Ankylosing Spondylitis and Klebsiella

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2 Ankylosing Spondylitis and Klebsiella

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4 Alan Ebringer Ankylosing Spondylitis and Klebsiella

5 Alan Ebringer B.Sc., M.D., FRCP, FRACP, FRCPath Professor of Immunology King s College London Honorary Consultant Rheumatologist Middlesex Hospital UCH School of Medicine King s College London Division of Life Sciences London, SE1 8WA, UK United Kingdom ISBN ISBN (ebook) DOI / Springer London Heidelberg New York Dordrecht Library of Congress Control Number: Springer-Verlag London 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

6 This book is dedicated to the memory of the late Dr. A.C. Boyle ( ), Chief Consultant Rheumatologist at the Middlesex Hospital, who served with Field Marshal Slim in Burma. During his service overseas, his wife was killed by a fl ying bomb. He trained many rheumatologists in the UK and emphasised that public speaking should be an attribute of consultants. Trainees were expected to give a 10-min talk, as long as it was not on a medical topic. We learned about Wagner s heroes, stock exchange and trips down the Amazon. One budding Consultant Rheumatologist gave a learned talk on joints in Chippendale furniture and Hepplewhite chairs. When he was approached that we could probably explain HLA-B27 in ankylosing spondylitis, his answer was utter poppycock and promptly provided the funds, hospital facilities and patients to set up an Ankylosing Spondylitis Research Clinic of the Middlesex Hospital. When the fi rst results came, linking Klebsiella to his ankylosing spondylitis patients, he declined to be on the paper with the gruff reply Nonsense, nobody would believe it.

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8 To Wendy, Andrew and Lawrence

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10 Acknowledgements The discovery of a new link between a disease and the environment depends on many individuals who by their efforts and insight have helped to establish this association. First of all I would like to thank and acknowledge the work of the two Research groups, one from the Westminster Hospital in London and the other one from Los Angeles in the United States who by their discovery of a link between ankylosing spondylitis and HLA-B27 have made it possible for us from King s College and the Middlesex Hospital to study B27 disease. Especially I would like to thank Dr. D.C.O. James of the Westminster group who helped us in tissue typing patients for HLA-B27 and provided access to tissue typed healthy control subjects. Secondly I would like to acknowledge the help we have received from my medical colleagues in the Department of Rheumatology at the Middlesex Hospital, now part of the University College London Hospital in helping to set up the Ankylosing Spondylitis Research Clinic of the Middlesex Hospital which ran from 1974 till Especially I would like to thank Dr. A.C. Boyle, Dr. Mary Corbett, Dr. M. Shipley and Prof. D. Isenberg who were bemused by the idea that a bowel microbe could be involved in ankylosing spondylitis but gave unstinting support and help over the years. My brother Dr. Roland Ebringer was an enthusiastic supporter who ran the clinic from 1974 till 1980 when he returned to Australia to practise rheumatology. Professor G. Panayi and Dr. A. Trull from the Department of Rheumatology at Guy s Hospital also collaborated in some of these early studies. One also requires the help of skilled and dedicated nursing staff. Sisters Abigail Olaleye, Avery Davis, Jean Heath and Evelyn Williams by their concern and sympathy for the patients helped to ensure a smooth and ef fi cient outpatient research clinic. Thirdly I would like to thank the skilled laboratory work of many research workers and Ph.D. doctoral fellows, initially from Queen Elizabeth College and later from King s College who were responsible for the excellent results that eventually saw the light of day in refereed publications. Without their efforts we would not have been able to help the patients in the AS Research Clinic of the Middlesex Hospital and de fi ne the concept of B27 disease. I would like to thank Dr. H. Avakian, Dr. P. Cowling, Dr. Jane Welsh, Dr. M. Baines, Dr. C. Wilson, Dr. M. Childerstone, ix

11 x Acknowledgements Dr. Teresa Ptaszynska, Dr. Shiva Khalafpour, Dr. G. Robinson, Dr. T. Rashid, Dr. P. Cunningham, Dr. Mariam Ghuloom, Dr. Faranak Shodjai-Moradi, Dr. Khatereh Ahmadi, Dr. Ilham Abuljadayel, Dr. M. Fielder and Dr. H. Tiwana who struggled brilliantly with coded runs when they did not know which samples came from patients and which belonged to healthy blood donor subjects. In the earlier years, Don Robinson, Professor of Biochemistry, and John Pirt, Professor of Microbiology, at Queen Elizabeth College encouraged us academically and fi nancially in our studies into the biochemical and microbiological aspects of autoimmune diseases. Dr. C. Wilson Ph.D., FRCPath and Dr. Tasha Rashid M.B.Ch.B., M.Phil., were with us for over 20 years and provided outstanding medical and microbiological expertise. Research does not grow in a vacuum and requires fi nancial support. Over the years we have been helped by the Matilda Poole Research Fund of the Middlesex Hospital, Medical Research Council, Science Research Council, Nuf fi eld Foundation, Arthritis Research Council, Government of Bahrain and the American Friends of King s College. Fourthly I would like to express my gratitude to the many patients who explained to me the varieties of pains and symptoms which they endured over the years and helped us in de fi ning the concept of B27 disease. The outstanding feature of their contribution was the recurring complaint or disappointment that the early stages of their disease went unrecognised for so many years and sometimes even decades. The imputation or suggestion that these pains were not worthy of attention, or worse the product of a nervous or neurotic disposition, sometimes bordering on outright malingering, was not kindly accepted by this large population of sufferers with B27 disease. Finally I would like to thank and acknowledge three of my former patients who suggested that this book should be written. Ms. Judith Beard who was followed for 28 years, Mr. George McCaffery who provided fi nancial support for the internet website Kick-AS and popularised in cyberspace the idea of a Low Starch Diet for patients with ankylosing spondylitis and Ms. Carol Sinclair who discovered the low starch diet by herself and wrote a book about it. This book would not have been possible without the support of all these people but the errors of omission or commission as well as the opinions expressed are all my own.

12 Contents 1 Ankylosing Spondylitis as a Scientific Problem Ankylosing Spondylitis: An Introduction Clinical Features of Ankylosing Spondylitis Radiological Features of Ankylosing Spondylitis The Disability of Ankylosing Spondylitis The Social and Financial Costs of Ankylosing Spondylitis Molecular Mimicry and Rheumatic Fever The Properties of the Ankylosing Spondylitis Problem King s College Immunology Unit References History of the Origin of Ankylosing Spondylitis Introduction Ankylosing Spondylitis and the Egyptian Pharaohs Ankylosing Spondylitis in the Middle Ages Ankylosing Spondylitis and Realdo de Colombo Connor s Observations in France The Eighteenth Century in Europe The Nineteenth Century in London Bechterew in St. Petersburg Strűmpell in Erlangen and Berlin Pierre Marie and Léri in France Buckley s Observations in the 1930s The Heart and Ankylosing Spondylitis Diagnostic Help from Physics Conclusion References xi

13 xii Contents 3 The Discovery of HLA-B27 in Ankylosing Spondylitis and Related Disorders The Tissue Typing Unit at the Westminster Hospital HLA-B27 in Ankylosing Spondylitis Acute Anterior Uveitis and HLA-B HLA-B27 in Reiter s Disease and Reactive Arthritis HLA-B27 as the Predisposing Gene Geography of HLA-B General Discussion and Conclusions The Middlesex Hospital in London The Ankylosing Spondylitis Research Clinic of the Middlesex Hospital References Molecular Mimicry Between HLA-B27 and Klebsiella Bacteria Investigated by Using Rabbit Antisera Introduction: The Problem of HLA-B27 in Ankylosing Spondylitis Rabbit Immunisations Immunodiffusion Experiments Haemagglutination Method Bacterial Agglutination Radio-Binding Assay with Klebsiella Sonicate Preparation (KSP) Lymphocytotoxicity Assay Results of Immunodiffusion Experiments Haemagglutination Results Bacterial Agglutination Results Results of Radio-Binding Assay with Klebsiella Sonicate Preparation (KSP) Cytotoxicity Results Discussion and Conclusions References Molecular Mimicry Between HLA-B27 and Klebsiella Bacteria Investigated by Using Human Tissue Typing Sera Introduction: Molecular Mimicry and Tissue Typing Sera Bristol HLA Tissue Typing Sera Haemagglutination Method Labelling of Klebsiella Sonicate Preparation (KSP) Radio-Binding Assay for 125 I-Klebsiella Sonicate Preparation Competition Assay for 12 I-Klebsiella Sonicate Preparation Results of Haemagglutination Studies with HLA Typing Sera Results of Radio-Binding Assay for 125 I-Klebsiella Sonicate Preparation by HLA Typing Sera

14 Contents xiii 5.10 Results of Competition Binding Assays Discussion and Conclusions References Muscle Changes in Ankylosing Spondylitis Introduction: Involvement of Muscle Pathology in Ankylosing Spondylitis Muscle Stiffness, Muscle Pain and the Enthesis Patients and Controls Blood Samples, Muscle Biopsies and Histology Muscle Strength and Electromyographic Studies Results of Histological and Biochemical Investigations Muscle Strength Measurements and Surface Electromyography Pathological and Clinical Implications References Raised Serum IgA Is Present in Ankylosing Spondylitis Patients Introduction: Immunoglobulin Levels and Disease Activity in Ankylosing Spondylitis Ankylosing Spondylitis Patients and Controls Methods Used in Estimating Serum Immunoglobulins Results of Serum IgA Estimations Results of Serum IgG Estimations Results of Serum IgM Estimations Discussion Pathological and Clinical Implications References Faecal Cultures in Ankylosing Spondylitis and Uveitis Introduction: The Origin of Ankylosing Spondylitis Ankylosing Spondylitis Patients and Controls Active Disease Probably Active Disease Inactive Disease Collection and Investigations of Urinary and Faecal Specimens Results of Urine Investigations Results of Faecal Investigations Acute Anterior Uveitis and Faecal Cultures Results of Faecal Cultures in Patients with Uveitis Discussion Pathological and Clinical Implications References

15 xiv Contents 9 Biochemical Parameters and Klebsiella in Ankylosing Spondylitis Introduction: The Use of Biochemical Parameters in Ankylosing Spondylitis Selection of Ankylosing Spondylitis Patients and Controls Assessment of Disease Activity Active Disease Probably Active Disease Inactive Disease Methods Used in These Studies C-Reactive Protein Estimation Erythrocyte Sedimentation Rate Measurement Faecal Cultures C-Reactive Protein and Disease Activity Erythrocyte Sedimentation Rate and Disease Activity Isolation of Klebsiella and Disease Activity C-Reactive Protein and Erythrocyte Sedimentation Rate in Ankylosing Spondylitis Patients with and Without Klebsiella Discussion Pathological and Clinical Implications References Binding of Klebsiella Antisera to HLA-B27 Cells Introduction: The Problem of HLA-B27 in Ankylosing and Its Link to Klebsiella Patients and Control Subjects Rabbit Antisera Specificity Tests on Antisera Enzyme Immunoassay to Investigate the Binding of Anti-Klebsiella Sonicate Preparation to HLA-B27 Lymphocytes Absorption Experiments Results of Antisera Specificity Results of Enzyme Immunoassay and Absorption Experiments Pathological and Clinical Implications References IgA Antibodies to Klebsiella and Other Gram-Negative Bacteria in Ankylosing Spondylitis Introduction: The Problem of Elevated Serum IgA in Ankylosing Spondylitis and Its Link to Klebsiella Selection of Serum Samples from Ankylosing Spondylitis Rheumatoid Arthritis, Psoriasis Patients and Healthy Controls Enzyme-Linked Immunosorbent Assay (ELISA) Absorption Studies C-Reactive Protein Results