Clyde Wilson

ANTIBODIES TO PROTEUS IN RHEUMATOID ARTHRITIS

Antibodies to proteus species were measured in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and in healthy controls by a Coombs agglutination method. The titres to Proteus mirabilis were higher in 30 RA patients being treated with gold than in 24 patients with active AS (p less than 0.001), 28 patients with inactive AS (p less than 0.001), and 41 healthy control subjects (p less than 0.001). Control studies with Klebsiella pneumoniae var oxytoca showed high antibody titres only in active AS patients.

Shared amino acid sequences between major histocompatibility complex class II glycoproteins, type XI collagen and Proteus mirabilis in rheumatoid arthritis.

OBJECTIVES--To show molecular similarity between two sequences of Proteus mirabilis (haemolysin--ESRRAL; urease--IRRET) with HLA-DR antigens (EQRRAA) which are associated with rheumatoid arthritis (RA) and type XI collagen (LRREI), respectively; and, in patients with RA, to measure levels of antibody against a 16-mer synthetic peptide containing the ESRRAL sequence, and the haemolysin and urease proteins of Proteus mirabilis. METHODS--The homologous sequences EQRRAA and ESRRAL were modelled with Alchemy III, using the crystalline structure of DRB1*0101 (HLA-DR1). Sera from 40 patients with RA, 30 with ankylosing spondylitis (AS), and 30 controls were tested against synthetic ESRRAL peptide and the haemolysin of Proteus mirabilis by enzyme linked immunosorbent assay. Similar tests were also carried out on sera from 20 patients with RA, 40 with AS, and 15 controls, against Proteus mirabilis urease. RESULTS--Molecular modelling of the homologous sequences ESRRAL/EQRRAA and IRRET/LRREI showed stereochemical similarities. Antibodies to the 16-mer synthetic peptide containing the ESRRAL sequence, the haemolysin, and urease proteins were significantly increased in RA patients compared with AS patients (p < 0.001) and healthy controls (p < 0.001). No such increases were observed with three control peptides including the EDERAA sequence of DRB1*0402 (HLA-DR4/Dw10), the haemolysin proteins of Streptococcus pyogenes and Vibrio parahaemolyticus, and the urease of Bacillus pasteurii. CONCLUSION--The additive effect of the immune responses to the two Proteus mirabilis antigens, haemolysin (ESRRAL) and urease (IRRET), could be relevant in the aetiopathogenesis of RA.

Antibodies to Klebsiella, Proteus, and HLA-B27 peptides in Japanese patients with ankylosing spondylitis and rheumatoid arthritis

OBJECTIVE To determine whether patients with ankylosing spondylitis (AS) and patients with rheumatoid arthritis (RA) from Japan have antibodies to Klebsiella pneumoniae and Proteus mirabilis and to assess whether such antibodies are activated against peptides sharing sequences with HLA-B27. METHODS Serum samples from 152 Japanese patients, 52 with AS, 50 with RA, and 50 healthy controls, were tested against 3 bacteria (K. pneumoniae, P. mirabilis, and Escherichia coli) and 3 synthetic peptides (HLA-B27, pullulanase-D, and scrambled pullulanase-D control peptide) by ELISA under coded conditions. Samples were tested for elevations in IgG, IgA, and IgM antibody classes in patients with active AS or RA, in patients with RA with probable disease, and in patients with inactive AS. Disease activity was determined by an elevated serum C-reactive protein (> 10 mg/l) level and elevated erythrocyte sedimentation rate (> 20 mm/h). RESULTS Patients with active AS showed specific elevations in serum IgA antibody levels against K. pneumoniae compared to patients with RA and controls (p < 0.001). No such elevation was seen in the IgG and IgM antibody classes. Patients with inactive AS showed no elevation in any class of antibody against K. pneumoniae compared to controls or patients with RA. Patients with active or probably active RA showed significant elevations in IgG antibody levels against P. mirabilis compared to AS and controls (p < 0.001). Patients with AS (active or inactive), RA (active or probably active), and controls showed no elevations in any antibody class to E. coli. Both active and inactive AS patients had specific autoantibodies against HLA-B27 peptide compared to patients with RA and controls (active AS: IgG, IgA, IgM, p < 0.001; inactive AS: IgG and IgA, p < 0.001). Patients with active AS had IgG and IgA antibodies against pullulanase-D peptide, which contains a sequence that cross reacts with HLA-B27 compared to controls (p < 0.001). CONCLUSION These results provide the first evidence of AS and RA patients in Japan having specific elevations of antibody to K. pneumoniae and P. mirabilis, respectively. This suggests that K. pneumoniae in AS and P. mirabilis in RA may play a role in triggering and/or exacerbating these diseases.

The Use of a Low Starch Diet in the Treatment of Patients Suffering from Ankylosing Spondylitis

SummaryThe majority of ankylosing spondylitis AS) patients not only possess HLA-B27, but during active phases of the disease have elevated levels of total serum IgA, suggesting that a microbe from the bowel flora is acting across the gut mucosa.Biochemical studies have revealed that Klebsiella bacteria, not only possess 2 molecules carrying sequences resembling HLA- B27 but increased quantities of such microbes are found in fecal samples obtained from AS patients and such patients have Crohn’s like lesions in the ileo- caecal regions of the gut. Furthermore AS patients from 10 different countries have been found to have elevated levels of specific antibodies against Klebsiella bacteria. It has been suggested that these Klebsiella microbes, found in the bowel flora, might be the trigger factors in this disease and therefore reduction in the size of the bowel flora could be of benefit in the treatment of AS patients.Microbes from the bowel flora depend on dietary starch for their growth and therefore a reduction in starch intake might be beneficial in AS patients. A “low starch diet” involving a reduced intake of “bread, potatoes, cakes and pasta” has been devised and tested in healthy control subjects and AS patients. The “low starch diet” leads to a reduction of total serum IgA in both healthy controls as well as patients, and furthermore to a decrease in inflammation and symptoms in the AS patients.The role of a “low starch diet” in the management of AS requires further evaluation.

Sequence similarity between HLA-DR1 and DR4 subtypes associated with rheumatoid arthritis and proteus/serratia membrane haemolysins.

Rheumatoid arthritis (RA) is found more often in subjects carrying the HLA-DR1 antigen and some subtypes of the HLA-DR4 antigen than in those without these antigens. Analysis of probes specific for HLA-DR4 has shown that amino acids encoding positions 69-74 (EQRRAA) of the beta chain indicates susceptibility to RA. A hexamer sequence of proteus haemolysin spanning residues 32-37 (ESRRAL) has been identified which resembles biochemically, and discriminates by charge, between HLA types associated with RA (DR1, Dw4, Dw14, Dw15), and those not linked with the disease (Dw10, Dw13).

Molecular mimicry between HLA-DR alleles associated with rheumatoid arthritis and Proteus mirabilis as the Aetiological basis for autoimmunity.

Molecular mimicry is one of the pathological mechanisms proposed to explain the association between microorganisms and autoimmune diseases. This review deals with the association between bacteria and rheumatic diseases with a special emphasis on rheumatoid arthritis where upper urinary tract infection by Proteus mirabilis is the possible cause of this severe, arthritic condition. Prospective trials involving anti-Proteus therapy should be carried out.

Rheumatoid arthritis: proposal for the use of anti-microbial therapy in early cases.

Rheumatoid arthritis (RA) is a chronic disease, affecting women more than men, especially in those possessing the “shared epitope” (EQK/RRAA) amino acid sequences present in HLA‐DR1/4 molecules. Proteus mirabilis carries sequences showing molecular mimicry to the “shared epitope” and to type XI collagen of hyaline cartilage. Elevated levels of antibodies to P.mirabilis have been reported from 14 different countries involving 1375 RA patients and the microbe has been isolated from urine cultures of such patients. Our working hypothesis is that the disease develops as a result of repeated episodes of Proteus upper urinary tract infections. Prospective studies involving the trial of anti‐Proteus measures in RA patients should be evaluated in the management of this disease. Antibiotics, high fluid intake, and fruit extracts, such as cranberry juice, have all been found to be effective in the treatment of urinary tract infections. Such measures could be used as possible additional adjuncts to the standard therapy with NSAIDs and DMARDs.

The Link between Ankylosing Spondylitis, Crohn's Disease, Klebsiella, and Starch Consumption

Both ankylosing spondylitis (AS) and Crohns disease (CD) are chronic and potentially disabling interrelated conditions, which have been included under the group of spondyloarthropathies. The results of a large number of studies support the idea that an enteropathic pathogen, Klebsiella pneumoniae, is the most likely triggering factor involved in the initiation and development of these diseases. Increased starch consumptions by genetically susceptible individuals such as those possessing HLA-B27 allelotypes could trigger the disease in both AS and CD by enhancing the growth and perpetuation of the Klebsiella microbes in the bowel. Exposure to increased levels of these microbes will lead to the production of elevated levels of anti-Klebsiella antibodies as well as autoantibodies against cross-reactive self-antigens with resultant pathological lesions in the bowel and joints. Hence, a decrease of starch-containing products in the daily dietary intake could have a beneficial therapeutic effect on the disease especially when used in conjunction with the currently available medical therapies in the treatment of patients with AS and CD.

Molecular Mimicry: The Geographical Distribution of Immune Responses to Klebsiella in Ankylosing Spondylitis and its Relevance to Therapy

SummaryThe discovery that HLA- B27 is linked to ankylosing spondylitis (AS) and HLA- DR1/DR4 to rheumatoid arthritis (RA) has provided new approaches to the study of the possible causation of these diseases. Several theories have been proposed to explain these associations but only one, namely “molecular mimicry”, has provided a specific aetiological agent for each of these diseases. p]Molecular mimicry between HLA- B27 and two molecules in Klebsiella microbes: nitrogenase and pullulanase D has been reported whilst in Proteus microbes, the haemolysin molecule shows sterochemical similarity to HLA- DR1/DR4. Elevated immune responses to Klebsiella microbes have been demonstrated in AS patients from 10 different countries and this wide geographical distribution suggests that the same aetiological agent is probably acting in producing this condition. p]Furthermore RA patients show similar immune responses to Proteus microbes. Whether AS or RA are caused by these bacteria can only be resolved by tissue typing all rheumatol ogical patients early, in the course of their disease and then assessing their response to antibiotic chemotherapy in longitudinal studies involving double- blind crossover trials. p]It is possible that in the future, the course of AS or even RA could be modified by adequate antibiotic chemotherapy or even diets which affect the substrates on which these bacteria grow.

Ankylosing Spondylitis, HLA-B27 and Klebsiella - An Overview: Proposal for Early Diagnosis and Treatment

Ankylosing spondylitis (AS) is a potentially disabling rheumatic disease for which no curative treatment has yet been discovered. An extensive computer-based and manual search was undertaken to evaluate the role of microbes in the pathogenesis of AS. All together 147 papers were scrutinised. A total of 24 studies carried out on 1330 AS patients and 1191 healthy controls involving 15 different countries showed significantly elevated Klebsiella antibodies in AS patients when compared to controls. Molecular analysis has shown that Klebsiella microbes possess antigens, which cross-react with self-antigens, such as HLA-B27 and spinal collagens. Diagnostic criteria have been developed in which a person who is HLA-B27 positive and has clinical and laboratory evidence of an inflammatory backache for at least three months is proposed to have pre-AS. A specific elevation of anti- Klebsiella antibodies would confirm the diagnosis. A proposal for an early treatment using anti-Klebsiella measures is suggested. So far, apart from Klebsiella no other microbes have been shown to have a link with the development of AS. It is suggested that identifying and treating patients with Klebsiella reactive arthritis/pre-AS could involve the use of anti- Klebsiella measures, such as antibiotics and low starch diet together with immunosuppressive drugs in an endeavour to prevent the irreversible sequelae of established AS.