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Introduction

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

Adjuvant-induced arthritis (AIA), the first experimental arthritis model, was described in 1956 (1, 2), at a time when experimental autoimmune diseases affecting the central nervous system, peripheral nervous system, thyroid, and eye had been described, and autoimmunity began to be considered a significant mechanism in the pathogenesis of organ-specific inflammatory disease (3, 4). AIA, which appeared in rats immunized with Mycobacterium tuberculosis in oil, showed suggestive similarities in clinical onset and course, as well as the pattern of lesions in joints, skin, eye, and mucosae, to reactive arthritis associated with infection by enteric organisms (primarily gram-negative bacilli) (for review, see ref. 5). The intensified, precocious appearance of AIA lesions at joint or skin sites traumatized by various means suggested that the disease might represent a disseminated autoimmune response to a joint or connective tissue antigen (6). Indeed, AIA could be transmitted by transferring sensitized lymph node cells (7, 8) or thoracic duct cells (9) from sensitized donors to normal recipients, without administering M tuberculosis to the latter group.

Lesion pathogenesis

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

The morphologic character of early AIA lesions in the various tissues studied (1, 2, 5, 6, 10, 11) conforms to descriptions of cell-mediated immunity (CMI), as seen in autoimmune disease models such as experimental autoimmune encephalomyelitis (EAE), and in allograft immunity and tuberculin sensitivity (3, 12, 13). An initial infiltration of lymphocytes and histiocytes around small veins is followed by edema, fibrin deposition, and foci of necrosis, accompanied by proliferation of synoviocytes and fibroblasts and activation of osteoblasts and osteoclasts. Gross synovitis is followed by periarthritis, peritendinitis, and periostitis, then pannus formation (with destruction of cartilage and bone), and finally fibrous or bony ankylosis.

CMI lesions are commonly mediated by T cell receptor α/β (TCRα/β) T cells, and disease can be transferred with M tuberculosis–sensitized α/β T cell clones, uncontaminated with other cells (14–17). Because AIA is undiminished in rats thymectomized at birth and given adjuvant as adults (18), it was inferred that TCRγ/δ T cells mediated disease in the absence of α/β T cells (19). An important subset of γ/δ T cells leave the rat thymus well before birth, are unaffected by neonatal thymectomy (20), and have been shown to function as polarized Th1 effectors in a variety of experimental and natural situations (see ref. 19). In contrast, depletion of γ/δ T cells from birth did not prevent or ameliorate AIA (21).

The inflammatory infiltrate in the joint lesions of AIA contains T cells activated by specific antigens that inhibit cartilage proteoglycan synthesis by means of diffusible factors (22). Th1 cytokines such as interleukin 17 (IL-17), interferon-γ (IFNγ), and tumor necrosis factor α (TNFα) are expressed in early AIA together with cytokines characteristic of macrophage activation, namely IL-1β, and the chemokine macrophage inflammatory protein 1α (23, 24). In a later phase of the disease, levels of IL-4, IL-6, and JE (the murine homolog of monocyte chemoattractant protein 1) and transforming growth factor β (TGFβ) are elevated. There is local release of proteolytic enzymes and/or free radicals of oxygen (25). The result is progressive breakdown of collagen types II and IX, matrix damage, and, in time, degradation of bone (26).

Cross-reactive antigens/epitopes

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

The immunizing antigen of the injected M tuberculosis has been shown to be a heat-shock protein (HSP), mycobacterial Hsp60 (also termed 65-kd antigen of mycobacteria), and the responsible epitope is the 180–188 amino acid sequence or, more narrowly, peptide 180–186 (27, 28). The cross-reactive antigen in the mammalian host proved not to be a mammalian HSP but rather the link protein of a cartilage proteoglycan (15,17; for review, see refs. 16 and29). A single mycobacterial Hsp60–specific TCRα/β T cell clone, designated A2b, recognized not only rat cartilage proteoglycan but also purified human cartilage proteoglycan and antigen(s) present in human synovial fluid and in the medium of human chondrocyte cultures (17).

The oily adjuvant or mineral oil constituents such as pristane, in the absence of mycobacteria, induce AIA in DA rats (i.e., animals of a different genetic background) (30–33). In this case, tissue (or mammalian) Hsp60 261–271 may serve as both the immunizing and eliciting epitope underlying disease (34). One of us has noted elsewhere (19) the ease with which immunization against any of a wide variety of cartilage proteoglycans, glycoproteins, syndecans, mammalian HSPs, collagens, and other joint antigens occurs secondary to joint damage and creation of a local adjuvant or immunizing microenvironment. There may be sequential involvement of different epitopes of a single antigen (epitope spreading) or even of different antigens, and responses to individual epitopes may be predominantly Th1, Th2, or both in sequence.

It is notable that, in postenteritic arthritis in human subjects, the responsible organisms express closely similar antigens/epitopes, and there is a high degree of conservation in T cell responses triggered by such diverse organisms as Shigella sonnei, Yersinia enterocolitica, Chlamydia trachomatis, and Salmonella species, as shown by a comparative TCR β-chain repertoire analysis of synovial fluid and peripheral blood T cells (35). The dominant epitope recognized by pathogenic CD4+ and CD8+ T cells in, for example, Yersinia-triggered disease, is Hsp60 (36). Synovial CD4+ T cell clones from such cases recognize a 12-mer epitope (peptide 322–333) of Yersinia Hsp60, presented by multiple DR alleles, which overlaps a B27-restricted CD8+ T cell epitope. Although no cross-responsiveness to tissue Hsp60 was detected, the T cells produced IL-10, which may contribute to regulation of the anti-Yersinia immune response and therefore to persistence of bacterial infection leading to reactive arthritis.

Hsp60 is also present in the joint synovia of patients with rheumatoid arthritis (RA). We showed in 1986, in collaboration with Holoshitz et al, that TCRα/β T lymphocytes from patients with RA recognize M tuberculosis components cross-reactive with glycoproteins of human cartilage (37). More extensive study established that DN γ/δ T cells, reactive with Hsp60 of M tuberculosis in the absence of major histocompatibility complex (MHC) restriction, are also present in RA synovia and synovial fluid (38).

Regulation driven by T cells recognizing HSP epitopes

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

Lewis rats pretreated with M tuberculosis in saline or in oily adjuvant, either at birth or shortly before immunization, become refractory to the usual sensitizing dose of M tuberculosis in oil while remaining fully susceptible to EAE or bacillus Calmette-Guérin (BCG) sensitization (7, 39). Cells obtained from pretreated, sensitized donors are unable to transfer disease, whereas transfer of sensitized cells from untreated donors produces AIA equally readily in M tuberculosis–treated and normal recipients. The molecular events underlying resistance of this type have been worked out in some detail (29, 40, 41) (Table 1). The pathogenic M tuberculosis Hsp60 180–188 itself can serve as a protective ligand (48, 49). With a single substituent (alanine at position 183), it becomes a powerful altered peptide ligand (APL), which may act as a partial agonist or antagonist of the pathogenic process (42, 43).

Table 1. Structural determinants in regulation of adjuvant disease in rats*
MoleculeEpitope/idiotopeActionRef.
  • *

    mtHsp60 = mycobacterial heat-shock protein 60; TCR = T cell receptor.

mtHsp60p180–188Effector27
 p180–188 (183A)Antagonist42, 43
 p256–265Regulatory29, 40, 44, 45
 Carboxy-terminal (between p417–431 and p521–535)Regulatory46
mtHsp70p234–252Regulatory58
 p111–125Regulatory47
mtHsp60 (given intranasally)p176–190Regulatory48
p176–190 (183A)Highly regulatory43
TCR Vα11p66–80Effector50
TCR Vβ18p17–31Regulatory51

A striking new development here is the discovery that the down-regulatory response after pretreatment with M tuberculosis is related mainly to a second regulatory epitope, peptide 256–265 (256–270), of mycobacterial Hsp60, which shares a partial sequence with rat tissue Hsp60 256–265 (45). Immunization with this mycobacterial Hsp60 protein, rather than with whole M tuberculosis, renders rats resistant to AIA and, at the same time, to many other forms of arthritis. Other forms of arthritis that were tested included avridine-, streptococcal cell wall–, and Yersinia-associated arthritis in rats, and pristane- and collagen-induced arthritis in mice (29, 40, 52). One is struck by the close relationship of the regulatory tissue Hsp60 peptide to the arthritogenic peptide (tissue Hsp60 261–271) of pristane-induced arthritis. Resistance is associated with the development of regulatory T cells specific for mycobacterial Hsp60 256–265, which can transfer the state of resistance (i.e., can inhibit the effector function of clones specific for peptide 180–188). These regulatory T cells have been seen to produce IFNγ, IL-4, and IL-10 (52, 53). In pristane-induced adjuvant disease, preadministration of the arthritogenic tissue Hsp60 261–271 intraperitoneally similarly deviated the animals' responses to subsequent immunization with pristane from Th1 to Th2 (production of IL-4, IL-5, and IL-10) and protected them against disease (54).

Protection was seen in experiments using mycobacterial Hsp70 (55); this again depended on the recognition of a highly conserved sequence (peptide 111–125), cross-reactive at the T cell level with the tissue (rat) Hsp70 (47). These T cells produced IL-10 upon stimulation, supporting the contention that this epitope as well induced a regulatory phenotype in the responding T cells. The same epitope, when administered intranasally, produced protection against induction of both mycobacterial and avridine-induced arthritis in rats. Intracellular staining for IL-10 revealed that mycobacterial Hsp70-specific CD4+ T cells accumulated IL-10 (and IL-4), which was not seen in T cells specific for various bacterial control antigens (56). Also, other mycobacterial Hsp70 epitopes that induce IL-10 and suppress adjuvant disease have been found (57).

T cells primed with mycobacterial Hsp60 256–270 also proved to be highly reactive against syngeneic antigen-presenting cells (APCs), responding with proliferation, production of INFγ, IL-4, and IL-10, and increased expression of B7-2 (53). The response is augmented if the APCs are heat-shocked, the inference being that the responsible epitope is expressed as a mammalian HSP in the APC as well. Transfer of these T cells protects against adjuvant-induced disease. Thus, conserved sequences in the various cross-reactive mammalian HSPs appear at sites of inflammation, both in the injured tissue itself and in infiltrating, locally activated APCs. T cells reactive with mycobacterial Hsp60 are found in the diseased synovia in all forms of experimental arthritis (58) and include both effector and regulatory subpopulations.

Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

An experiment was performed recently with conserved non-HSP bacterial immunogens (superoxide dismutase of Escherichia coli, G3PDH of Bacillus, and aldolase of Staphylococcus), which are homologous to enzymes of their mammalian hosts, to determine whether they might have a protective effect comparable with that of mycobacterial HSP (56). All 3 antigens are immunogenic: they readily induced proliferative T cell responses and delayed-type hypersensitivity reactions. Yet none of these antigens affected arthritis induction in either adjuvant-induced or avridine-induced arthritis models. A crucial point here is that these antigens may not be represented in cartilage, either as such or in the form of a homolog. However, the fact that they are not related to microbial or tissue HSP may be more significant.

The possible presence in adjuvant-induced disease of effector or regulatory cells in the CD8+ T cell subset recognizing epitopes presented by class I MHC has had little support thus far. A database search has uncovered >30 human proteins with peptide sequences that can be fitted in HLA–B27 and show close homology or identity with peptides of Chlamydia or Ureaplasma, organisms frequently associated with reactive arthritis (59). So far, none of the proteins identified by these 2 approaches has been a component of cartilage, and none has been tested for arthritogenic activity. It is relevant that Hsp60 is the dominant epitope recognized by CD4+ and CD8+ T cells in reactive arthritis following Yersinia or other gram-negative enteric infections (35, 36). Conversely, the epitope incriminated in both Klebsiella pneumoniae–related reactive arthritis and ankylosing spondylitis is a peptide of the enzyme nitrogenase, which is strongly expressed in the joint synovia (60, 61).

Regulation driven by B cell epitopes and/or antibody

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

Active vaccination of Lewis rats with a cocktail of B cell epitopes, as well as passive protection with the corresponding antibodies, induced suppression of arthritis (62). The mechanism whereby induction of a B cell response suppresses adjuvant-induced disease is unclear. In the vaccination experiment, disease was not eliminated completely. Passive transfer of antibody to mycobacterial Hsp60 31–46 achieved, at best, a slight reduction of disease. One may speculate about a possible role, in the vaccination experiment, of Th2 cells (or even the B cells themselves) in down-regulating the pathogenic Th1 cell response.

DNA vaccination, leading to regulation

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

A recent innovation has been vaccination with DNA constructs encoding arthritogenic peptide sequences of mycobacterial Hsp60 or the corresponding human tissue Hsp60 (cross-reactive at the T cell level) (63, 64). Such vaccination inhibits adjuvant-induced disease; however, the regulatory mechanism responsible is far from clear. The one consistent finding is a T cell proliferative response to both mycobacterial and tissue HSP accompanied by enhanced TGFβ secretion and associated with disease suppression. INFγ and IL-10 responses to a variety of disease-associated antigens are variable.

Regulation driven by idiotopes of effector T cell receptor or antibody

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

The early transfer experiments using cloned arthritogenic T cells in immunologically intact recipients pointed to another aspect of resistance to adjuvant-induced disease, related to the host's response against idiotypic sequences of the disease-inducing receptor of T cells (14, 29). As is well known, antiidiotype usually is recognized as an internal image of the epitope used to elicit the initial response. The A2b clone of TCRα/β T cells recognizing mycobacterial Hsp60 180–188 was shown to use α- and β-chain V regions Vα11 and Vβ18 (51). Several α and β peptides clustered within the same contact determinant region (CDR1) of this TCR proved to be immunogenic; when one of these, Vβ18 peptide 17–31, was used to immunize, it resulted in production of T cells that recognized clone A2b and resulted in suppression of arthritis in the immunized rats (51). The antiidiotypic T cells recognized CDR1 of the TCR β-chain peptide in the context of the class II MHC expressed on activated effector T cells. Recipients of a transfer of antiidiotype-specific cells become resistant to arthritis induced by M tuberculosis. In contrast to the Vβ18 results, immunization of normal animals with Vα11 peptide 66–80 or antiidiotypic cells recognizing Vα11 peptide 66–80 leads to an arthritis (44, 50). The peptide 66–80 elicits classic delayed-type hypersensitivity, even in naive rats, suggesting that there is a preexisting level of T cell priming, and that this reactivity is increased in rats with AIA. In contrast, nasal application of the antiidiotypic Vα peptide 66–80 results in a decrease both of subsequent arthritis and the accompanying delayed-type hypersensitivity (50).

It is clear that in normal rats (and, one supposes, in normal humans) a network, including both pathogenic and regulatory subpopulations, of T cells that recognize certain HSP sequences as well as the idiotypes of other T cells is present. We have shown that closely similar regulatory interactions are present in a variety of arthritis models.

Regulation driven by mucosal exposure to HSP

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

The gut-associated lymphoid tissues represent the major contact area between the host and the external microbial world. While monitoring the gut for the presence of pathogens, these tissues show a major orientation toward establishment of long-term tolerance to elements of the microflora (which function as an auxiliary digestive organ) and to food (65). Regulatory cytokines, such as IL-10 and TGFβ, produced not only by cells of the adaptive immune system but also, as in the case of IL-10, by intestinal epithelial cells, dominate the regulatory mechanisms that have been identified. Tolerance-promoting activity for lipopolysaccharides has been demonstrated at the level of the gut (66), while antigen-specific oral tolerance proved more difficult to induce in germ-free animals as compared with conventional animals (67). Thus, contact with microbial antigens in the gut contributes to the development of a tolerant state toward the microflora at the level of both innate and adaptive immunity. Given the potential of HSP to interact with receptors of the innate immune system and the immunodominance of these proteins in adaptive immune responses, the gut may well constitute the primary site of interaction between HSP and host immune regulatory mechanisms. By comparing repertoires of T cells in rats housed in facilities with different degrees of cleanliness, Moudgil et al observed that the presence of exogenous flora induces T cell responses to regulatory determinants within mycobacterial Hsp60 (46).

The impact of gut microflora composition on susceptibility to arthritis has been documented by Nieuwenhuis et al (68). Oral vancomycin, which reduced gram-positive flora and led to an expansion of gram-negative flora such as E coli, impaired the severity of AIA. This effect was neutralized by addition of tobramycin/colistine, which also reduced gram-negative flora. Cobelens et al obtained more direct evidence for a role of HSP at the level of the mucosa by showing that intragastric mycobacterial Hsp60, when given at the start of disease in combination with soybean trypsin inhibitor, produced a dramatic and instantaneous suppressive effect on AIA (69). The dosage regimen in these experiments (30 μg of mycobacterial HSP given 4 times on alternating days) was comparable with that in low-dose oral tolerance regimens leading to stimulation of IL-10– and TGFβ-producing T cells. More recently, Cobelens et al demonstrated that β2-adrenergic agonists, such as salbutamol, have the capacity to promote production of IL-10 and TGFβ in intestinal cells (70). When salbutamol was given orally in combination with mycobacterial Hsp60, a suppressive effect on development of AIA was noted. In separate experiments, oral administration of ovalbumin in combination with salbutamol resulted in ovalbumin-specific tolerance lasting several months. These observations have been extended speculatively to the more general problem of mucosal tolerance involving HSPs of commensal flora in the gut (71).

Mucosal exposure by the intranasal route, using the arthritogenic epitope mycobacterial Hsp60 76–190, prevents AIA and other experimental arthritis (avridine-induced arthritis), whereas nonarthritogenic epitopes such as peptide 211–225 do not (44). Effective tolerance can be induced by intranasal exposure as late as 11 days after immunization. The APL 80–188 (alanine 183) given intranasally is much more down-regulatory than is the wild-type epitope and is even effective in treating ongoing AIA (43). This regulatory activity can be transferred with activated splenocytes, is associated with production of IL-4, IL-10, and TGFβ, and can be blocked by anticytokine antibodies, especially antibodies to IL-10.

Regulation driven by competing antigens

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

Adjuvant-induced disease is also prevented by inclusion of a competing antigen in the inoculation mixture—apparently any antigen capable of inducing an α/β T cell response, such as bovine serum albumin (BSA), bovine gamma globulin, or the myelin antigens of EAE (72, 73). There is no competition if the response to the competing antigen fails, as in animals previously tolerized against the antigen used, neonatally thymectomized animals, or animals treated with immunosuppressive drugs or irradiation. In experiments with BSA in neonatally thymectomized rats, in which neither delayed sensitization to BSA nor EAE could be produced, the arthritis was undiminished by the competing protein (72). Timed infusions of normal lymph node cells, which restored the BSA sensitization, showed that suppression is affected in the first hours after the injection of the BSA-containing mixture. Either γ/δ T cells or unprimed CD8+ α/β T cells, both of which are capable of reacting to specific antigen within a few hours (74, 75), might be responsible for the competition.

Discussion

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES

Studies of adjuvant-induced disease have generated an astonishing variety of immunomanipulative, disease-inhibiting approaches (Table 2). It must be significant that, with the single exception of competition of antigens, all of these approaches involve the use of a bacterial or tissue HSP or HSP peptides. Certain techniques (e.g., use of oral Hsp60) were effective even in treating ongoing disease and must be judged as powerful immunotherapies. Most of the approaches summarized above have been demonstrated to act nonspecifically on the cellular mechanisms of the arthritogenic inflammatory process itself rather than on specific responses to autoantigens, with, at best, a questionable relationship to autoimmune joint disease. This is a unique aspect of adjuvant-induced disease, because other experimental autoimmune diseases are induced with specific autoantigens, and these same antigens are used, more or less effectively, in therapy. In the case of adjuvant-induced disease, the mycobacterial HSP 180–188 used to induce AIA mimics cartilage-derived link protein, yet HSP-based intervention was equally effective in oil-induced (pristane and avridine) disease, which targets a different tissue component. It would appear that successful disease inhibition by HSP does not involve a specific antigen.

Table 2. Immunoactive agents of potential value in therapy of arthritis*
MoleculeMechanism of actionRef.
  • *

    mtHsp60 = mycobacterial heat-shock protein 60; maHsp60 = mammalian Hsp60; TGFβ = transforming growth factor β; TCR = T cell receptor; IFNγ = interferon-γ; APL = altered peptide ligand; IL-10 = interleukin-10; BSA = bovine serum albumin.

T cell epitopes (e.g., mtHsp60)Generation of specific/nonspecific regulatory cells27, 45, 47
Altered peptide ligandsGeneration of specific/nonspecific regulatory cells42, 43
B cell epitopesGeneration of specific Th2 cells and antibody; down-regulation of specific Th1 cells62
DNA (encoding mtHsp60 or maHsp60)Up-regulation of TGFβ1 in epitope-specific T cell responses63, 64
Recombinant vaccinia virus (maHsp60 and mtHsp60)Induction of HSP-specific T cells76, 77
Idiotopes of effector T cell TCRRegulatory cells, IFNγ production14, 49, 51
Mucosal administration of specific epitopes, APL, or idiotopesRegulatory cells; up-regulation of IL-10, TGFβ in specific/nonspecific T cell responses43, 48, 69, 70
Nonself epitopes (e.g., bovine gamma globulin, BSA)Competition of antigens (mechanism?)72

We are anxious to explore the possibility of translating such experimental interventions to the treatment of arthritis in humans. Classic mycobacterial AIA most closely resembles reactive arthritis and may actually be the direct counterpart of BCG-induced transient arthritis, which is seen in patients undergoing immunotherapy for cancer (78). Given the broad impact of HSP administration, irrespective of disease-inciting antigen, it is tempting to regard the manipulative interventions analyzed here as possibly relevant to a range of inflammatory joint diseases that go beyond AIA and reactive arthritis. We are warned, however, by the discovery that adjuvant-induced disease could be induced with a TCR peptide from a disease-producing T cell clone, that AIA (and presumably its human counterpart) is like a hall of endless mirrors, with idiotypes following antiidiotypes ad infinitum, carrying unknown risks for the development of additional disease as a consequence of immunotherapy.

For Hsp60, the analysis of responses in children with juvenile idiopathic arthritis (JIA) has been most revealing. Proliferative responses to human Hsp60 were frequently observed in patients with remitting pauciarticular JIA and not in patients with progressive polyarticular or systemic JIA (79–81). In longitudinal studies, spontaneous remission was found to be preceded by elevated responses, which declined after remission. A recent study revealed up-regulated expression of CD30, a marker associated with regulatory T cell activity in human arthritis (82), on human Hsp60–responding T cells in these patients (de Kleer IM, et al: unpublished observations). These data suggest a critical contribution of regulatory mammalian Hsp60–specific T cells in the process leading to disease remission in JIA. Thus, in principle, the manipulation of mammalian Hsp60–reactive T cell activity in humans can be a goal of novel immunotherapies, at least for JIA and possibly for reactive arthritis. A nagging question is whether JIA is to be regarded as a form of reactive arthritis (83).

We have already commented on the uniform presence in postenteritic arthritis of T cells, both CD4+ and CD8+, recognizing an immunodominant epitope of microbial Hsp60 and producing IL-10. However, clinical evidence linking such cells to disease inhibition or recovery from the active disease process is lacking.

In human RA, the analysis of T cell responses using peptides selected by the algorithms for pan DR epitope binding has led to the definition of mycobacterial and mammalian HSP epitopes with T cell stimulatory qualities in a larger and more accessible group of patients. Depending on the peptides selected, the patients' cells developed distinctive up- or down-regulatory cytokine profiles and the expression of other phenotypic T cell markers (Prakken BJ: personal communication). On the basis of this analysis and the comparison with the T cell response patterns observed in remitting and nonremitting JIA, it is anticipated that potentially curative peptides can be selected for clinical testing in RA. It remains uncertain, for obvious reasons, whether protein or peptide interventions have the potential to suppress a fully developed chronic arthritis.

Therefore, a first objective of clinical testing must be to monitor immune deviations at the level of antigen-specific T cells, by capturing and analyzing such T cells before and following protein or peptide administration. In this way, successful immune manipulative effects, such as cytokine switches to regulatory responses, can be correlated with possible disease-suppressive effects. In other studies, the endoplasmic reticulum resident mammalian HSP BiP has been presented at a possible target antigen in RA (84). Furthermore, TNFα production by T cells derived from patients with RA was shown to become suppressed in coculture with human Hsp60–stimulated T cells (85).

Drugs involving microbial HSPs have recently become available; these may have modes of action very similar to those observed in studies of adjuvant-induced disease. For example, Subreum (Laboratoires OM, Geneva, Switzerland), an oral, slow-acting antirheumatic drug available in Europe, is an extract of selected clinically relevant E coli strains and contains Hsp70 as one of the major protein constituents. When tested in adjuvant-induced disease, it suppressed disease and promoted the activity of microbial HSP-specific T cells that produced regulatory cytokines (86). In clinical trials, it has manifested a disease-suppressive potential that is comparable with that of other currently available slow-acting antirheumatic drugs (87).

The best hope for therapy in rheumatic disease may involve the combination of an HSP-based treatment with another form of antirheumatic therapy. Roord and Albani (personal communication) have pioneered an approach in experimental adjuvant-induced disease in which nasally induced tolerance was combined with TNF inhibition (by treatment with Enbrel [etanercept]). In their experimental set-up, the mycobacterial Hsp60 mimicry epitope 180–188 was administered intranasally, together with the drug, to animals with ongoing arthritis. Whereas 3 doses of Enbrel alone were required to suppress disease, 1 dose of drug was sufficient when it was used in combination with the nasally administered peptide. In treated animals, the T cell cytokine profile was shifted toward production of IL-4 and IL-10, suggesting that cytokine-targeted intervention was reinforcing the tolerance-promoting activity of the peptide.

Taken together, studies in experimental adjuvant-induced diseases may have yielded innovative possibilities for immune interventions in arthritis, and their entrance into the phase of clinical testing is expected to be soon.

REFERENCES

  1. Top of page
  2. Introduction
  3. Lesion pathogenesis
  4. Cross-reactive antigens/epitopes
  5. Regulation driven by T cells recognizing HSP epitopes
  6. Are epitopes of non-HSP antigens or non-CD4 T cells relevant to regulation in adjuvant disease?
  7. Regulation driven by B cell epitopes and/or antibody
  8. DNA vaccination, leading to regulation
  9. Regulation driven by idiotopes of effector T cell receptor or antibody
  10. Regulation driven by mucosal exposure to HSP
  11. Regulation driven by competing antigens
  12. Discussion
  13. REFERENCES
  • 1
    Pearson CM. Development of arthritis, periarthritis and periostitis in rats given adjuvant. Proc Soc Exp Biol Med 1956; 91: 95101.
  • 2
    Pearson CM, Wood FD. Studies of polyarthritis and other lesions induced in rats by injection of mycobacterial adjuvant. I. General clinical and pathologic characteristics and some modifying factors. Arthritis Rheum 1959; 2: 44059.
  • 3
    Waksman BH. Experimental allergic encephalomyelitis and the “autoallergic” diseases. Int Arch Allergy 1959; 14 Supp: 187.
  • 4
    Waksman BH. Auto-immunization and mechanisms of auto-immunity. Medicine 1962; 41: 92141.
  • 5
    Pearson CM, Waksman BH, Sharp JT. Studies of arthritis and other lesions induced in rats by injection of mycobacterial adjuvant. V. Changes affecting the skin and mucous membranes: comparison of the experimental process with human disease. J Exp Med 1961; 113: 485510.
  • 6
    Waksman BH, Pearson CM, Sharp JT. Studies of arthritis and other lesions induced in rats by injection of mycobacterial adjuvant. II. Evidence that the disease is a disseminated immunologic response to exogenous antigen. J Immunol 1960; 85: 40317.
  • 7
    Flax MH, Waksman BH. Delayed cutaneous reactions in the rat. J Immunol 1962; 89: 496504.
  • 8
    Waksman BH, Wennersten C. Passive transfer of adjuvant arthritis in rats with living lymphoid cells of sensitized donors. Int Arch Allergy 1963; 23: 12939.
  • 9
    Whitehouse DJ, Whitehouse MW, Pearson CM. Passive transfer of adjuvant-induced arthritis and allergic encephalomyelitis in rats using thoracic duct lymphocytes. Nature 1969; 224: 1322.
  • 10
    Burstein NA, Waksman BH. The pathogenesis of adjuvant disease in the rat. II. A radioautographic study of early lesions with the use of H3-thymidine. Yale J Biol Med 1964; 37: 195203.
  • 11
    Putnam DA, Lubaroff DM, Waksman BH. Bone marrow as source of cells in reactions of cellular hypersensitivity. III. Adjuvant arthritis in the rat. Arthritis Rheum 1968; 11: 1123.
  • 12
    Waksman BH. A comparative histopathologic study of delayed hypersensitive reactions. In: WolstenholmeGEW, O'ConnorM, editors. Ciba foundation symposium on cellular aspects of immunity. London: Churchill; 1960. p. 280322.
  • 13
    Waksman BH. Delayed hypersensitive reactions: a growing class of immunologic phenomena. J Allergy 1960; 31: 46875.
  • 14
    Holoshitz J, Naparstek Y, Ben Nun A, Cohen IR. Lines of T lymphocytes induce or vaccinate against autoimmune arthritis. Science 1983; 219: 568.
  • 15
    Cohen IR, Holoshitz J, van Eden W, Frenkel A. T lymphocyte clones illuminate pathogenesis and affect therapy of experimental arthritis. Arthritis Rheum 1985; 28: 8415.
  • 16
    Cohen IR. Autoimmunity to hsp65 and the immunologic paradigm. Adv Intern Med 1992; 37: 295311.
  • 17
    Van Eden W, Holoshitz J, Nevo Z, Frenkel A, Klajman A, Cohen IR. Arthritis induced by a T-lymphocyte clone that responds to Mycobacterium tuberculosis and to cartilage proteoglycans. Proc Natl Acad Sci U S A 1985; 82: 511720.
  • 18
    Arnason BG, Jankovic BD, Waksman BH, Wennersten C. Role of the thymus in immune reactions in rats. II. Suppressive effect of thymectomy at birth on reactions of delayed (cellular) hypersensitivity and the circulating small lymphocyte. J Exp Med 1962; 116: 17786.
  • 19
    Waksman BH. Immune regulation in adjuvant disease and other arthritis models: relevance to pathogenesis of chronic arthritis. Scand J Immunol 2002; 56: 1234.
  • 20
    Ferrick DA, Sydora B, Wallace V, Gemmell-Hori L, Kronenberg M, Mak TW. Self-reactive gamma delta T lymphocytes: implications for T-cell ontogeny and reactivity. Immunol Rev 1991; 120: 5169.
  • 21
    Pelegri C, Kuhnlein P, Buchner E, Schmidt CB, Franch A, et al. Depletion of γ/δ T cells does not prevent or ameliorate, but rather aggravates, rat adjuvant arthritis. Arthritis Rheum 1996; 39: 20415.
  • 22
    Wilbrink B, Holewijn M, Bijlsma JW, Van Roy JL, van der Zee R, Boog CJ, et al. Antigen-activated T cells inhibit cartilage proteoglycan synthesis independently of T-cell proliferation. Scand J Immunol 1992; 36: 73343.
  • 23
    Bush KA, Walker JS, Lee CS, Kirkham BW. Cytokine expression and synovial pathology in the initiation and spontaneous resolution phases of adjuvant arthritis: interleukin-17 expression is upregulated in early disease. Clin Exp Immunol 2001; 123: 48795.
  • 24
    Szekanecz Z, Halloran MM, Volin MV, Woods JM, Strieter RM, Kenneth Haines G 3rd, et al. Temporal expression of inflammatory cytokines and chemokines in rat adjuvant-induced arthritis. Arthritis Rheum 2000; 43: 126677.
  • 25
    Konttinen YT, Hukkanen M, Segerberg M, Rees R, Kemppinen P, Sorsa T, et al. Relationship between neuropeptide immunoreactive nerves and inflammatory cells in adjuvant arthritic rats. Scand J Rheumatol 1992; 21: 559.
  • 26
    Kojima T, Mwale F, Yasuda T, Girard C, Poole AR, Laverty S. Early degradation of type IX and type II collagen with the onset of experimental inflammatory arthritis. Arthritis Rheum 2001; 44: 1207.
  • 27
    Van Eden W, Thole JE, van der Zee R, Noordzij A, van Embden JD, Hensen EJ, et al. Cloning of the mycobacterial epitope recognized by T lymphocytes in adjuvant arthritis. Nature 1988; 331: 1713.
  • 28
    Van Eden W. Heat shock protein in autoimmune arthritis: a critical contribution based on the adjuvant arthritis model. APMIS 1990; 98: 38394.
  • 29
    Van Eden W. Heat-shock proteins as immunogenic bacterial antigens with the potential to induce and to regulate autoimmune arthritis. Immunol Rev 1991; 121: 528.
  • 30
    Kleinau S, Erlandsson H, Holmdahl R, Klareskog L. Adjuvant oils induce arthritis in the DA rat. I. Characterization of the disease and evidence for an immunological involvement. J Autoimmun 1991; 4: 87180.
  • 31
    Holmdahl R, Goldschmidt TJ, Kleinau S, Kvick C, Jonsson R. Arthritis induced in rats with adjuvant oil is a genetically restricted α/β-T-cell dependent autoimmune disease. Immunology 1992; 76: 197202.
  • 32
    Vingsbo C, Sahlstrand P, Brun JG, Jonsson R, Saxne T, Holmdahl R. Pristane-induced arthritis in rats: a new model for rheumatoid arthritis with a chronic disease course influenced by both major histocompatibility complex and non-major histocompatibility complex genes. Am J Pathol 1996; 149: 167583.
  • 33
    Carlsson BC, Jansson ÅM, Larsson A, Bucht A, Lorentzen JC. The endogenous adjuvant squalene can induce a chronic T cell mediated polyarthritis in rats. Am J Pathol 2000; 156: 205765.
  • 34
    Francis JN, Lamont AG, Thompson SJ. The route of administration of an immunodominant peptide derived from heat-shock protein 65 dramatically affects disease outcome in pristane-induced arthritis. Immunology 2000; 99: 33844.
  • 35
    Dulphy N, Peyrat MA, Tieng V, Douay C, Rabian C, Tamousza R, et al. Common intra-articular T cell expansions in patients with reactive arthritis: identical beta-chain junctional sequences and cytotoxicity toward HLA-B27. J Immunol 1999; 162: 383039.
  • 36
    Mertz AK, Wu P, Sturniolo T, Stoll D, Rudwaleit M, Lauster R, et al. Multispecific CD4+ T cell response to a single 12-mer epitope of the immunodominant heat-shock protein 60 of Yersinia enterocolitica in Yersinia-triggered reactive arthritis: overlap with the B27-restricted CD8 epitope, functional properties, and epitope presentation by multiple DR alleles. J Immunol 2000; 164: 152937.
  • 37
    Holoshitz J, Klajman A, Drucker I, Lapidot Z, Yaretzky A, Frenkel A, et al. T lymphocytes of rheumatoid arthritis patients show augmented reactivity to a fraction of mycobacteria cross-reactive with cartilage. Lancet 1986; 2: 3059.
  • 38
    Holoshitz J, Koning F, Coligan JE, De Bruyn J, Strober S. Isolation of CD4- CD8- mycobacteria-reactive T lymphocyte clones from rheumatoid arthritis synovial fluid. Nature 1989; 339: 2269.
  • 39
    Gery I, Waksman BH. Studies on the mechanism whereby adjuvant disease is suppressed in rats pretreated with mycobacteria. Int Arch Allergy 1967; 31: 5768.
  • 40
    Van Eden W, Anderton SM, van der Zee R, Prakken BJ, Broeren CP, Wauben MH. (Altered) self peptides and the regulation of self reactivity in the peripheral T cell pool. Immunol Rev 1996; 149: 5573.
  • 41
    Van Eden W. Immunity to heat shock proteins and arthritic disorders. Infect Dis Obstet Gynecol 1999; 7: 4954.
  • 42
    Wauben MHM, Boog CJP, van der Zee R, Joosten I, Schlief A, van Eden W. Disease inhibition by major histocompatibility complex binding peptide analogues of disease-associated epitopes: more than blocking alone. J Exp Med 1992; 176: 66777.
  • 43
    Prakken BJ, Roord S, van Kooten PJS, Wagenaar JPA, van Eden W, Albani S, et al. Inhibition of adjuvant-induced arthritis by interleukin-10–driven regulatory cells induced via nasal administration of a peptide analog of an arthritis-related heat-shock protein 60 T cell epitope. Arthritis Rheum 2002; 46: 193746.
  • 44
    Van Eden W, van der Zee R, Taams LS, Prakken AB, van Roon J, Wauben MH. Heat-shock protein T-cell epitopes trigger a spreading regulatory control in a diversified arthritogenic T-cell response. Immunol Rev 1998; 164: 16974.
  • 45
    Anderton SM, van der Zee R, Prakken B, Noordzij A, van Eden W. Activation of T cells recognizing self 60-kD heat shock protein can protect against experimental arthritis. J Exp Med 1995; 181: 94352.
  • 46
    Moudgil KD, Chang TT, Eradat H, Chen AM, Gupta RS, Brahn E, et al. Diversification of T cell responses to carboxy-terminal determinants within the 65-kD heat-shock protein is involved in regulation of autoimmune arthritis. J Exp Med 1997; 185: 130716.
  • 47
    Wendling U, Paul L, van der Zee R, Prakken B, Singh M, van Eden W. A conserved mycobacterial heat shock protein (hsp) 70 sequence prevents adjuvant arthritis upon nasal administration and induces IL-10-producing T cells that cross-react with the mammalian self-hsp70 homologue. J Immunol 2000; 164: 27117.
  • 48
    Prakken BJ, Wauben M, van Kooten P, Anderton S, van der Zee R, Kuis W, et al. Peptide-induced nasal tolerance for a mycobacterial heat shock protein 60 T cell epitope in rats suppresses both adjuvant arthritis and nonmicrobially induced experimental arthritis. Proc Natl Acad Sci U S A 1997; 94: 32849.
  • 49
    Feige U, van Eden W. Infection, autoimmunity and autoimmune disease. Experientia 1996; 77: 35973.
  • 50
    Van Tienhoven E, van Kooten PJ, Veenstra JG, van der Hage MH, van Eden W, Broeren CP. Induction of experimental autoimmune arthritis by a public epitope of the T cell receptor variable alpha domain of an arthritogenic T cell clone. Eur J Immunol 2000; 30: 216471.
  • 51
    Broeren CPM, Lucassen MA, van Stipdonk MJB, van der Zee R, Boog CJP, Kusters JG, et al. CDR1 T-cell receptor β-chain peptide induces major histocompatibility complex class II-restricted T-T cell interactions. Proc Natl Acad Sci U S A 1994; 91: 59976001.
  • 52
    Grippenberg-Lerche C, Toivanen A, Toivanen P. Yersinia-associated arthritis in rats: effect of 65 kDa heat shock protein, bovine serum albumin and incomplete Freund's adjuvant. Clin Exp Rheumatol 1995; 13: 3215.
  • 53
    Paul AG, van Der Zee R, Taams LS, van Eden W. A self-hsp60 peptide acts as a partial agonist inducing expression of B7-2 on mycobacterial hsp60-specific T cells: a possible mechanism for inhibitory T cell regulation of adjuvant arthritis? Int Immunol 2000; 12: 104150.
  • 54
    Thompson SJ, Francis JN, Siew LK, Webb G, Jenner R, Colston PJ, et al. An immunodominant epitope from mycobacterial 65-kDa heat shock protein protects against pristane-induced arthritis. J Immunol 1998; 160: 462834.
  • 55
    Kingston AE, Hicks CA, Colston MJ, Billingham ME. A 71-kD heat shock protein (hsp) from Mycobacterium tuberculosis has modulatory effects on experimental rat arthritis. Clin Exp Immunol 1996; 103: 7782.
  • 56
    Prakken BJ, Wendling U, van der Zee R, Rutten VP, Kuis W, van Eden W. Induction of IL-10 and inhibition of experimental arthritis are specific features of microbial heat shock proteins that are absent for other evolutionarily conserved immunodominant proteins. J Immunol 2001; 167: 414753.
  • 57
    Tanaka S. Activation of T cells recognizing an epitope of heat shock protein 70 can protect against rat adjuvant arthritis. J Immunol 1999; 163: 55605.
  • 58
    Boog CJ, de Graeff-Meeder ER, Lucassen MA, van der Zee R, Voorhorst-Ogink MM, van Kooten PJ, et al. Two monoclonal antibodies generated against human hsp60 show reactivity with synovial membranes of patients with juvenile chronic arthritis. J Exp Med 1992; 175: 180510.
  • 59
    Santori FR, Brown SM, Vukmanovic S. Genomics-based identification of self-ligands with T cell receptor-specific biological activity. Immunol Rev 2002; 190: 14660.
  • 60
    Kingsbury DJ, Mear JP, Witte DP, Taurog JD, Roopenian DC, Colbert RA. Development of spontaneous arthritis in β2-microglobulin–deficient mice without expression of HLA–B27: association with deficiency of endogenous major histocompatibility complex class I expression. Arthritis Rheum 2000; 43: 22906.
  • 61
    Guerassimov A, Zhang Y, Banerjee S, Cartman A, Webber C, Esdaile J, et al. Autoimmunity to cartilage link protein in patients with rheumatoid arthritis and ankylosing spondylitis. J Rheumatol 1998; 25: 14804.
  • 62
    Ullmansky R, Cohen CJ, Szafer F, Moallem E, Fridlender ZG, Kashi Y, et al. Resistance to adjuvant arthritis is due to protective antibodies against heat shock protein surface epitopes and the induction of IL-10 secretion. J Immunol 2002; 168: 64639.
  • 63
    Ragno S, Colston MJ, Lowrie DB, Winrow VR, Blake DR, Tascon R. Protection of rats from adjuvant arthritis by immunization with naked DNA encoding for mycobacterial heat shock protein 65. Arthritis Rheum 1997; 40: 27783.
  • 64
    Quintana FJ, Carmi P, Mor F, Cohen IR. Inhibition of adjuvant arthritis by a DNA vaccine encoding human heat shock protein 60. J Immunol 2002; 169: 34228.
  • 65
    Wills-Karp M, Santeliz J, Karp CL. The germless theory of allergic disease: revisiting the hygiene hypothesis. Nat Rev Immunol 2001; 1: 6975.
  • 66
    Khoury SJ, Lider O, al-Sabbagh A, Weiner HL. Suppression of experimental autoimmune encephalomyelitis by oral administration of myelin basic protein. III. Synergistic effect of lipopolysaccharide. Cell Immunol 1990; 131: 30210.
  • 67
    Sudo N, Sawamura S, Tanaka K, Aiba Y, Kubo C, Koga Y. The requirement of intestinal bacterial flora for the development of an IgE production system fully susceptible to oral tolerance induction. J Immunol 1997; 159: 173945.
  • 68
    Nieuwenhuis EES, Visser MR, Kavelaars A, Cobelens PM, Fleer A, Harmsen W, et al. Oral antibiotics as a novel therapy for arthritis: evidence for a beneficial effect of intestinal Escherichia coli. Arthritis Rheum 2000; 43: 25839.
  • 69
    Cobelens PM, Heijnen CJ, Nieuwenhuis EES, Kramer PPG, van der Zee R, van Eden W, et al. Treatment of adjuvant-induced arthritis by oral administration of mycobacterial Hsp65 during disease. Arthritis Rheum 2000; 43: 2694702.
  • 70
    Cobelens PM, Kavelaars A, Vroon A, Ringeling M, van der Zee R, van Eden W, et al. The beta2-adrenergic agonist salbutamol potentiates oral induction of tolerance suppressing adjuvant arthritis and antigen-specific immunity. J Immunol 2002; 169: 502835.
  • 71
    Van Eden W, Wendling U, Paul L, Prakken B, van Kooten P, van der Zee R. Arthritis protective regulatory potential of self-heat shock protein cross-reactive T cells. Cell Stress Chaperones 2000; 5: 4527.
  • 72
    Waksman B, Isakovic K. Effect of sensitization to BSA on adjuvant disease in normal and neonatally thymectomized rats. Proc Soc Exp Biol Med 1965; 119: 6768.
  • 73
    Gery I, Waksman BH. Competition of antigens in adjuvant disease of rats. Arthritis Rheum 1967; 10: 2404.
  • 74
    McMenamin C, McKersey M, Kuhnlein P, Hunig T, Holt PG. Gamma delta T cells down-regulate primary IgE responses in rats to inhaled soluble protein antigens. J Immunol 1995; 154: 43904.
  • 75
    Sano G, Hafalla JC, Morrot A, Abe R, Lafaille JJ, Zavala F. Swift development of protective effector functions in naïve CD8+ T cells against malaria liver stages. J Exp Med 2001; 194: 1739.
  • 76
    Hogervorst EJ, Schouls L, Wagenaar JP, Boog CJ, Spaan WJ, van Embden JD, et al. Modulation of experimental autoimmunity: treatment of adjuvant arthritis by immunization with a recombinant vaccinia virus. Infect Immun 1991; 59: 202935.
  • 77
    Lopez-Guerrero JA, Ortiz MA, Paez E, Bernabeau C, Lopez-Bote JP. Therapeutic effect of recombinant vaccinia virus expressing the 60-kd heat-shock protein on adjuvant arthritis. Arthritis Rheum 1994; 37: 14627.
  • 78
    Goupille P, Poet JL, Jattiot F, Mattei JP, Vedere V, Tonolli-Serabian I, et al. Three cases of arthritis after BCG therapy for bladder cancer. Clin Exp Rheumatol 1994; 12: 1957.
  • 79
    De Graeff-Meeder ER, van der Zee R, Rijkers GT, Schuurman HJ, Kuis W, Bijlsma JW, et al. Recognition of human 60 kD heat shock protein by mononuclear cells from patients with juvenile chronic arthritis. Lancet 1991; 337: 136872.
  • 80
    De Graeff-Meeder ER, van Eden W, Rijkers GT, Prakken BJ, Kuis W, Voorhorst-Ogink MM, et al. Juvenile chronic arthritis: T cell reactivity to human HSP60 in patients with a favorable course of arthritis. J Clin Invest 1995; 95: 93440.
  • 81
    Prakken AB, van Eden W, Rijkers GT, Kuis W, Toebes EA, de Graeff-Meeder ER, et al. Autoreactivity to human heat-shock protein 60 predicts disease remission in oligoarticular juvenile rheumatoid arthritis. Arthritis Rheum 1996; 39: 182632.
  • 82
    Gerli R, Pitzalis C, Bistoni O, Falini B, Costantini V, Russano A, et al. CD30+ T cells in rheumatoid synovitis: mechanisms of recruitment and functional role. J Immunol 2000; 164: 4399407.
  • 83
    Life P, Hassell A, Williams K, Young S, Bacon P, Southwood T, et al. Responses to gram negative enteric bacterial antigens by synovial T cells from patients with juvenile chronic arthritis: recognition of heat shock protein HSP60. J Rheumatol 1993; 20: 138896.
  • 84
    Corrigall VM, Bodman-Smith MD, Fife MS, Canas B, Myers LK, Wooley P, et al. The human endoplasmic reticulum molecular chaperone BiP is an autoantigen for rheumatoid arthritis and prevents the induction of experimental arthritis. J Immunol 2001; 166: 14928.
  • 85
    Van Roon J, van Eden W, van Roy J, Lafeber F, Bijlsma JWJ. Stimulation of suppressive T cell responses by human but not bacterial 60 kDa heat-shock protein in synovial fluid of patients with rheumatoid arthritis. J Clin Invest 1997; 100: 45963.
  • 86
    Bloemendal A, van der Zee R, Rutten VP, van Kooten PJ, Farine JC, van Eden W. Experimental immunization with anti-rheumatic bacterial extract OM-89 induces T cell responses to heat shock protein (hsp)60 and hsp70: modulation of peripheral immunological tolerance as its possible mode of action in the treatment of rheumatoid arthritis (RA). Clin Exp Immunol 1997; 110: 728.
  • 87
    Farine JC, Meredith M. Subreum and rheumatoid arthritis: a novel immunomodulating drug from Natural Product Developments. In: RainsfordKD, editor. Advances in antirheumatic therapy. Boca Raton (FL): CRC Press; 1996. p. 16780.