Microsoft Word - 1.doc Correlation between some immunological Drs Nahida , Eman , Samira and Ali parameters and clinical presentation in RA patients J Fac Med Baghdad Vol. 50, No.2, 2008 235 Correlation between some immunological parameters and clinical presentation in RA patients Nahida R. Abbas* MSc Eman Sh. AL- Obeidy**M.Sc Samira N. AL- Naim***MSc Ali E. Kadim*"*BSc Summary: Background: Complement (C) & CRP in patients with Rheumatoid arthritis (RA)'could be trigger disease activity. Aim: To study the correlation between C, CRP, IgM,, IgG, IgA & some clinical presentation in RA patients. Methods: Latex agglutination test(AG) & single radial immunoassay(SRIA) were used to asses CRP, IgMJgGJgA,, C, in 74 patients with RA. Results: IgA & IgG were significantly increased, while the mean ofC3, C4 were slightly elevated in RA patients . Conclusion: There is correlation between IgG and IgM with joint deformity and joint swelling respectively, while C3 was showed statistically significant P<0.01 with joint stiffness, joint swelling and Rheumatoid nodule, where as CRP was statistically significant P<0.01withjoint swelling.. Key words : RA.C.CRP, IgM, IgG, IgA, SRI A, AG. Introduction: Rheumatoid arthritis (RA) is one of the mysterious autoimmune diseases which is still unresolved characterized by inflammation of synovial membrane, principally affecting peripheral joints in a symmetric fashion, commonly leads to cartilage destruction, bone erosion and joint deformities; extra-articular manifestations such as vasculitis and subcutaneous nodules can also occur, hence it's course is quite variable (1 -3). *MSc \ Immunology,Institute of medical technology/Al-Mansor. ** MSc \ Immunology, Medical city, ***MSc \ Microbiology,Institute of medical technology/Al-Mansor. ****BSc \ Microbiology,Institute of medical technology/Al-Mansor The pathogenesis of RA is incompletely understood ,although there is evidence that cytokines such as tumor necrosis factor a & interleukin-1 are involved (4). Furthermore, there is substantial evidence that the complement system(C) is also involved in the pathogenesis of RA(5-9),Increased level of C products in the serum & synovial fluid of RA patients (7,8) and correlate with disease activity(9).There are many factors that trigger complement activation in RA patients ,one of these may be C-reactive protein(CRP), since this acute phase protein can activate C. Original Article Fac Med Baghdad 2008; Vol.50, No.2 Received July 2006 Accepted Jun.2007 Correlation between some immunological Drs Nahida , Eman , Samira and Ali parameters and clinical presentation in RA patients J Fac Med Baghdad Vol. 50, No.2, 2008 236 Patients & Methods Patients: Seventy four patients (19 male, 55 female) with RA who met the American College of Rheumatology (ACR)1987revised criteria (10) attending the rheumatology consultation clinic or admitted to Baghdad Teaching Hospital in a period between November 2001 and February 2002 . Fifty patients clinically diagnosed with SLE according to ACR criteria 1997 for classification of SLE (11), thirty healthy individuals chosen from blood bank donors, who have no history or clinical evidence of RA or any chronic disease as a control groups .They were age and sex matched. Laboratory investigation: Serum C3&C4 complement components & IgM, IgG, IgA were measured using the single radial immunoassay method, and results were expressed in mg / dl ,while CRP was detected by latex agglutination test and results were expressed in mg / L . Results From 74 RA patients studied , the ratio male to female was 1:2.9 with mean age 42.1±11.Syr (range 18-67 )as shown in table 1&2. Table 1: Age distribution of studied groups. RA SLE Healthy control Age in years N % N % N % <20 1 1.4 4 8.0 2 6.7" 20-29 9 12.2 18 36.0 6 20.0 30-39 23 31.0 17 34.0 13 43.3 40-49 19 25.7 10 20.0 7 23.3 50-59 16 21.6 1 2.0 2 6.7 60+ 6 8.1 Total 74 100.0 50 100.0 30 100.0 Range 18-67 9-59 18-56 Mean 42.1 30.6 33.8 . SD 11.3 10.1 9.4 P (ANOVA) < 0.001 Correlation between some immunological Drs Nahida , Eman , Samira and Ali parameters and clinical presentation in RA patients J Fac Med Baghdad Vol. 50, No.2, 2008 237 . Table 2: Distribution of the studied groups by gender. RA SLE Healthy control N % N % N % Gender Female 55 74.3 44 88 23 76.7 Male 19 25.7 6 12 7 23.3 Total 74 100 50 100 30 100 Total Igs concentration level-s of IgA & IgG were significantly increased compared to healthy control (pO.OOl ,0.006 ) respectively while there was no difference in comparison to SLE patients, where as IgM level was normal in all studied groups as shown in table 3. Table 3 The difference in mean serum Immunoglobulin concentration (mg/d!) between studied groups. Serum Igs (mg/dl) RA (n=74) SLE (n=50) Healthy control (n=30) P(ANOVA) Serum IgA <0.001 Range 62.3-633.3 . 48-633.3 90-540 Mean 350.9 358.3 208.8 SD 129.3 174.7 105.9 Serum IgG 0.006 Range 643.7-2965.9 295.9-3042.3 700-1614.6 Mean 1462.8 1481 1114.5 SD 515.9 728.2 282.9 Serum IgM .0.43WSJ Range 48.1-277.3 40.8-277.3 93.2-205.2 Mean 151.6 140.5 146.1 * * * SD 48.9 49.9 33.1 * Normal range of Igs IgA: 90-540 mg/dl IgG: 700-1620 mg/dl IgM: 50-250 mg/dl Correlation between some immunological Drs Nahida , Eman , Samira and Ali parameters and clinical presentation in RA patients J Fac Med Baghdad Vol. 50, No.2, 2008 238 The mean of C3, C4 were slightly elevated in RA patients as shown in table 4 in comparison with healthy control, it was significantly difference higher PO.OOl in comparison to SLE patients group. . Table 4: Serum complement component concentration (mg/dl) levels in studied groups. Serum complement cone, (mg/dl) RA (n=74) SLE (n=50) Healthy control (n=30) P (ANOVA) Serum C3 <0.001 Range 35-260 ' 22.5-220 94.8-250 Mean 144.5 96.6 146.6 SD 43.8 47.4 44.8 Serum C4 <0.001 Range 8.3-84.9 2.5-70 20-72 Mean 32.6 19.5 33.1 * it SD 15.4 14.4 12.1 • Normal range C3: 84-250 mg/dl C4: 20-72 mg/dl Table 5 was showed that the mean of CRP levels was significantly higher than in control groups pO.OOl. Table 5: The difference in the mean of parameters between RA patients & control group. Parameters RA (n=74) SLE (n=50) Healthy control (n=30) P (ANOVA) C reactive protein (mg/L) <0.001 Range 5-96 • 5-12 5-5 Mean 17.6 ±18.4 6.4±2.5 5.0 * Normal range CRP> 6 mg/L Comparing the presence or absence of certain clinical criteria with positivity rate of different parameters as clearly seen in table 6 was showed statistically significant P<0.05 of IgG and IgM with joint deformity and joint swelling respectively, while C3 was showed statistically significant PO.01 with joint stiffness, joint swelling and Rheumatoid nodule, where as CRP was statistically significant PO.01 with joint swelling while others such as IgA and C4 was showed with no statistically significant with any one of these clinical criteria Correlation between some immunological Drs Nahida , Eman , Samira and Ali parameters and clinical presentation in RA patients J Fac Med Baghdad Vol. 50, No.2, 2008 239 Discussion: In this study 19 patients were male while 55were female with ratio 1:2.9 which is comparable to other Iraqi study 1:2.7 reported- by Ubaid ( 12 ) and Constantine 1:3.4 abroad ( 13 ) this is generally accepted to be related to sex hormones eg. Estrogen . Our data show that patients with RA have elevated levels of IgA&JgG were similar to other study (14), possible explanation of the above data propose that high level of IgG related to denaturation of IgG during initiation phase, while IgA concentration is proportionally associated with it's consumption in the synovium may be due to alternative pathway complement activation which confirmed by increased level of C3 in the patients sera. This explain the correlation between C3 complement component level and certain clinical features such as joint stiffness, joint swelling, and rheumatoid nodules which might be related to C. activation and increased opsonization of immune complexes by phagocytosis which is due to cellular infiltration in the synovium by the action of anaphylatoxins complement component resulting in fluid accumulation and hence swelling and stiffness, on the other hand cellular infiltration in extra-articular areas may be lead to nodules formation, these finding supported by Abbink,( 15 ) which showed that there was a good contribution between C. component action and damage in arthritis. Hence it is very logic to see in this study as well as abroad studies ( 16, 17 ), that increased level of serum complement components C3 & C4 were evidently noticed. Assessment Of serum concentration of CRP has been advocated as a objective measure of disease activity in RA patients , so elevated level were found to be correlated with joint swelling, this may be due to byproduct C. activation which is again a possible reason for swelling of the joint, this is quite accord with abroad studies (17, 18). In conclusion, we found evidence of complement activation C3 in RA patients & also CRP this acute phase protein should be considered an inflammation mediation in this disease. Table 6: Correlation between different parameters with certain clinical criteria.. Parameters Clinical criteria IgA JgG IgM C3 C4 CRP Joint stiffness Io.ll3 0.05 0.142 0.298 ** 3.158 0.102 Joint swelling 0.183 0.09 0.245 * 0.313 ** 0.077 0.385** Joint deformity 0.101 0.242 * 0.017 0.162 0.019 0.15 • Rheumatoid nodule 0.121 0.164 0.183 0.302 ** 0.14 0.128 Joint effusion 0.199 0.105 0.101 0.086 0.063 0.079 • * correlation significant at the 0.05 level ** correlation significant at the 0.01 level Correlation between some immunological Drs Nahida , Eman , Samira and Ali parameters and clinical presentation in RA patients J Fac Med Baghdad Vol. 50, No.2, 2008 240 REFERENCES . 1-Henry JB. Clinical diagnosis • and management by Laboratory methods. WB Saunders company. 19th ed. Philadephia. 1996: pp 1019-20. 2-Peakman M, Vergani D. Rheumatic diseases. In: Basic and Clinical immunology. 1997: 170-175. 3-Anderson RJ. Rheumatoid arthritis, Clinical and laboratory Features. In: Klippel J H, Crofford L J, Stone J H, ei'al. Primer on the Rheumatic Diseases. 12th edit. Atlanta Georgia-Arthritis Foundation. 2001;218-225. t 4-Fox DA.Cytokine blockade as a new strategy to treat rheumatoid arthritis: inhibition of tumor necrosis factor . Arch Intern Med 2000; 160:437-44. 5- Brodeur JP, Ruddy S, Schwartz LB, Moxley G. Synovial fluid levels of • complement SC5 b-9 and fragment Bb are elevated in patients with rheumatoid arthritis. Arthritis Rheum. 1991; 34:1531-7. , 6-Abbink JJ, Kamp AM, Nuijens JH, Eerenberg AJM, Swaak AJG, Hack CE. Relative contribution of contact and complement activation to inflammatory reactions in arthritic joints. Ann Rheum Dis. 1992;51:1122-8. 7-Swaak AJG, van Rooijen A, Planten O. Han H, Hattink O, Hack E. An analysis of the levels of complement components in the synovial fluid in rheumatic diseases. Clin Rheumatol. 1987; 22:350-7 8-Shingu M, Nagai Y, Isayama T, Naono T, Nobunaga M, Nagai Y. The effects of cytokines on metalloproteinase inhibitors (TIMP) and collagenase production by human chondrocytes and TIMP production by synovial cells and endothelial cells. Clin Explmmunol. 1993; 94:145.9. 9-Makinde VA, Senaldi G, Jaward AS. Berry H, Vergani D. Reflection of disease activity in rheumatoid arthritis by indices of activation of the classical complement pathway. Ann Rheum Dis. 1989; 48:302-6. 10:Arnett FC, Edworthy SM, Bloch DA, Mc.Shane DJ, Fries JF, Cooper NS. et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315-24. ' 11-Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of Systemic lupus erthymatosus. Arthritis and Rheum. 1997; 40: (1725-1734). 12-Ubaid AH: Formal education level as a marker of clinical status in RA among Iraqis. A thesis submitted to the college of Medicine, University of Baghdad for the partial fulfillment of the Master Degree in Community Medicine (1996). 13- Constantin A, Cances VL, Navaux F, et al. Stromelysin 1 (Mafrix Metalloproteinase 3) and HLA-DRB1 Gene Polymorphisms- J. Arth. & Rheum. 2002; 46(7): 1754-62. 14-Jorgensen C, Legouffe MC, Bolongna C, Brochier J. Sany J. IgA isotypes rheumatoid factor in rheumatoid arthritis: Clinical implications. Clin. Exp. Rheumatol. 1996; 14(3):301-4. i 15-Abbink JJ, Kamp AM, Nuijens JH, Eerenberg AJM, Swaak AJG, Hack CE. Relative contribution of contact and complement activation to inflammatory reactions in arthritic joints. Ann Rheum Dis. 1992;51:1122-8. . 16-Makinde VA, Senaldi G, Jaward AS. Berry H, Vergani D. Reflection of disease activity in rheumatoid arthritis by indices of activation of the classical complement pathway. Ann Rheum Dis. 1989; 48:302-6. 17-Molenaar ET, Voskuyl AE, Familian A, van- Mierlo GJ, Dijkmans BA, Hack CE. Complement Activation in patients with Rheumatoid Arthritis Mediated in Part by C- Reactive Protein. Arthritis Rheum. 2001; 44(5):997-02. 18-Wolbink GJ, Brouwer MC, Buysman S.ten Berger IJM, Hack CE. CRP- mediated activation of complement invivo: assessment by measuring circulating complement- C- reactive protein complexes. J. Immunol. 1996; 157:473-9.