathogenesis of those
lesions. Whether the nuclear antigens complexed to ANA
formed pathogenic immune complexes, as they might do in
lupus, cannot be ascertained simply by observing an association
with the occurrence of ANA. ANA may appear and disappear
during the course of infliximab therapy (1). The possibility
must be considered that the pathogenic immune complexes in
this patient were composed of infliximab and anti-infliximab
antibodies (also detected in the blood of this patient). This
possibility is further supported by the close temporal relationship between the onset of rash and the fourth infusion of
infliximab.
The speculation that coadministration of methotrexate
might have prevented the adverse reaction is supported by the
observation that the immunogenicity of infliximab is significantly reduced by combining methotrexate and infliximab (3).
In contrast, the incidence of anti-dsDNA induction was not
inhibited by methotrexate (1). The hypothesis that antiinfliximab antibodies played a part should be further investigated by seeking evidence of anti-infliximab antibodies in
blood and deposition of infliximab in skin lesions by probing
with an antiidiotype antibody.
Ravinder N. Maini, MBBChir, FRCP, FMedSci
Peter Charles, FIBMS
Kennedy Institute of Rheumatology Division
Imperial College of Science, Technology and Medicine
London, UK
1. Charles PJ, Smeenk RJT, De Jong J, Feldmann M, Maini RN.
Assessment of antibodies to double-stranded DNA induced in
rheumatoid arthritis patients following treatment with infliximab, a
monoclonal antibody to tumor necrosis factor ␣: findings in openlabel and randomized placebo-controlled trials. Arthritis Rheum
2000;43:2383–90.
2. Maini RN, St Clair EW, Breedveld F, Furst D, Kalden J, Weisman
M, et al, ATTRACT Study Group. Infliximab (chimeric antitumour necrosis factor ␣ monoclonal antibody) versus placebo in
rheumatoid arthritis patients receiving concomitant methotrexate: a
randomised phase III trial. Lancet 1999;354:1932–9.
3. Maini RN, Breedveld FC, Kalden JR, Smolen JS, Davis D, Macfarlane JD, et al. Therapeutic efficacy of multiple intravenous
infusions of anti-tumor necrosis factor ␣ monoclonal antibody
combined with low-dose weekly methotrexate in rheumatoid arthritis. Arthritis Rheum 1998;41:1552–63.
To the Editor:
In the November 2001 issue of Arthritis & Rheumatism,
Schnarr et al (1) reported finding chlamydial DNA in the
synovial fluid of 9 of 52 patients with undifferentiated oligoarthritis (UOA). They discussed the difficulty of attributing the
etiology of UOA to the synovial DNA, commenting that,
“Additional evidence supporting a bacterial etiology, such
as . . . bacteria-specific T cell responses, will be helpful.”
In 1980 (2), synovial mononuclear cells in Reiter’s
syndrome were found to respond to ureaplasmal and chlamydial antigens. In 1985 (3), synovial lymphocytes from 8 patients
with enteric reactive arthritis were shown to respond to enteric
antigens, and in 12 patients with sexually transmitted reactive
arthritis, they responded to either chlamydial or ureaplasmal
antigens. In contrast, synovial lymphocytes from 14 patients
with rheumatoid arthritis showed no responses to these antigens. In addition, in all cases, peripheral blood lymphocytes
usually showed minimal or no responses. Between 1989 and
1994, these observations were confirmed in several countries
(4–7).
In 1984 (8), synovial responses to chlamydia/
ureaplasma and enteric antigens were studied in 31 patients
with unexplained inflammatory arthritis confined to the knee
joints, and comparisons between responses in rheumatoid
arthritis and Reiter’s syndrome were made. In 10 of the 31
cases of UOA, the synovial lymphocytes responded as if the
patients had Reiter’s syndrome.
Because synovial lymphocyte responses to microbiologic antigen stimulation indicate the causes of undifferentiated and reactive arthritis, such reactivity can give significance
to the presence of microbiologic DNA or antigen in the
synovia of patients with arthritis of unknown etiology. The
mere presence of these substances in the joint is not proof of
pathogenicity, but an association between a specific immune
reaction within the joint and the same agent provides strong
incriminating evidence for specific immunopathology. Summaries of the accumulated data from a 12-year study of synovial
lymphocyte responses in 360 patients have provided documented support for these viewpoints and have extended the
observations to the probable microbiologic etiology of rheumatoid arthritis (9–12).
Denys K. Ford, MD
Vancouver, BC, Canada
1. Schnarr S, Putschky N, Jendro MC, Zeidler H, Hammer M,
Kuipers JG, et al. Chlamydia and Borrelia DNA in synovial fluid
of patients with early undifferentiated oligoarthritis: results of a
prospective study. Arthritis Rheum 2001;44:2679–85.
2. Ford DK, da Roza DM, Shah P, Wenman WM. Cell-mediated
immune responses of synovial mononuclear cells in Reiter’s syndrome against ureaplasmal and chlamydial antigens. J Rheumatol
1980;7:751–5.
3. Ford DK, da Roza DM, Schulzer M. Lymphocytes from the site of
2260
4.
5.
6.
7.
8.
9.
10.
11.
12.
disease but not blood lymphocytes indicate the cause of arthritis.
Ann Rheum Dis 1985;44:701–10.
Hermann E, Fleischer B, Mayet WJ, Poralla T, Meyer zum
Buschenfelde KH. Response of synovial fluid T cell clones to
Yersinia enterocolitica in patients with reactive Yersinia arthritis.
Clin Exp Immunol 1989;75:365–70.
Gaston JS, Life PF, Granfors K, Merilahti-Palo R, Bailey L,
Consalvey S, et al. Synovial T lymphocyte recognition of organisms
that trigger reactive arthritis. Clin Exp Immunol 1989;76:348–53.
Sieper J, Kingsley G, Palacios-Boix A, Pitzalis C, Treharne J,
Hughes R, et al. Synovial T lymphocyte-specific response to
Chlamydia trachomatis in Reiter’s disease. Arthritis Rheum 1991;
34:588–98.
Horowitz H, Horowitz J, Taylor-Robinson D, Sukenik S, Apte RN,
Bar-David J, et al. Ureaplasma urealyticum in Reiter’s syndrome.
J Rheumatol 1994;21:877–82.
Ford DK, da Roza DM, Ward RH. Arthritis confined to knee
joints: synovial lymphocyte responses to microbial antigens correlate with distribution of HLA. Arthritis Rheum 1984;27:1157–64.
Ford DK. Synovial lymphocytes can indicate specific microbiologic
causes of rheumatoid arthritis. Arthritis Rheum 1993;36:1350–2.
Ford DK, Schulzer M. Lymphocytes from the site of disease are
functionally different from peripheral blood lymphocytes and may
demonstrate etiologically related antigen specificity. Immunol Lett
1994;42:179–83.
Ford DK, Tingle A. Lymphocytes from site of disease indicate
probable microbiological etiology of “infective-immune” diseases
such as rheumatoid arthritis. Infect Agents Dis 1996;5:223–30.
Ford DK. Understanding rheumatoid arthritis. J Rheumatol 1997;
24:1464–6.
LETTERS
cytometry–based analysis of antigen-specific T cell responses),
and, of course, ultimately the cure of arthritis by eradication of
the persistent synovial infection can unequivocally prove the
pathogenetic significance of intraarticular organisms.
Sebastian Schnarr, MD
Michael C. Jendro, MD
Henning Zeidler, MD
Jens G. Kuipers, MD
Hannover Medical School
Hannover, Germany
1. Gerard HC, Branigan PJ, Schumacher HR Jr, Hudson AP. Synovial
Chlamydia trachomatis in patients with reactive arthritis/Reiter’s
syndrome are viable but show aberrant gene expression. J Rheumatol 1998;25:724–42.
2. Fendler C, Wu P, Eggens U, Laitko S, Sörensen H, Diestler A, et al.
Longitudinal investigation of bacterium-specific synovial proliferation in reactive arthritis and Lyme arthritis. Br J Rheumatol
1998;37:784–8.
3. Wilkinson NZ, Kingsley GH, Sieper J, Braun J, Ward ME. Lack of
correlation between the detection of Chlamydia trachomatis DNA
in synovial fluid from patients with a range of rheumatic diseases
and the presence of an antichlamydial immune response. Arthritis
Rheum 1998;41:845–54.
4. Jendro MC, Deutsch T, Körber B, Köhler L, Kuipers JG, KrausseOpatz B, et al. Infection of human monocyte-derived macrophages
with Chlamydia trachomatis induces apoptosis of T cells: a potential
mechanism for persistent infection. Infect Immun 2000;68:6704–11.
DOI 10.1002/art.10372
Reply
To the Editor:
We thank Dr. Ford for his interest in our article. We
consider the presence of chlamydial DNA in the synovium to
be a valuable hint concerning the etiology of undifferentiated
arthritis, but we agree that this does not unequivocally prove
the causative role of these bacteria in individual cases. Several
approaches are possible to prove causality: first, demonstration
of viable and metabolically active bacteria at the site of
inflammation, as has been convincingly shown by Gerard et al
(1); second, demonstration of antigen-specific host response to
the persisting bacteria; and third (the ultimate proof), cure of
the arthritis by eradication of the bacteria.
With respect to these different approaches, we do not
consider results of synovial lymphocyte proliferation assays to
be sufficient proof of causality. In contrast to the literature
cited by Dr. Ford, Fendler et al describe low specificity of
synovial lymphocyte proliferation assays due to cross-reactivity
or other antigen-independent factors, such as the ratio of T
cells to macrophages or the grade of T cell activation (2).
Consequently, they argue against use of proliferation assays for
diagnostic purposes. Wilkinson et al did not even find a
correlation between the presence of intraarticular chlamydial
DNA and the antichlamydial synovial T cell response in 4
patients with sexually acquired reactive arthritis and in 31
patients with UOA (3). In our opinion, reduced T cell reactivity in the presence of viable chlamydiae could be explained by
the phenomenon of chlamydia-infected macrophages inducing
T cell apoptosis (4).
In summary, only a combination of techniques such as
polymerase chain reaction (PCR), reverse transcriptase PCR,
specific readout systems for host response (e.g., flow
DOI 10.1002/art.10375
Criteria for TUNEL labeling in determining apoptosis
in human osteoarthritis cartilage: comment on the
article by Aigner et al
To the Editor:
We read with great interest the article by Aigner and
colleagues (1) reporting apoptosis limited to the deep zone in
osteoarthritic (OA) human cartilage. This result contrasts with
those of most of the published studies (2–7). The TUNEL
technique has limitations: it gives false-positive results, and the
reaction may appear even in necrotic chondrocytes, as previously reported (8,9). Although TUNEL is still a useful method,
results must be interpreted very cautiously and require additional support, including detection of other molecules of the
apoptotic cascade, such as Fas and caspase 3 (the 17–22-kd
fraction), and even the “ladder” DNA fragmentation sign.
The use of human cartilage also imposes certain restrictions, because it is not always possible to ascertain the
complete clinical history of the patient. Some patients may
have received drugs that can substantially modify the results, as
in the case of locally infiltrated glucocorticoids, which indeed
stimulate apoptosis (10). The type of OA must also be
considered. OA in elderly patients differs from traumatic OA,
which can induce severe cartilage breakdown. The sampling
method is another key factor. In a previous study (7), we
demonstrated that cartilage obtained by arthroscopy displayed
more TUNEL labeling compared with cartilage obtained by
arthroplasty, suggesting that the procedure used for removing
tissue might influence the results. In that study, very small
tissue samples were manipulated arthroscopically before fixa-
LETTERS
tion. In contrast, using arthroplasty, entire condyles were
removed and immediately fixed before the cartilage was divided into small portions to assess the TUNEL reaction. All of
these factors must be evaluated when using human cartilage.
The occurrence of apoptosis in human OA cartilage
has been further supported by reports of Fas/FasL expression
(3) and detection of the DNA ladder fragmentation sign (5).
These observations strongly indicate that apoptosis might not
be as limited as suggested by Aigner et al. In view of the
current knowledge, it seems rather risky to assess apoptosis
only by TUNEL-labeled apoptotic bodies, because the
TUNEL technique is associated with serious pitfalls, and the
apoptotic bodies could easily be missed, as has been reported
(9).
Using different experimental models and techniques in
addition to TUNEL, several authors (including our group)
have described apoptosis within the entire depth of the cartilage. As already reported, our rat OA model (11) showed that
both the intensity and the arrangement of TUNEL nuclear
labeling varied according to both progression of damage (5–60
days after surgery) and cartilage zone. In earlier stages of
disease, the superficial chondrocytes displayed intense nuclear
labeling and changed morphologically from flattened to
rounded. These chondrocytes were not contracted, and they
did not display highly condensed chromatin. On the contrary,
they showed an ultrastructural pattern characterized by
rounded nuclei, a prominent rough endoplasmic reticulum,
and frequent Golgi membranes (12). In contrast, chondrocytes
in the middle and deep zones showed contraction and fragmentation, and labeling was fuzzy or absent. In addition, when
we compared nuclear TUNEL labeling of chondrocytes from
OA cartilage for all experiments, it was evident that the
number of labeled nuclei and the intensity of labeling varied
from abundant and intense (in the early stages) to scarce and
fuzzy (in late stages).
These results, which are not possible to assess in
human OA, made us assume that the intensity of TUNEL
labeling is greater prior to the appearance of the presumed
typical morphologic pattern in apoptosis, and also that the
labeling seems to disappear according to the breakdown of
DNA. Therefore, combining research using human cartilage
samples with that involving an experimental model might
provide a more integral view than that provided by a single
approach. Confident use of TUNEL detection kits most certainly requires adjustment of the limitations provided by the
manufacturers and the use of accurate controls (1). However,
it is important to consider that when the TUNEL technique is
performed outside of certain suggested parameters, falsenegative results are possible.
Also worthy of discussion is the morphology of apoptosis in chondrocytes, which seems to differ from that described in lymphocytes. Regardless, in our experiments, the
morphology in both human OA and the experimental OA in
rats most certainly was not that of necrosis. Furthermore, some
clustered chondrocytes displayed TUNEL labeling, and the
morphology was different from the presumed morphology of
an apoptotic chondrocyte. It is possible that apoptotic death in
chondrocytes might be diverse and different from that described in other cell types.
Regarding the article by Aigner et al, we are also
concerned because the authors credited our group with results
2261
that are opposite to those that we reported (7). For instance,
we described intense labeling in cartilage samples obtained by
arthroscopy. In addition, we suggested that the difference in
the intensity of TUNEL labeling was apparently opposite to the
apoptotic morphologic changes. It is highly unlikely that we
would establish a correlation between positive TUNEL labeling and apoptotic morphology, because such a correlation
would probably be different from that expected, as documented above. We believe that the authors might have inadvertently misinterpreted our results while using them as a
major argument to sustain part of their hypothesis.
Cell death in OA cartilage is an intriguing subject that
is still not fully characterized and is worthy of clarification.
More information regarding this issue might help shed light on
the pathogenesis of OA, which could in turn lead to development of new therapeutic strategies.
Juan B. Kouri, MD, PhD
Karin Abbud-Lozoya, PhD
Centro de Investigacion y de Estudios Avanzados
del Instituto Politecnico Nacional
Universidad Nacional Autónoma de Mexico
Mexico City, Mexico
1. Aigner T, Hemmel M, Neureiter D, Gebhard PM, Zeiler G,
Kirchner T, et al. Apoptotic cell death is not a widespread
phenomenon in normal aging and osteoarthritis human articular
knee cartilage: a study of proliferation, programmed cell death
(apoptosis), and viability of chondrocytes in normal and osteoarthritic human knee cartilage. Arthritis Rheum 2001;44:1304–12.
2. Blanco FJ, Guitian R, Vázquez-Martul E, de Toro FJ, Galdo F.
Osteoarthritis chondrocytes die by apoptosis: a possible pathway
for osteoarthritis pathology. Arthritis Rheum 1998;41:284–9.
3. Hashimoto S, Setareh M, Ochs RL, Lotz M. Fas/Fas ligand
expression and induction of apoptosis in chondrocytes. Arthritis
Rheum 1997;40:1749–55.
4. Hashimoto S, Ochs RL, Komiya S, Lotz M. Linkage of chondrocyte apoptosis and cartilage degradation in human osteoarthritis.
Arthritis Rheum 1998;41:1632–8.
5. Kim HA, Lee YJ, Seong SC, Choe KW, Song YW. Apoptotic
chondrocyte death in human osteoarthritis. J Rheumatol 2000;27:
455–62.
6. Kouri JB, Rosales-Encina JL, Chaudhuri PP, Luna J, Mena R.
Apoptosis in human osteoarthritic cartilage: a microscopy report.
Med Sci Res 1997;25:245–8.
7. Kouri JB, Aguilera JM, Reyes J, Abbud-Lozoya K, Gonzalez S.
Apoptotic chondrocytes from osteoarthrotic human articular cartilage and abnormal calcification of subchondral bone. J Rheumatol 2000;27:1005–19.
8. Gold R, Schmid M, Giegerich H, Breitschopf H, Hartung HP,
Toyka KV, et al. Differentiation between cellular apoptosis and
necrosis by the combined use of in situ tailing and nick translation
techniques. Lab Invest 1994;71:219–25.
9. Walker JA, Quirke P. Viewing apoptosis through a ‘TUNEL’.
J Pathol 2001;195:275–6.
10. Wyllie AH. Glucocorticoid-induced thymocyte apoptosis is associated with endogenous endonuclease activation. Nature 1980;284:
555–6.
11. Abbud-Lozoya K, Kouri JB. A novel rat osteoarthrosis model to
assess apoptosis and matrix degradation. Pathol Res Pract 2000;
196:729–45.
12. Kouri-Flores JB, Abbud-Lozoya KA, Roja-Morales L. Kinetics of
the ultrastructural changes from an osteoarthrosis rat model: a
window of comparison to the cellular mechanism of apoptosis in
human chondrocytes. Ultrastruct Pathol 2002;26:33–40.
2262
DOI 10.1002/art.10346
Parvovirus B19 infection of cultured skin fibroblasts
from systemic sclerosis patients: comment on the
article by Ray et al
To the Editor:
We read with interest the recent article by Ray and
coworkers reporting that human parvovirus B19 infection can
induce in vitro invasive properties in normal human synovial
fibroblasts (1). Their study further supports previous observations suggesting that B19 infection could be involved in the
pathogenesis of rheumatoid arthritis and other rheumatic
disorders, including systemic sclerosis (SSc) (2–5). SSc is a
connective tissue disease of unknown etiology; its pathogenesis
involves overproduction of collagen by altered fibroblasts and
alterations of the microvasculature and immune system (6–7).
Numerous genetic, environmental, and infectious agents have
been proposed as possible etiologic factors (6–8).
We previously demonstrated the presence of parvovirus B19 infection in bone marrow and/or skin biopsy specimens
from a significant number of unselected SSc patients (4–5).
Bone marrow may represent a reservoir from which the virus
could spread to SSc target tissues (9). Given the role of
fibroblasts in scleroderma fibrotic lesions (6), we investigated
the presence of parvovirus B19 DNA in cultured skin fibroblasts from 8 unselected SSc patients (3 men, 5 women;
mean ⫾ SD age 52 ⫾ 10 years, mean disease duration 10 ⫾ 9
years). Patients were classified according to the American
College of Rheumatology (formerly the American Rheumatism Association) preliminary criteria (10) and were consecutively recruited after they had given informed consent to enter
the study.
Skin biopsy specimens obtained from the patient’s
forearm were used for fibroblast and keratinocyte cultures.
Skin samples were washed in a phosphate buffered saline
(PBS) solution supplemented with antibiotics and cut into thin
strips, which were placed in petri dishes containing Dispase II
solution (12.5 units/ml; Boehringer Mannheim, Indianapolis,
IN) for 40–60 minutes. Sheets of epidermis were separated
from underlying dermis and incubated in a trypsin–EDTA
solution (0.25% trypsin/0.02% EDTA; Sigma-Aldrich, Milan,
Italy) for 15 minutes to obtain a single-cell suspension of
keratinocytes. Isolated dermis was cut into small pieces (2–3
mm2), and fibroblasts were isolated by collagenase digestion
(80 units/ml; Worthington Biochemical, Lakewood, NJ). Cells
were then seeded on 25-cm2 culture flasks containing a small
amount of culture medium (Dulbecco’s modified Eagle’s medium [DMEM]) supplemented with 10% fetal bovine serum
(Sigma, St. Louis, MO), 4 mM L-glutamine (Sigma), and
penicillin/streptomycin ([100 units/ml]/[100 ␮g/ml]; Seromed,
Berlin, Germany).
Keratinocyte cultures were obtained by using irradiated Swiss BALB/c 3T3 fibroblast feeder layers in culture
medium (DMEM/Ham’s F-12 [3:1]) with 10% FBS (Sigma), 4
mM L-glutamine, penicillin/streptomycin (100 units/ml)/(100
␮g/ml), 0.4 mg/ml hydrocortisone succinate, 5 ␮g/ml insulin
(Sigma), 5 ␮g/ml transferrin, 2 ⫻ 10⫺9M triiodo-L-thyronine,
10⫺9M cholera toxin, and 24 ␮g/ml adenine.
After 6–7 days, preconfluent primary keratinocytes
LETTERS
and fibroblasts were dissociated into single cells by using a
0.05% trypsin/0.02% EDTA PBS-buffered solution. Keratinocyte cultures were first incubated with 0.02% EDTA solution
to remove the feeder layer. Human fibroblasts and keratinocytes were expanded (split ratio 1:2; up to 6 passages when
possible) and preserved in liquid nitrogen. For some samples
the number of passages was limited because of bacterial
contamination. Because of the initial quality of tissue samples,
keratinocyte isolation was unsuccessful in 3 cases.
Virologic studies included the detection of serum
anti-B19 IgG and IgM antibodies using enzyme immunoassay
(Biotrin, Dublin, Ireland) and B19 DNA in the serum, wholeskin biopsy, and cultured fibroblasts and keratinocytes by
nested polymerase chain reaction (PCR) technique. In 5 of 8
subjects, parvovirus B19 infection was also evaluated in bone
marrow biopsy samples. The target sequence for the amplification reaction was in the nonstructural region. The primers P1
(1399–1422 nucleotides [nt]) and P6 (1682–1659 nt) were used
in the first reaction, whereas the primers P2 (1498–1525 nt)
and P5 (1600–1576 nt) were employed as inner primers in the
second reaction. The first and second reactions were performed for 35 cycles, each at 94°C for 45 seconds, 55°C for 60
seconds, and 72°C for 90 seconds.
The main clinical, serologic, and virologic findings of 8
SSc patients are summarized in Table 1. On the basis of
virologic data, patients can be divided in 2 groups: 1) 4 subjects
with serum anti-B19 (IgG type), and parvovirus B19 infection
of the whole skin (in 3 of them B19 DNA was also found in
bone marrow biopsy specimens) and 2) 4 B19-negative subjects.
The presence of B19 DNA was demonstrated in all
passages of fibroblast cultures in 4 of 4 patients with parvovirus
B19 infection of the whole skin (Table 1). Comparable levels of
viral DNA, evaluated by semiquantitative PCR, were found in
all passages of B19-positive fibroblast cultures. B19 DNA was
never detected in the keratinocyte cultures. No significant
clinical or serologic differences between B19-positive and
B19-negative SSc patients were observed.
This preliminary study demonstrated that parvovirus
B19 may infect skin fibroblasts of SSc patients. The pathologic
hallmark of SSc is fibrosis of the skin and various internal
organs (6–7). Scleroderma fibroblasts present an abnormally
activated phenotype responsible for collagen overproduction
(6); inflammatory cell-derived solution mediators might trigger
this fibroblast dysfunction. Alternatively, it could be a primary
event caused by deep alterations in the regulatory pathways
controlling connective tissue gene expression. This latter
mechanism is suggested by several studies showing that cultured scleroderma fibroblasts produce increased amounts of
type I collagen compared with fibroblasts from healthy subjects
(6). Moreover, this hyperactivity is maintained for several
passages in culture in the absence of potential extracellular
activating signals (6). The ability of parvovirus B19 to persistently infect scleroderma fibroblasts might be responsible for
fibroblast alterations. This possible event is in keeping with the
phenotype changes observed by Ray et al in normal human
synovial fibroblasts infected by parvovirus B19 in vitro (1).
SSc represents a spectrum of clinical and serologic
variants and is probably caused by a multifactorial process,
including genetic and exogenous (toxic or infectious) factors
LETTERS
2263
Table 1. Demographic, clinical, serologic, and virologic findings in the SSc patients*
Parvovirus B19 DNA (PCR)
Patient
Age/
sex
Cutaneous
subset
Main
clinical
features
1
2
3
4
5
6
7
8
42/F
59/F
50/F
56/M
70/M
51/M
54/F
36/F
Diffuse
Limited
Limited
Diffuse
Limited
Diffuse
Diffuse
Diffuse
L
E, U
E, U
L, H, E, U
L, H, E, U
L, E, U
L, E, U
L, E, U
Serum
autoantibodies
Anti-B19
antibodies
Anti–Scl-70
ACA
ACA
Anti–Scl-70, ANA
ACA
ANA
ANA
Anti–Scl-70
IgG⫹
IgG⫹
IgG⫹
IgG⫹
–
–
–
–
Serum
Bone
marrow
Whole
skin
Cultured
fibroblasts
(culture
no.)
–
–
–
–
–
–
–
–
⫹
⫹
⫹
ND
ND
–
–
ND
⫹
⫹
⫹
⫹
–
–
–
–
⫹ (3/3)
⫹ (3/3)
⫹ (6/6)
⫹ (6/6)
⫺ (2/2)
⫺ (6/6)
⫺ (5/5)
⫺ (6/6)
Cultured
keratinocytes
(culture no.)
⫺ (2/2)
⫺ (2/2)
ND
ND
⫺ (4/4)
⫺ (6/6)
⫺ (3/3)
ND
* PCR ⫽ polymerase chain reaction; L ⫽ lung; ANA ⫽ antinuclear antibodies; E ⫽ esophagus; U ⫽ cutaneous ulcers; ACA ⫽ anticentromere
antibodies; ND ⫽ not detected; H ⫽ heart involvement.
(6–8). In this context, parvovirus B19 might be included among
the potential causative agents of the disease.
Clodoveo Ferri, MD
Dilia Giuggioli, MD
Marco Sebastiani, MD
University of Pisa
Pisa, Italy
Susi Panfilo, MD
Giovanni Abatangelo, MD
University of Padova
Padova, Italy
Krystyna Zakrzewska, MD
Alberta Azzi, MD
University of Florence
Florence, Italy
1. Ray NB, Nieva DRC, Seftor EA, Khalkhali-Ellis Z, Naides
SJ. Induction of an invasive phenotype by human parvovirus B19
in normal human synovial fibroblasts. Arthritis Rheum 2001;44:
1582–6.
2. Naides SJ. Rheumatic manifestations of parvovirus B19 infection.
Rheum Dis Clin North Am 1998;24:375–401.
3. Kerr JR. Pathogenesis of human parvovirus B19 in rheumatic
disease. Ann Rheum Dis 2000;59:672–83.
4. Ferri C, Zakrzewska K, Longombardo G, Giuggioli D, Storino FA,
Pasero G, et al. Parvovirus B19 infection of bone marrow in
systemic sclerosis. Clin Exp Rehumatol 1999;17:718–20.
5. Ferri C, Zakrzewska K, Giuggioli D, Longombardo G, Sebastiani
M, Storino F, et al. Parvovirus B19 infection in the skin and bone
marrow of systemic sclerosis patients [abstract]. Arthritis Rheum
2000;43 Suppl 9:315.
6. Jimenez SA, Hitraya E, Varga J. Pathogenesis of scleroderma:
collagen [review]. Rheum Dis Clin North Am 1996;22:647–74.
7. White B. Immunopathogenesis of systemic sclerosis. Rheum Dis
Clin North Am 1996;22:695–708.
8. Pandey JP, LeRoy EC. Human cytomegalovirus and the vasculopathies of autoimmune diseases (especially scleroderma), allograft rejection, and coronary restenosis. Arthritis Rheum 1998;41:
10–5.
9. Cassinotti P, Burtonoboy G, Fopp M, Siegl G. Evidence for
persistence of human parvovirus B19 DNA in bone marrow. J Med
Virol 1997;53:229–32.
10. Subcommittee for Scleroderma Criteria of the American Rheu-
matism Association Diagnostic and Therapeutic Criteria Committee. Preliminary criteria for the classification of systemic sclerosis
(scleroderma). Arthritis Rheum 1980;23:581–90.
DOI 10.1002/art.10352
Reply
To the Editor:
The report by Ferri and colleagues offers a tantalizing
suggestion that parvovirus B19 plays a role in the pathogenesis
of SSc. Using nested PCR methodology, the authors found B19
DNA in cultured skin fibroblasts from 4 of 8 SSc patients, but
not in their serum. Although these results are promising, we
believe that it would be premature to conclude that parvovirus
B19 is a causative agent in SSc, a caveat recognized by the
authors. Normal skin fibroblasts were not tested as a control.
Söderlund et al demonstrated PCR positivity for B19 DNA in
the synovium of 13 (48%) of 27 healthy military recruits
undergoing arthroscopy for trauma (1). Like Ferri et al,
Söderlund and colleagues reported serum anti-B19 IgG positivity in all patients with B19 DNA–positive tests. It is possible
that the parvovirus B19 detected in the cultured fibroblasts
represents latent infection. Like many other DNA viruses,
parvovirus B19 may prove to be capable of prolonged latency.
The challenge in studying latent virus infection is in proving
Koch’s postulates and demonstrating that the virus causes
disease rather than sojourns as an innocent passenger.
Confirming parvovirus B19 as an etiologic agent of SSc
will require additional study. First, fibroblasts from a larger
number of patients with SSc will need to be tested for B19 in
order to strengthen the epidemiologic association between B19
and disease. These patients should be compared with age- and
sex-matched normal individuals recruited concurrently, to control for geographic and temporal variations in communityacquired parvovirus B19 infection. In addition, fibroblasts
from patients with skin disease other than SSc should be tested
to eliminate the possibility that latent B19 is rendered detectable in SSc patient skin fibroblasts due to nonspecific immune
stimulation of viral replication. B19 in unstimulated normal
skin would remain at background levels below the detection
2264
LETTERS
threshold. Larger numbers of patients will also allow discernment of patterns of disease manifestation and serologic markers uniquely associated with B19 infection.
Second, in situ hybridization of B19 DNA and immunocytochemical staining for B19 proteins and fibroblast phenotype markers would allow confirmation that the B19 DNA
detected by the sensitive nested PCR is indeed in the cultured
fibroblasts. Direct visualization and phenotyping of the infected cell would eliminate the possibility that the B19 signal
detected in the low-passage primary fibroblast cultures resides
in a contaminating cell such as a blood-derived leukocyte.
Similar visualization of B19 and phenotypic cell markers in
intact skin biopsy specimens would offer histologic localization
of the infected cells. Parvovirus B19 has broad tissue tropism
reflecting the broad distribution of its cell surface glycosphingolipid receptors, a requirement for an etiologic agent of a
multisystemic disease (2). The association would be further
strengthened by the presence of B19 in fibroblasts in SScinvolved internal organs but its absence in disease-free organs.
Third, a plausible and testable paradigm of B19 virus–
cell interactions is required to explain disease induction. Ray et
al demonstrated B19 induction of an invasive phenotype in
normal human synovial fibroblasts, a finding of potential
significance in rheumatoid arthritis pathogenesis (3). Ferri et
al suggested that parvovirus B19 induces a similar invasive
phenotype in cutaneous fibroblasts in SSc, but this has not
been directly demonstrated. The mechanism by which B19
alters cellular function at the molecular level will need to be
described. Demonstrating parvovirus B19-induced upregulation of collagen matrix deposition would support a role
for B19 in SSc. Parvovirus B19 infection is widespread and
common, while SSc remains relatively uncommon. Additional
host and environmental factors that enable the hypothesized
B19 alterations would need to be identified.
Nancy B. Ray, PhD
Zhila Khalkhali-Ellis, PhD
Daniel R. C. Nieva, BA
Elisabeth A. Seftor, BS
University of Iowa
Iowa City, IA
Stanley J. Naides, MD
Milton S. Hershey Medical Center
and Pennsylvania State University
Hershey, PA
1. Söderlund M, von Essen R, Haapasaari J, Kiistala U, Kiviluoto O,
Hedman K. Persistence of parvovirus B19 DNA in synovial
membranes of young patients with and without chronic arthropathy. Lancet 1997;349:1063–5.
2. Cooling LL, Koerner TA, Naides SJ. Multiple glycosphingolipids
determine the tissue tropism of parvovirus B19. J Infect Dis
1995;172:1198–205.
3. Ray NB, Nieva DR, Seftor EA, Khalkhali-Ellis Z, Naides SJ. Induction of an invasive phenotype by human parvovirus B19 in
normal human synovial fibroblasts. Arthritis Rheum
2001;44:1582–6.
DOI 10.1002/art.10475
On my knees (Instructions to Authors)
Oh Doctor, please don’t end this Trial,
Be patient with your Patient’s Methods,
Collect my Results, but withhold your Conclusions,
Consider me not statistically yet significant,
Don’t Table me as data figures,
Figure me beyond the Figures,
I am not figurative, I’m bone and flesh, so
Don’t Abstract me, instead, instruct me, hence
Have a Discussion on me but never a Summary
And, yes, please keep being my Reference.
Softly release my stiffness,
Stiffly ease my softness,
I’ll follow your steps, please try to heal
And watch my step, as well as heel,
And guide me up the hill
Toward the right direction, since
The more affected are my knees,
The more they need affection.
Dan Caspi, MD
Tel Aviv Medical Center
Tel Aviv, Israel
Документ
Категория
Без категории
Просмотров
1
Размер файла
466 Кб
Теги
etiology, articles, microbiologie, antigen, possible, reactive, stimulating, response, arthritiscomment, arthritis, synovial, schnarr, lymphocytes, rheumatoid, undifferentiated, indicates
1/--страниц
Пожаловаться на содержимое документа