632 Ann Rheum Dis 2001;60:632–634

CONCISE REPORTS Ann Rheum Dis: first published as 10.1136/ard.60.6.632 on 1 June 2001. Downloaded from

Intra-articular co-infection by Borrelia burgdorferi and Chlamydia trachomatis

N Putschky, S Schnarr, J Wollenhaupt, H Zeidler, J G Kuipers

Abstract Polymerase chain reaction (PCR) is the Objective—Chlamydia trachomatis and method of choice for detecting persisting bacte- Borrelia burgdorferi infections are fre- ria in joints.1 Recently, universal PCRs have quently the cause of unexplained oligoar- been developed for use in the diagnosis of undif- thritis, as shown by identification of ferentiated arthritis. However, their sensitivity is bacteria specific DNA in joint material lower than species specific PCRs and, to date, from patients with reactive arthritis, the universal PCR has not detected B burgdorferi Lyme arthritis, and undiVerentiated oligo- in cases of undiVerentiated arthritis.23 Never- arthritis. The aim of this study was to theless, universal PCR has detected several determine whether the two organisms organisms simultaneously in one inflamed joint 23 occur simultaneously in joint material which have not been related to arthritis. from patients with arthritis. This study was undertaken to determine Methods—Seventy six patients with unex- whether C trachomatis and B burgdorferi, the plained arthritis were prospectively stud- two most important arthritis triggering organ- 14 ied. Synovial fluid was obtained from all isms in western countries, can be simultane- patients and examined for DNA from C ously detected by species specific PCR in trachomatis and B burgdorferi using spe- unexplained oligoarthritis, or whether the cific polymerase chain reaction (PCR) detection of one of these bacteria excludes the protocols. Data concerning prior genito- presence of the other. urinary infection or a history of tick bite were recorded and serum antibodies to C Methods trachomatis and B burgdorferi were de- As part of a comprehensive study on early termined. arthritis we prospectively studied 76 patients Results—Six patients (8%) had DNA from with unexplained oligoarthritis visiting a terti- http://ard.bmj.com/ both C trachomatis and B burgdorferi in ary care outpatient clinic for the first time. The the same synovial fluid specimen (mean results of an extended rheumatological diag- leucocyte count 11.925/mm3, 65% granulo- nostic programme in patients who fulfilled the cytes). These patients (four men, two criteria for unclassified arthritis will be pub- women; mean age 33.7 years) all had lished elsewhere. In this study patients with oligoarthritis of the knee, ankle, or both unexplained oligoarthritis are analysed.

(mean disease duration 11.3 months). Synovial fluid was obtained from all patients on October 2, 2021 by guest. Protected copyright. From the history and serological exami- and examined for DNA from C trachomatis and nation, four patients had some evidence of B burgdorferi using species specific PCR proto- actual or previous infection with one or cols5: C trachomatis nested PCR was used to other of the bacteria, while the other two target C trachomatis major outer membrane patients had a positive serological test for protein (MOMP) with 152 base pairs using the 6 Division of Chlamydia only. primer CT05/CT06//CT03/CT04 and Borre- Rheumatology, Conclusions—DNA from two diVerent lia burgdorferi sensu lato nested PCR was used to Medical School, 30625 microorganisms which are known to be target B burgdorferi outer surface protein A Hannover, Germany triggering agents for arthritis may be (OspA) with 146 base pairs using the primer N Putschky present simultaneously in joint material BBSL1/BBSL2//MRL7/MRL11a.78Both tests S Schnarr were able to detect the specific bacteria with a H Zeidler from patients with unexplained oligoar- J G Kuipers thritis. This finding raises the question as sensitivity of one organism/ml synovial fluid. to whether, in such cases, one or both bac- Numerous negative controls were included; Division of teria contribute to the pathogenesis of the PCRs were defined as positive only when the Rheumatology, disease or whether they are only innocent results were reproducible twice and when all General Hospital bystanders. negative controls remained negative. The Eilbek, 22981 correct identity of the PCR products was con- Hamburg, Germany (Ann Rheum Dis 2001;60:632–634) J Wollenhaupt firmed by restriction analysis or by direct sequencing of the PCR product.5 Correspondence to: Chlamydia trachomatis and Borrelia burgdorferi Data concerning prior infection of the Dr med N Putschky are thought to cause arthritis by persisting genitourinary tract and a history of tick bite [email protected] intra-articularly in a metabolically active were recorded and serum antibodies for Ctra- Accepted 13 December 2000 though usually a non-culturable state.1 chomatis IgA/IgG (ELISA test; Medac, Wedel,

www.annrheumdis.com Intra-articular co-infection by B burgdorferi and C trachomatis 633

Table 1 Characteristics of six patients with unexplained oligoarthritis PCR positive for that monocytes that have phagocytosed bacte- both Borrelia burgdorferi and Chlamydia trachomatis DNA in the synovial fluid

ria elsewhere in the body may have been Ann Rheum Dis: first published as 10.1136/ard.60.6.632 on 1 June 2001. Downloaded from disseminated into the inflamed joint. There- Patient no fore, because of its extreme sensitivity, a 123456positive PCR result may reveal a previously unexpected degree of intrinsic microbial pres- Sex (male/female) M M M F M F 2 Age (years) 25 27 48 21 36 45 ence at many anatomical sites. Recently, AVected joints (knee/ankle) k k/k/a k/k k a/a k/k Schumacher et al reported the detection of C Duration (months) 9 18 30 2 1 8 10 Inflammatory low back pain9 +−+−+−trachomatis in healthy joints and in the joints HLA-B27 + − − − + − of patients with diseases not related to C Leucocytes in SF (n/mm3) 23250 6450 10400 13150 14700 3600 trachomatis such as osteoarthritis,11 which Neutrophils in SF (%) 88 33 49 85 67 70 History of tick bite/ECM −/− +/− −/− −/− +/+ −/− suggests that the presence of C trachomatis in B burgdorferi serology + + − − − + joints does not necessarily indicate that C History of urogenital infection − − − − + − trachomatis is the causative factor. Further- C trachomatis in urogenital smears* − + − − − + Chlamydia serology IgA/IgG (ELISA) −/+ +/+ −/+ −/+ −/− −/− more, they noted several patients with diVerent forms of arthritis in whom DNA from C SF = synovial fluid; ECM = erythema chronicum migrans. trachomatis as well as from C pneumoniae was *Detected by immunofluorescence or culture. found in the synovial tissue of the same Germany) and B burgdorferi (haemagglutina- individual.12 tion test; Labor Diagnostik, Heiden, Germany) The detection of two known arthritis causing were determined. For detection of active microorganisms in one inflamed joint sets the urogenital chlamydial infection urethral smears scene for several possible pathogenetic models. were taken and examined by immunofluores- Either both organisms are causing inflamma- cence or culture. tion, or one organism is triggering the disease and the second is an innocent bystander disseminated into the inflamed joint by in- Results creased vascularisation, or none of them is DNA from either C trachomatis or B burgdorferi responsible for the disease. The finding of two was present in synovial fluid from 22 of the 76 pathogenic organisms at the disease site does patients (29%)5; the results of these patients not primarily indicate that they are both inno- will be published elsewhere (Schnarr et al, sub- cent bystanders; numerous examples of co- mitted). Surprisingly, in a further six patients infection, either bacterial or viral, are known in (8%), DNA from both C trachomatis and B medicine.13 In four of the six patients reported burgdorferi was reproducibly detected in the here, additional evidence such as coincidental same synovial fluid specimen. Table 1 shows history, serological tests, and urogenital smears the individual characteristics of the “double for C trachomatis indicated co-infection by both positive patients” (four men, two women; mean B burgdorferi and C trachomatis. Some patients age 33.7 years), all of whom had oligoarthritis were seronegative for B burgdorferi or C tracho- of the knee, ankle, or both (mean disease dura- matis, or both. This may be because C tion 11.3 months). Three of the six patients http://ard.bmj.com/ trachomatis is an intracellular agent or because (two positive, one negative for HLA-B27) also of the relatively low sensitivity of the serological complained of inflammatory low back pain.9 test used for B burgdorferi. Furthermore, most With regard to their history and the results of patients (nos 1, 2, 3, and 6) had already been serological tests, two patients (nos 3 and 4) had treated with steroids before serological testing. positive serological tests for Chlamydia only. To examine the pathogenesis and define the Four patients (nos 1, 2, 5, and 6) had some precise causative role of these organisms, evidence of ongoing or previous infection with further analysis of the host-bacteria interaction on October 2, 2021 by guest. Protected copyright. both organisms: patient 5 had had erythema such as specific T cell responses, gene induc- chronicum migrans and a urogenital infection tion, and cytokine profiles need to be studied. in the past, and patients 2 and 6 had active Antibiotic treatment should be reserved for asymptomatic urogenital infection with C patients with chlamydial infections of the uro- trachomatis at the time of the investigation. genital tract, those with arthritis in whom B burgdorferi DNA is detected in the inflamed Discussion joint, or those with unambiguously positive B We describe for the first time the simultaneous burgdorferi serological tests. No benefit of anti- detection in the synovial fluid from inflamed biotic treatment has so far been reported for joints of DNA from C trachomatis and B patients in whom C trachomatis DNA has been burgdorferi, two bacterial species which have detected in the joints.14 been typically associated with the pathogenetic process leading to arthritis. This study was supported by BMBF grant 01VM9708/4 to J G Kuipers, J Wollenhaupt, and H Zeidler. Molecular biological techniques such as PCR are increasingly being used to identify a 1 Kuipers JG, Köhler L, Zeidler H. Reactive or infectious arthritis. Ann Rheum Dis 1999;58:661–4. potential bacterial aetiology in arthritic dis- 2 Wilbrink B, van der Heijden IM, Schouls LM, van Embden eases.1 In general, detection of specific bacterial JDA, Hazes JMW, Breedveld FC, et al. Detection of bacte- rial DNA in joint samples from patients with undiVerenti- DNA or RNA in the inflamed joint (synovial ated arthritis and reactive arthrititis, using polymerase fluid or synovial tissue) is considered evidence chain reaction with universal 16S ribosomal RNA primers. Arthritis Rheum 1998;41:535–43. for a bacterial aetiology. However, recent pub- 3 Wilkinson NZ, Kingsley GH, Jones HW, Sieper J, Braun J, lications using broad range or specific PCRs23 Ward ME. The detection of DNA from a range of bacterial species in the joints of patients with a variety of arthritides have identified DNA from organisms not using nested, broad-range polymerase chain reaction. previously related to arthritis. It was speculated Rheumatology 1999;38:260–6.

www.annrheumdis.com 634 Putschky, Schnarr, Wollenhaupt,et al

4 Kvien TK, Glennas A, Melby K, Granfors K, Andrup O, 9 Calin A, Porta J, Fries JF, Schurman DJ. Clinical history as Karstensen B, et al. Reactive arthritis: incidence, triggering a screening test for ankylosing spondylitis. JAMA 1977;

agents and clinical presentation. J Rheumatol 1994;21: 237:2613–4. Ann Rheum Dis: first published as 10.1136/ard.60.6.632 on 1 June 2001. Downloaded from 115–22. 10 Schumacher HR Jr, Arayssi T, Crane M, Lee J, Gerard H, 5 Schnarr S, Jendro MC, Putschky N, Zeidler H, Hammer M, Hudson AP, et al. Chlamydia trachomatis nucleic acids can Wollenhaupt J. High frequency of Chlamydia and Borrelia be found in the synovium of some asymptomatic subjects. in patients with unclassified oligoarthritis: results of a pro- Arthritis Rheum 1999;42:1281–4. spective study. Arthritis Rheum 1997;40(suppl):S142. 11 Wang GF, Clayburne G, Rothfuss S, Cheng FD, Zhang H, 6 Kuipers JG, Nietfeld L, Dreses-Werringloer U, Koehler L, Schumacher R. Chlamydia trachomatis nucleic acids also Wollenhaupt J, Zeidler H. Optimised sample preparation of occur in some osteoarthritis controls. Arthritis Rheum synovial fluid for detection of Chlamydia trachomatis DNA by polymerase chain reaction. Ann Rheum Dis 1999;58: 1998;41(suppl):S244. 103–8. 12 Schumacher HR Jr, Gerard HC, Arayssi TK, Pando JA, 7 Demaerschalck I, Ben-Messaoud A, De-Kesel M, Hoyois B, Branigan PJ, Saaibi DL, et al. Lower prevalence of Lobet Y, Hoet P, et al. Simultaneous presence of diVerent Chlamydia pneumoniae DNA compared with Chlamydia Borrelia burgdorferi genospecies in biological fluids of trachomatis DNA in synovial tissue of arthritis patients. Lyme disease patients. J Clin Microbiol 1995;33:602–8. Arthritis Rheum 1999;42:1889–93. 8 Liebling MR, Nisho MJ, Rodriguez A, Sigal LH, Jin T, 13 Fourmaux S, Bebear C. Urogenital infections linked to Louie JS. The polymerase chain reaction for the detection Chlamydia and mycoplasmas. Prog Urol 1997;7:132–6. of Borrelia burgdorferi in human body fluids. Arthritis 14 Köhler L, Kuipers JG, Zeidler H. Managing seronegative Rheum 1993;36:665–9. spondarthritides. Rheumatology 2000;34:360–8.

Is your paper being cited? http://ard.bmj.com/

CiteTrack service

CiteTrack will alert you by email whenever new content in Annals of the Rheumatic Diseases or a participating journal is published that matches criteria you want to track on October 2, 2021 by guest. Protected copyright. Topics: Tell CiteTrack which words or subjects to watch for in new content Authors: Be alerted whenever key authors you are following publish a new paper Articles: Know whenever a paper of interest to you is referenced by another paper www.annrheumdis.com

www.annrheumdis.com