Download Critical Review A role for anti-HSP60 antibodies in arthritis: a critical review

Critical Review
A role for anti-HSP60 antibodies in arthritis:
a critical review
T Gelsing Carlsen1*, T Bennike1, G Christiansen2, S Birkelund1
Abstract
Introduction
As a result of the high sequence similarity between 60-kDa heat shock
proteins (HSP60), found in both
prokaryotic and eukaryotic cells, it
has been suggested, but never
concluded, that anti-HSP60 antibodies could be of importance in the
pathology of arthritis diseases
explained by a concept named molecular mimicry. In a number of clinical
studies, antibodies to both human
and bacterial HSP60 have been
detected in serum from patients with
different inflammatory diseases, but
divergent
results
have
been
published. Recent progress, however,
has increased the specificity in tests
used to determine the humoral
response to HSP60. In this review,
these new findings are compared
with old questioning the durability of
molecular mimicry as a hypothesis
for arthritis pathogenesis.
The current literature was examined
through a thorough PubMed search
using appropriate keywords in relation
to anti-HSP60 antibodies and arthritisrelated disease. Main research articles
were selected for review.
Discussion
Recent reports have added new information to the interpretation of the
humoral immune response to HSP60.
By introducing determination of IgG
*Corresponding author
Email: [email protected]
Department of Health Science and Technology, Fredrik Bajers Vej 3b, Denmark.
2
Department of Biomedicine – Medical Microbiology & Immunology, Aarhus University,
Denmark
1
subclasses by the ELISA (enzymelinked
immunosorbent
assay),
HSP60-specific antibodies were
shown to be predominantly of the
IgG1 and IgG3 isotypes for bacterial
and human HSP60, respectively,
thereby improving the strategy to
test the hypothesis of cross-reaction.
Conclusion
The hypothesis of molecular
mimicry comes from attempts to
link bacteria to the development of
arthritis. However, based on a critical investigation of the literature, it
is here argued that investigation on
the role of HSP60 in the development of arthritis in addition to antiHSP60, serology should include a
more functional study on how
HSP60 can reach the extracellular
locations and whether it is tolerogenic. Second, studies are needed
on how the different subclasses of
IgG-specific human HSP60 may
stimulate the immune environment
into an anti- or pro-inflammatory
state.
Introduction
A disease-related role for antibodies
against 60-kDa heat shock proteins
(anti-HSP60) in arthritis was
suggested in 1984 by Lakomek et al.1.
The group demonstrated by the use
of immunofluorescence staining that
antibodies from a significant amount
of sera from ankylosing spondylitis
(AS) patients (39% of 62 patients)
did bind antigens present in the puffs
generated in polytene chromosomes
of Drosophila melanogaster by heat
shock. These antigens were induced
from a specific locus (93D) by heat
shock and thus the proteins were
called HSPs2.
In bacteria, HSP60 is also called
GroEL, in which the L stands for large
as it represents the larger subunit of a
complex between two rings of 7
HSP60 subunits joined together with
a ring of GroES, the smaller subunit of
the complex (S for small) (Figure 1).
Similarly, in eukaryotic cells, HSP60 is
associated with HSP10, and the
complex is located within the mitochondrial matrix. The primary role of
HSP60 is to facilitate protein folding
inside the mitochondria. Therefore,
they have also been termed molecular chaperones, and HSP60 has
recently been renamed HSPD1 in a
new nomenclature3. In this review,
however, we will use bacterial and
human HSP60 throughout the article.
Proteins within the HSP60 family
are highly conserved, which from
alignment of the amino acid (aa)
sequence shows close to 50% identity
between bacterial and human HSP60.
The high homology led to the hypothesis that bacterial HSP60 might induce
a break in immune tolerance as a result
of molecular mimicry leading to autoimmunity4. Cross-reactivity between
bacterial and human antigens was first
suggested by Ebringer et al. who in an
attempt to link the presence of antibodies to Klebsiella and recurrent
inflammation in AS, suggested that
linear or conformational epitopes
common to microbial antigens and
host cell molecules would give rise to
autoimmunity through an immune
cross-reaction5. In the case of Ebringer
et al., it was suggested that the crossreaction was between a component of
gram-negative bacteria and human
leukocyte antigen B27 (HLA-B27) as
this antigen was found to be a major
susceptibility gene for AS5,6. HLA-B27
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Gelsing Carlsen T, Bennike T, Christiansen G, Birkelund S. A role for anti-HSP60 antibodies in arthritis: a critical review. OA Arthritis 2013 Jul 01;1(2):14.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Cellular & Molecular
Mechanisms
Page 1 of 7
Page 2 of 7
Figure 1: The structure of the E. coli GroEL–GroES protein complex. The
structure of the E. coli GroEL–GroES protein complex has been solved by X-ray
crystallography (PDB 1AON)32. (A) Its barrel-like appearance is created by 14
identical subunits of relative molecular mass of 58 kDa (GroEL also known as
HSP60) assembled as two heptameric rings stacked back to back (green and
blue, respectively). (B) Each subunit of HSP60 presents itself with three domains:
equatorial, intermediate and apical (not shown). On top of the hollow barrel, in
which protein folding is executed through specific interaction between
polypeptide and hydrophobic side groups, a heptameric ring or ‘cap’ (gray) of
seven identical 10 kDa subunits (GroES also known as HSP10) associates to
create the GroEL–GroES complex. The association of the HSP10 heptamer comes
with the cost of ATP and has an allosteric effect on the complex assuring proper
folding of the encapsulated polypeptide. Electron microscopy of the human
GroEL–GroES protein complex illustrates that human in contrast to the E. coli
complex, might be formed from one ring of 7 HSP60 subunits33. As for now, the
mammalian HSP60/HSP10 structure has not been solved.
encodes the �1 domain in a cell surface
molecule named major histocompatibility complex (MHC) class I.
Today, diverging reports have been
published on the pathogenic role of
antibodies to human HSP60 in
arthritis (Table 1). Moreover, it was
recently revealed that the mouse
model of arthritis poorly mimics the
human inflammatory disease7. This
critical review will first address
HSP60 biology and its interaction
with the immune system. Second, it
will discuss the literature regarding
anti-HSP60 cross-reactivity in human
clinical studies, and lastly end up
questioning its potential relevance as
a bacterial trigger of arthritis.
Discussion
The authors have referenced some of
their own studies in this review. These
referenced studies have been
conducted in accordance with the
Declaration of Helsinki (1964), and
the protocols of these studies have
been approved by the relevant ethics
committees related to the institution
in which they were performed. All
human subjects, in these referenced
studies, gave informed consent to
participate in these studies.
Human HSP60
The gene encoding human HSP60 is
located on chromosome 28. The
protein has a mitochondrial leader
sequence in its N-terminal end, indicating its role as an intra-mitochondrial protein. Human HSP60, most
likely released from damaged cells, is
found outside cells where it is able to
interact with cells of both the innate
and the adaptive immune system
(Figure 2)9. This suggests a multifunctional role for HSP60 and consequently introduces the concept of
moonlighting proteins reviewed in the
literature10. However, a defined mechanism for the transport of human
HSP60 to the membrane and across,
has yet to be determined in a healthy
mammalian cell. Some suggest that
human HSP60 can be transported in
extracellular vesicles called exosomes
with the involvement of lipid rafts11.
However, because exosomes have long
been seen as ‘cell garbage’, it is still a
new topic and not completely understood12. Also, a large part of HSP60
secretion has been observed from
cancer cells, in which alternative
forms of HSP60 transcripts are
suggested to lead the protein through
specific internal cellular membrane
structures referred to as the endoplasmic
reticulum
(ER)-Golgi
pathway13. However, we would suggest
not extracting conclusive content from
cancer research and apply it on normal
homeostasis and the secretary routes
of proteins.
A more clearly suggested mechanism is the release of human HSP60
from damaged or dead cells. Death of
cells can be either harsh or gentle to
the extracellular environment termed
necrosis or apoptosis, respectively.
Apoptosis is a well-defined process,
whereby the cell, as a result of an
unbalance between pro- and antiapoptotic members of the Bcl-2 family,
actively triggers a cascade of events
including mitochondrial cytochrome
C release and caspase-proteolysis14.
This ultimately leads to cell shrinking
and fragmentation into small
membrane-bound apoptotic bodies.
Compared with necrosis, the process
is gentle to the surroundings without
eliciting an inflammatory response.
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Gelsing Carlsen T, Bennike T, Christiansen G, Birkelund S. A role for anti-HSP60 antibodies in arthritis: a critical review. OA Arthritis 2013 Jul 01;1(2):14.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Critical Review
Page 3 of 7
Figure 2: Immunological interactions triggered by HSP60 biology. Cellular stress can be triggered by external changes in
pH, O2, from the presence of oxygen radicals, toxic metabolites from inflammation and the recognition of pathogen-associated
molecular patterns (PAMPs) through toll-like receptor 4 (a). This can cause a heat shock response and may lead to apoptosis or
necrosis of the cell, thereby releasing human HSP60 from the mitochondria into the extracellular space (b). A HSP60 peptide
from an intracellular bacterium gets presented on a MHC I molecule for CD8+ T cell recognition (c). A matured dendritic cell
(DC) presents a peptide derived from bacterial HSP60 to a CD4+ T cell in the lymph node (d). A population of activated and
clonally expanded CD4+ T cells also recognise the peptide of human HSP60 leading to an autoimmune reaction including IgGx
producing plasma cells specific for human HSP60 (e). IgGx antibodies to human HSP60 are potential targets for Fc receptors on
macrophages (mj) inducing the production of pro-inflammatory cytokines (interleukin (IL)-1, IL6 and tumor necrosis factor
(TNF) �) (f). Cytokines and extracellular hHSP60 further activate polymorphonuclear neutrophilic cells (PMNs) and
complement (g). Modified from expert reviews in molecular medicine, fig003jrl, ©2000 Cambridge University Press.
Finally, phagocytes take up the apoptotic bodies through recognition of
specific surface-associated phosphatidyl serine. Necrosis, on the other
hand, results in an uncontrolled
explosion of the cell, induced by outer
stimuli (figure 2a). The event causes
inflammation typically involving a
broad zone of cells and to us represents the most likely process by which
human HSP60 appears in the external
environment and triggers immune
reactions.
Bacterial HSP60
In some bacteria, HSP60 is an important virulence factor, where it functions as a factor for the survival of
bacteria and has a wide array of other
functions. HSP60 of Mycobacterium
tuberculosis, for example, inhibits
monocyte activation and acts as a key
signal for the generation of granulomas15. In Enterobacteraerogenes,
HSP60 is an insect neurotoxin16.
Furthermore, it has been observed on
the surface of several pathogens,
suggesting a role for attachment and
invasion acting as a potent target for
our immune system17. Largely based
on Escherichia coli studies, bacterial
HSP60 has been shown to be diffusely
distributed within the bacterial cytoplasm (matrix) and has been
observed to make a 20-fold increase
upon a heat shock18. Furthermore, no
members of the HSP60 family contain
a leader sequence or other recognis-
able motifs that would suggest a
secretory role.
Reactive arthritis (ReA), a subgroup
of the spondyloarthritis, represents
one of more than 100 different forms
of arthritis-related diseases. ReA is
defined as a non-purulent joint
inflammation that usually follows a
bacterial gastrointestinal (Campylobacter jejuni, Salmonella, Shigella) or
urogenital (Chlamydia trachomatis)
infection within a time-interval of 1–3
weeks. As for now, no viable bacteria
have ever been isolated from the
inflamed joints in this disease. Reports
that demonstrate presence of bacterial antigens in inflamed joints do not
contain evidence of bacterial
HSP6019,20. Therefore, if antibodies to
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For citation purposes: Gelsing Carlsen T, Bennike T, Christiansen G, Birkelund S. A role for anti-HSP60 antibodies in arthritis: a critical review. OA Arthritis 2013 Jul 01;1(2):14.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Critical Review
Page 4 of 7
human HSP60 have a link to a bacterial trigger, it must be a distant role.
The epitope recognised by antibodies on bacterial HSP60 consists of
a
three-dimensional
structure
presented on the protein surface
(also named a conformational
epitope). Before such antibodies can
be generated, an antigen-presenting
cell must take up the HSP60 protein
through a scavenger receptor, process
it and present a linear peptide in MHC
class II to a CD4+T cell (Figure 2d).
Hereby HSP60-specific CD4+ T cells
are amplified. In parallel, B cells
presenting antibodies specific for
HSP60 on their surface will take up
HSP60, process it and present a linear
fragment within MHC class II. This in
turn can lead to CD4+ T celldependent activation of the antigenspecific B cell. B cell activation is
executed through antigen recognition
and costimulatory molecules by
which plasma cells producing Ig
molecules of different classes are
generated through somatic hypermutation and switching (Figure 2e). In
that way, the IgG antibodies are
produced. IgG can be divided into
four subclasses, IgG1-4, which are
defined by a structural difference in
the Fc receptor. In a recent study21,22
HSP60 specific-antibodies were only
present in the IgG1 and IgG3 isotypes,
as discussed in the next section.
Cross-reaction of interspecies
HSP60
To investigate the hypothesis of
molecular mimicry and a diagnostic
potential of anti-HSP60 in arthritis,
several studies have used enzymelinked
immunosorbent
assay
(ELISA) in which detection of serum
antibodies against bacterial and
human HSP60 was measured for a
disease group and compared with a
healthy control group (the most
important findings are shown in
Table 1). In the majority of these
publications, indirect ELISA is used.
In indirect ELISA, the antigen is
immobilised and targeted with
serum antibodies followed by detection with conjugated antibodies
specific for the class of interest (e.g.
IgA, IgM, IgG) (Table 1). Measurements are carried out by optical
density (OD) readings, and the ELISA
is optimised for the best dynamic
range, with or without quantification. A significant correlation to
disease or difference between
disease and control of measured
antibody levels has generated information regarding the role of antihuman HSP60 antibodies in a
number of inflammatory diseases
(Table 1). However, in our opinion,
such results based on ELISA can be
questioned as will be discussed.
The first significant attempt to
assess the like of autoimmunity as a
result of cross-reaction between
bacterial
(Mycobacterium
bovis
MbHSP65) and human HSP60 was
carried out by Handley et al. in
199523. The use of a plasmid (pRSET)
that contained a 4.5 kDa fusion
peptide with a polyhistidine tail
made it possible to produce a pure
recombinant protein using metal ion
(Ni2+) affinity chromatography. By
generating specific antisera in
rabbits towards probability-selected
Table 1 Study overview: cross-reaction as a potential trigger in arthritis
Study
Method
HSP60 antigens
Inflammatory
disease
Tsoulfa et al.24
Indirect ELISA
IgGtotal
Mb HSP65
Ra
McLean et al.23
Indirect ELISA
IgGtotal
Mb HSP65
Ra & AS
Stevens et al.25
Indirect ELISA
IgA, M, IgGtotal
Mb HSP65
CD & UC
Larsen et al.34
Micro-IF
IgGtotal
GroEL
ReA
Handley et al.28
C-ELISA
IgGtotal
Mb HSP65
GroEL
Human
Ra, ReA, SLE &
TB
Pockley et al.35
Sandwich ELISA
IgGtotal
Mb HSP65
Human
Healthy
Domìnguez-Lòpez
et al.26
Indirect ELISA
IgGtotal
Kleibsiella pneumonia AS
Yersinia enterocolitica
Shigella flexneri
Escherichia coli
Salmonella typhi
Domínguez-López
et al.29
Streptococus pyogenes
AS
Bodnàr et al.27
Mb HSP65
AS
Hjelholt et al.
Human
Chlamydia
trachomatis
Salmonella
e.enteritidis
Campylobacter jejuni
TFI
36
Hjelholt et al.21
Gelsing Carlsen
et al.22
Indirect ELISA
IgGsubclasses
Axial SpA
AS, Ankolysing spondylitis; CD, Chron’s disease; Mb, mycobacterial; Ra, rheumatoid arthritis; ReA,
reactive arthritis; SpA, spondylo arthritis; SLE, systemic lupus; TB, active tuberculosis; TFI, tubal factor
infertility; UC, ulcerative colitis.
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Gelsing Carlsen T, Bennike T, Christiansen G, Birkelund S. A role for anti-HSP60 antibodies in arthritis: a critical review. OA Arthritis 2013 Jul 01;1(2):14.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Critical Review
Page 5 of 7
Critical Review
conformation of the antigen. Most
recombinant antigens are until 2009
purified under denaturing conditions29 leaving the purified antigen
misfolded (Table 1). This will cause
problems if the epitopes recognised
by the antibodies are conformational.
In the case of HSP60, the folding of
the protein is important for binding
of antibodies (Figure 3). Carlsen et al.
described a purification method
without prior denaturation of the
antigen22. To test the sensitivity of the
ELISA using a purified antigen, we
Figure 3: Comparison of ELISA results using either denatured or native
purified HSP60. A difference in antibody affinity for denatured (a) and nondenatured (b) HSP60 was evaluated from a serial two-fold dilution (1/20–1/80) of
serum treated with different concentrations of enzyme-conjugated sheep-antihuman IgG1 (1/2500–1/80,000). Each dot represents the mean of two measurements
supplied with the standard deviation. The serum sample was taken from an axial
SpA patient, who was tested seropositive for Campylobacter jejuni HSP60. The ELISA
plate was coated with 4 mg/ml denatured and non-denatured C. jejuni HSP60.
Coating was prepared on the same plate to reduce intra-assay variation.
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Gelsing Carlsen T, Bennike T, Christiansen G, Birkelund S. A role for anti-HSP60 antibodies in arthritis: a critical review. OA Arthritis 2013 Jul 01;1(2):14.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
surface-associated epitopes delivered subcutaneous as a peptide
conjugate, they were able to separate
an IgGtotal response to bacterial HSP60
from human HSP60. Also, they could
demonstrate that in serum IgGtotal
antibodies to human HSP60 were
significantly higher than IgGtotal antibodies to MbHSP65 in both normal
persons and in patients with Ra.
Finally, they demonstrated that
serum from Ra patients did not show
higher levels of such antibodies than
was found in normal serum samples.
These findings are regarded as the
first report questioning a bacterial
triggered HSP60 autoimmunity.
Probably because M. bovis cannot
induce rheumatoid arthritis (Ra),
several groups have hypothesised
cross-reactivity based simply on
ELISA. IgGtotal measurements have
revealed a relationship between
HSP60 antibodies and Ra, whether it
comes from an indirect, sandwich or
competitive ELISA (C-ELISA)23-27.
Such results are often inconclusive
because determination of IgGtotal may
mask differences that can be determined using subclass determination.
The lack of IgG subclass determination has in several cases shown correlations and thereby leads to the
assumption of molecular mimicry. In
one of these studies, antibodies to
human HSP60 correlated to antibacterial HSP60 antibodies (r2 =
0.735). More importantly, the correlation could be inhibited from a
C-ELISA in six different sera (not from
the same disease group) using soluble
bacterial HSP60 (E. coli) as a competitive antigen28. Had the authors determined IgG subclass antibodies to
HSP60, they may have changed their
conclusions. Not least because it was
noticed from the assay that the inhibition of anti-bacterial antibodies
was far better with bacterial HSP60
antigen than with human HSP60,
suggesting that a minority of the antibodies are cross-reacting.
An important part of generating
recombinant antigens for ELISA is the
Page 6 of 7
compared the native version of C.
jejuni HSP60 (A) with the denatured
protein (B) using dilution series of a
seropositive serum from a patient
with SpA. The measurements were
carried out in duplicates on the same
plate to diminish intra-assay variation. Results presented in Figure 3
show from the lines highlighted by
arrows that more sensitivity (based
on the slope steepness between two
measurements) is achieved from the
native antigen, and this is important
for obtaining the best resolution and
interpretation of ELISA measurements.
Because E. coli is used for producing
recombinant HSP60, it has been speculated that E. coli-derived lipopolysaccharide (LPS) contamination
could cause false-positive results in
the HSP60 ELISA. This, however, has
been ruled out from several experiments reviewed in the literature30. It
is now generally accepted that LPS
can be completely removed or
reduced to insufficient levels using
polymyxin B (an LPS-binding antibiotic) and therefore has no influence
on ELISA result. Moreover, the most
widely used E. coli clone for the
production of recombinant proteins,
BL21 is a rough mutant missing the
O-chain of LPS seen in wild type
E. coli. Therefore, the LPS is not
immunogenic, but the lipid-A part is
present, so it can activate toll-like
receptor 4 (TLR-4) in cellular
assays31.
In the publications by Hjelholt et al.
and Carlsen et al.21,22, it was found that
the dominant subclass for human
HSP60 in SpA is IgG3, while antibodies
to bacterial HSP60 were dominated by
IgG1 (Figure 4). In both studies, there
was a significant correlation between
SpA and IgG1 and IgG3 antibodies to
human HSP60 but either weak or no
correlation of SpA to antibodies to
bacterial HSP60. It was therefore
concluded that while antibodies
against human HSP60 are associated
with SpA and are predominantly of the
IgG3 subclass, antibodies against
HSP60 and SpA probably reflects a
general activation of the immune
system combined with increased
appearance of human HSP60 outside
inflammatory-associated
damaged
cells in the joints of patients with SpA.
Our studies showed that generation of antibodies to human HSP60
was independent of presence of antibodies to bacterial HSP60 and therefore the hypothesis of molecular
mimicry could not be supported.
Conclusion
Figure 4: IgG subclasses distribution to bacterial and human HSP60
in axial SpA patients. A bar diagram
illustrating the distribution of IgG
subclasses towards bacterial (Chlamydia trachomatis, Campylobacter
jejuni, Salmonella Enteritidis) and
human HSP60 in 82 patients with
axial SpA measured with ELISA21.
Here, the patients positive for antibodies to bacterial (the sum of all
anti-bacterial HSP60 antibodies) and
human HSP60 were evaluated based
on a cut-off value of OD>0.5. The percentage of seropositive for IgG1 and
IgG3 was calculated and compared
for bacterial and human HSP60.
bacterial HSP60 are predominantly of
the IgG1 subclass, indicating that there
is no cross-reaction, and a role for
anti-human HSP60 based on the ELISA
results cannot support molecular
mimicry as a pathogenic mechanism
for arthritis diseases. The study by
Hjelholt et al.21 showed in addition a
weak correlation between anti-human
HSP60 IgG3 and one of the several
disease parameters. This was not seen
in cohort study in which antibodies
were determined over time comprising
48% of the samples analysed, probably due to the reduced number of
patients participating in this study21,22.
The association between elevated
levels of antibodies against human
The hypothesis of molecular mimicry
comes from the attempt to link
bacteria to the development of
arthritis, but it is argued here that
investigation on HSP60 serology
should be switched to a more functional study on how HSP60 begins to
appear in the extracellular locations
and whether it is tolerogenic. Second,
it remains to be investigated how the
different subclasses of IgG specific for
human HSP60 may stimulate the
immune environment into an anti- or
pro-inflammatory state.
Abbreviations list
AS, ankylosing spondylitis; CD, chrons
disease; CD4, cluster of differentiation 4; C-ELISA, competitive enzymelinked immunsorbent assay; DC,
dendritic cell; HLA-B27, human
leukocyte antigen B27; HSP, heat
shock protein; Ig, immunoglobulin;
LPS, lipopolysaccharide; OD, optical
density; PAMPs, pathogen-associated
molecular patterns; Ra, rheumatoid
arthritis; ReA, reactive arthritis; SpA,
spondyloarthritis; TB, active tuberculosis; TFI, tubal factor infertility; TLR,
toll-like receptor; UC, ulcerative
colitis.
Acknowledgement
I would like to thank Professor Svend
Birkelund from the Department of
Health Science and Technology,
Section of Biomedicine, University of
Aalborg, Denmark, for his valuable
help and advice and Professor Gunna
Christiansen from the Department of
Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Gelsing Carlsen T, Bennike T, Christiansen G, Birkelund S. A role for anti-HSP60 antibodies in arthritis: a critical review. OA Arthritis 2013 Jul 01;1(2):14.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Critical Review
Page 7 of 7
Biomedicine, Section for Medical
Microbiology & Immunology, Aarhus
University Denmark for commenting
and making corrections. Finally, I
would like to thank Ph.D. student
RomanaMaric for proofreading.
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Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Gelsing Carlsen T, Bennike T, Christiansen G, Birkelund S. A role for anti-HSP60 antibodies in arthritis: a critical review. OA Arthritis 2013 Jul 01;1(2):14.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
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