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The Journal of Immunology, 1998, 160: 3737-3742.
Copyright © 1998 by The American Association of Immunologists

TCR Usage by Homocysteine-Specific Human CTL1

Myo-Myo Chilvers, Paul Wordsworth*, Andy Stubbs2 and Xiao-Ming Gao3

Department of Biochemistry, Imperial College of Science, Technology and Medicine, London, and * Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, United Kingdom


    Abstract
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
We have recently demonstrated that homocysteine can modify HLA class I Ags and induce homocysteine-specific CTL (Hom-CTL) responses in humans. Here, we have investigated TCR usage by Hom-CTL from five patients with ankylosing spondylitis or reactive arthritis. TCR of HLA-A68-restricted Hom-CTL from two unrelated donors share the same TCR V{alpha}, Vß, and Jß gene segments (AV4, BV23, and BJ2S1, respectively) with similar third complementarity determining regions (CDR3) of the ß-chains. Interestingly, the V{alpha} and Vß gene segments employed by an HLA-B27-restricted Hom-CTL clone are also closely related to AV4 and BV23, indicating strong selection pressure for AV4, BV23, and related gene products in the homocysteine-specific TCR. An arginine or lysine residue frequently appeared at position {alpha}93 in the CDR3 of the TCR {alpha}-chains from Hom-CTL restricted by HLA-A68 or -B8. This may suggest a potential salt bridge between the carboxyl group of homocysteine and specific TCR. TCR usage by HLA-B27-restricted Hom-CTL from unrelated individuals appears to be less conserved, although two T cell clones from one individual rearranged the same V gene segments with identical lengths of CDR3. Implications of these data for the molecular mechanisms for homocysteine modification of HLA Ags are also discussed.


    Introduction
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Homocysteine is an important metabolite of the transsulfuration pathway, a chief route of disposal of methionine, which converts the sulfur atom of methionine into that of cysteine (1). In humans, about 15 to 20 mmol of homocysteine is formed each day, and plasma homocysteine concentration is approximately 10 to 12 µM in middle-aged subjects (1, 2, 3). Many factors can affect the levels of plasma homocysteine, including age, gender, renal function, disorders of the transsulfuration pathway, and intake of folate and vitamin B12 (1, 2, 3). Homocysteine of high concentration can cause damage to the endothelium of blood vessels, although its mechanism is unclear (3). Moderate hyperhomocysteinemia, which occurs in about 10% of the Caucasian population, is an independent risk factor for cardiovascular diseases (3, 4, 5).

HLA class I Ags are expressed on the surface of virtually all nucleated cells in the body, and their function is to present endogenously produced protein fragments to CD8+ CTL. We have recently shown that homocysteine can modify, through disulfide bonding, class I HLA Ags (e.g., HLA-B27, -A68, and -B8) of the cell (6). We have also identified CTL, in patients with ankylosing spondylitis (AS)4 or reactive arthritis (ReA) and also in some healthy subjects, that are capable of specifically lysing autologous B cells that had been treated with homocysteine in vitro (6). It is reasonable to suggest that homocysteine-specific CTL (Hom-CTL) may play an important part in homocysteine-mediated damage to tissues (e.g., blood vessel endothelium or synovial membrane) in vivo. Their presence may also be related to the development of autoimmune diseases. Further understanding of the nature of these CTL is therefore of significance. In this study, we have analyzed TCR usage by Hom-CTL from five patients with AS or ReA.


    Materials and Methods
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Subjects and generation of Hom-CTL in vitro

Five patients suffering from either AS (CR, MM, and MT) or ReA (AB and BD) were included in this study; their tissue type for HLA-A and -B alleles are shown in Table IGo. Isolation of Hom-CTL from PBL was as previously described (6). Briefly, PBL from donors were cultured (2 x 106 cells/well, 24-well Costar plates) in RPMI 1640 supplemented with 10% FCS, glutamine, penicillin, and streptomycin (Sigma Chemical, Poole, U.K.) (R10) in the presence of DL-homocysteine (250 µM, Sigma) for 5 days. Recombinant human IL-2 (rhIL-2, a gift from EuroCetus, Amsterdam, The Netherlands) was added to a final concentration of 10 U/ml on day 3. These cultures were restimulated twice with homocysteine-treated (5 mM, overnight at 37°C in R10), irradiated (3000 rad), autologous PBL (2 x 106 cells) and rhIL-2 before being tested for specific cytotoxicity. Immortal B cell lines (BCL) were developed by EB virus transformation of fresh PBL. C1R cells, a mutant human BCL that expresses HLA-C molecules and B35 at very low level, were transfected with HLA-B2705, -B8, or -A68 genes as previously described (6). CTL cultures were tested for specificity in standard 51Cr release assays using homocysteine-treated autologous BCL or C1R cells expressing appropriate HLA Ags as target cells (see below).


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Table I. TCR {alpha}- and ß-chain usage by Hom-CTL1

 
In an earlier survey, Hom-CTL were identified in 2 of more than 20 healthy individuals tested in our laboratory. One of these CTL lines, ET Hom-CTL, was included for TCR analysis.

Cloning of Hom-CTL

Hom-CTL clones were obtained by limiting dilution of specific CTL in 96-well round-bottom plates (Nunc) at 0.3, 1, 10, and 30 cells/well in the presence of 5 x 103 autologous B cells (treated overnight with 5 mM homocysteine), 2 x 104 allogeneic PBL from three donors, PHA (Wellcome, Dartford, U.K.) at 1 µg/ml, and rhIL-2 at 10 U/ml. The feeder cells were irradiated (3000 rad) immediately before being used. The T lymphocytes were fed twice using a similar mixture of feeder cells and rhIL-2 but in the absence of PHA. Cells that grew after two rounds of restimulation were transferred to 24-well plates (Costar) for expansion and specificity testing. The T cell clones were maintained in vitro by weekly restimulation with homocysteine-treated autologous BCL and rhIL-2 for up to 1 month.

51Cr release assays

BCL or C1R transfectant cells (2 x 106) were treated, or not treated, with DL-homocysteine overnight (5 mM) before being washed and labeled with 100 µCi 51Cr (Amersham, Little Chalfont, U.K.) for 60 min at 37°C. Standard 4-h 51Cr release assays were then performed using Hom-CTL lines or clones as effector cells and homocysteine-treated, 51Cr-labeled B cells (104 cells/well) as targets in round-bottom 96-well plates. Experimental wells and also medium alone (spontaneous release) and 1% Nonidet P-40 (maximum release)-treated target cells were dispensed in triplicates in 200 µl R10. The results were calculated as follows: percentage of specific lysis = [(experimental release - spontaneous release) x 100]/(maximum release - spontaneous release).

Anchor PCR (AnPCR)

Total cellular RNA (5 µg), extracted from approximately 2 x 106 T cells using RNAzol B (Cinna/Biotech Labs, Liverpool U.K.), was used in standard first-strand cDNA synthesis using avian myeloblastosis virus reverse transcriptase (Life Technologies, Paisley, U.K.) and oligo(dT) as a primer. The resultant cDNA was tailed with dGTP by terminal deoxy-transferase (Boehringer Mannheim, Mannheim, Germany) before use as template in PCR reactions. AnPCR reactions were performed using 5' poly(C) oligonucleotide (5'-CTATCTAGAGCGGCCGCCCCCCCCCCCCCC) containing a NotI site (underlined) and a C{alpha} oligo (5'-GATAGATCTTAGAGTCTCTCAGC), or a Cß oligo (5'-CGCGAATTCAGATCT CTGCTTCTGATG), containing a BglII site (underlined). Conditions for PCR amplification were 94°C for 5 min followed by 30 cycles of 94°C 2 min, 55°C 2 min, and 72°C 2 min using a Perkin-Elmer thermocycler.

Cloning and sequencing of AnPCR products

The AnPCR products were extracted using phenol/chloroform and digested with the restriction enzymes NotI and BglII (Amersham) before being run on 2.5% low melting point agarose gel in TAE buffer. DNA bands corresponding to approximately 400 base pairs were cut out and the DNA purified and cloned into an M13 mp18 vector as described by Moss et al. (7). From each Hom-CTL line, at least 20 independent TCR {alpha}- and ß-chain clones were sequenced; and from each Hom-CTL clone, between 4 and 11 independent TCR {alpha}- and ß-chain clones were sequenced. Nomenclature and classification for TCR V and J gene subfamilies were according to the World Health Organization-International Union of Immunological Societies (WHO-IUIS) Subcommittee on TCR Designation (8) and also after Moss et al. (7), Toyonaga et al. (9), and Arden et al. (10).


    Results
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Homocysteine-specific CTL lines and clones

Hom-CTL lines were generated by stimulating fresh PBL from donors with homocysteine in vitro as previously described (6). All CTL lines studied here were able to lyse specifically homocysteine-treated human B cells expressing appropriate HLA class I Ags (Fig. 1Go). Hom-CTL lines from two B27-negative patients, MM (with AS) and BD (with ReA), were restricted by HLA-A68 and -B8 (Fig. 1Go, A and C), respectively, and that from two B27-positive patients, MT (with AS) and AB (with ReA), were restricted by B27 (Fig. 1Go, F and E). T cell clones were obtained, by limiting dilution at 0.3 cell/well, from the MM and AB Hom-CTL lines. All six T cell clones (three from each line) lysed homocysteine-treated autologous B cells at a low E:T ratio (0.3:1) and showed no detectable lysis of homocysteine-treated, class-I HLA-mismatched B cells at an E:T ratio of 30:1 (not shown). The original Hom-CTL line from patient CR (with AS) was restricted by both A68 and B27, indicating a mixture of at least two different populations of T cells in the culture (6). T cell cloning on this line resulted in a number of oligoclonal Hom-CTL lines (from 30 cells/well), and two of these, CR-A and CR-B (restricted by A68 and B27, respectively), were included in this study (Fig. 1Go, B and D). Hom-CTL line from a healthy subject, ET, was also confirmed to be restricted by HLA-B27 (not shown).



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FIGURE 1. HLA restriction of Hom-CTL lines. Hom-CTL lines from donors AB, MM, CR, BD, and MT were tested for CTL activities against homocysteine-treated or not treated C1R cells expressing either HLA-A68 (solid circle), B8 (solid triangle), or B2705 (open circle) in standard 4-h 51Cr release assays. The results are expressed as percentage of specific lysis of the target cells by Hom-CTL. CR-A and CR-B are oligoclonal lines derived from the original CTL Hom-CTL line (6). Background lysis of cells not treated with homocysteine (not shown in the figure) was similar to that against homocysteine-treated, HLA-mismatched cells in these experiments.

 
TCR usage by HLA-B8-restricted Hom-CTL

The transcribed TCR gene segments in Hom-CTLs were amplified by AnPCR and the DNA sequences of the PCR products determined. In the HLA-B8-restricted BD Hom-CTL line, only 1 ß-chain of BV7S2 rearranged with BJ2S1 was identified (Table IGo). A subsequently repeated experiment gave the same result (not shown), confirming that the BV7S2/BJ2S1 ß-chain is part of the homocysteine-specific TCR. In contrast, four different {alpha}-chains were identified in this line (Table IGo). Two of the four {alpha}-chains used AV7S2 and made up nearly 70% of the in-frame sequences identified. It was therefore presumed that the AV7S2-containing {alpha}-chains might make up part of the homocysteine-specific TCR, although T cell clones would be needed for further confirmation. For specificity control, TCR {alpha}-chain transcripts of unstimulated PBL from the same donor (BD) were also analyzed in parallel experiments. As shown in Table IIGo, 16 different {alpha}-chains made up the 39 in-frame sequences determined. No V or J gene segments were preferentially rearranged, and none of the 16 {alpha}-chains was significantly dominant. Similar analysis was also performed on TCR ß-chain usage by fresh PBL from donor DB, and no selection of any particular BV or BJ gene segment was evident (not shown). These results suggest that the rearrangement of particular V and J gene segments by BD Hom-CTL was clearly Ag driven.


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Table II. TCR {alpha}-chains transcribed by fresh PBL from donor BD1

 
Marked conservation in TCR usage by HLA-A68-restricted Hom-CTL

The MM Hom-CTL line was highly specific and efficient in killing homocysteine-sensitized A68-positive C1R transfectant cells (Fig. 1GoA). CTL of this line transcribed predominantly a BV23S1/BJ2S1 ß-chain and two {alpha}-chains of AV22S1 rearranged with AJ17S1 and AV4S2 with AJ14S3 (Table IGo). As expected, all three T cell clones (MM1, MM2, and MM4) derived from this line used the BV23S1/BJ2S1 ß-chain. They also rearranged the AV4S2/AJ14S3 {alpha}-chain, although clone MM1 had an additional {alpha}-chain transcript of AV13S1/AJ13S2. DNA sequences of the TCR {alpha}- and ß-chains of the three clones, except that of the AV13S1/AJ13S2 {alpha}-chain of MM1, are identical to that of the parent Hom-CTL line, showing that they are actually sister clones. The AV22S1/AJ17S1 {alpha}-chain accounted for >40% of the in-frame {alpha}-chain sequences from the MM Hom-CTL line (Table IGo), but no T cell clones using this chain was obtained. It is not possible at the present stage to determine whether the AV22S1/AJ17S1 was not used by Hom-CTL or whether AV22S1/AJ17S1-expressing CTL were missed by chance during the cloning process.

In the A68-restricted Hom-CTL line from patient CR (CR-A), four different {alpha}-chains and three different ß-chains were identified (Table IGo). The AV4S1/AJ17S3 {alpha}-chain and BV23S1/BJ2S1 ß-chain were clearly dominant and therefore likely to represent the homocysteine-specific TCR. The similarity between these TCR and that of MM Hom-CTL was striking: they employed not only the same subfamilies of AV, BV, and BJ gene segments but also nearly identical third complementarity determining regions (CDR3) of the ß-chains (Tables I and III). These results indicate strong selection pressure for AV4 and BV23 gene segments and also conserved CDR3 in TCR of the A68-restricted Hom-CTL.

TCR usage by HLA-B27-restricted Hom-CTL

The AB Hom-CTL line was less efficient in killing homocysteine-treated, B27-positive BCL and also showed high background lysis of HLA-mismatched target cells (Fig. 1GoE). It was therefore not surprising that T cells of this line appeared to express heterogeneous TCRs (Table IGo). Useful information on TCR usage by AB Hom-CTL came from three T cell clones (AB1, AB5, and AB7) of this line. One of them (AB1) rearranged the AV20S1 and BV5S1 gene segments (Table IGo), which are closely related to the AV4 and BV23 genes (10) used by the A68-restricted Hom-CTLs. The other two clones, however, selected AV8 and BV13 with identical lengths of CDR3 of the ß-chains (Table IIIGo, Table IVGo).


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Table III. Comparison of CDR3 of TCR ß-chains used by HLA-A68-, B8-, and B27-restricted Hom-CTL1

 

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Table IV. Comparison of CDR3 of TCR {alpha}-chains used by HLA-A68-, B8-, and B27-restricted Hom-CTL1

 
Two different ß-chains of BV6S4 rearranged with BJ2S2 were identified in the AB Hom-CTL line (Table IGo), suggesting that recombination of BV6S4/BJ2S2 must have occurred in two different CTL clones. The CDR3 regions of both ß-chains are six amino acids in length and contain an "arginine-glycine" motif (Table IGo). In the absence of Hom-CTL clones using these ß-chains, however, it is unclear whether or not they were selected for recognition of homocysteine by the Hom-CTL.

In the B27-restricted MT Hom-CTL line, an AV10S1/AJ16S1 {alpha}-chain and a BV22S1/BJ2S7 ß-chain were the only two in-frame TCR transcripts identified, implying that the line was virtually clonal (Table IGo). These TCR chains are not related to that employed by AB Hom-CTL clones or A68- and B8-restricted Hom-CTL.

Despite their ability to specifically lyse homocysteine-treated B cells expressing HLA-B27 (Fig. 1GoD), T cells of the CR-B line expressed heterogeneous TCRs (Table IGo). It is difficult to determine which of the five {alpha}- and three ß-chains, as shown in Table IGo, actually belong to the homocysteine-specific TCR. It should be pointed out, however, that none of these TCR {alpha}- and ß-chains is related to that of MT or AB Hom-CTL. In conclusion, HLA-B27-restricted Hom-CTL from different patients do not seem to use similar TCR, although TCR of Hom-CTL clones from the same individual may show a certain degree of conservation.

As Hom-CTL could also be identified in a small percentage of healthy subjects, it was of interest to compare TCR usage by these T cells and those from the patients. TCR {alpha}- and ß-chain transcripts of the B27-restricted ET Hom-CTL line were therefore analyzed. As shown in Table IGo, the V gene segments employed by ET Hom-CTL are not closely related to those of T cells from the patients (Table IGo). Since TCR usage by B27-restricted Hom-CTL from the patients is not significantly conserved, however, it is difficult to determine whether the difference in TCR usage between Hom-CTL from the patients and from the healthy subject is disease related.

Comparison of CDR3s of TCR from Hom-CTL

It has been shown that the VDJ junctions of TCR {alpha}- and ß-chains form CDR3s that are responsible for contacting the antigenic peptides presented by MHC (11, 12, 13, 14, 15). Tables III and IV compare the predicted amino acid sequences of the CDR3s of TCR {alpha}- and ß-chains of the Hom-CTL included in this study. Interestingly, the ß-chain CDR3s of TCR from MM and CR-A Hom-CTL (restricted by HLA-A68) are almost identical in sequence (Table IIIGo). Although the ß-chain CDR3s of T cell clones AB5 and AB7 are identical in length, no apparent conservation in this region is evident among B27-restricted Hom-CTL from different individuals (Table IIIGo). Nearly all TCR {alpha}-chains from A68- and B8-restricted Hom-CTL have an arginine (R) or lysine (K) residue at position {alpha}93, although their CDR3 lengths are different (Table IVGo). In contrast, however, almost random usage of amino acid residues in the VDJ junction is observed in the TCR {alpha}-chains of B27-restricted Hom-CTL (Table IVGo).


    Discussion
 Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 
In a previous report (6), we have proposed two different, but not necessarily mutually exclusive, models to explain the molecular mechanisms for homocysteine modification of HLA Ags. First, homocysteine could modify HLA Ags such as A68 and B8 indirectly through cysteine-containing peptides bound to them (indirect modification model). Second, homocysteine could form a disulfide bond with an unpaired cysteine residue at position 67 (Cys67) of the HLA-B27 heavy chain (direct modification model). It is possible that both models are correct and that HLA-B27 could be modified by homocysteine via either pathway. The former hypothesis is in line with the finding that chemical (e.g., trinitrophenyl) or metal (e.g., nickel) modification of peptides presented by HLA Ags leads to recognition by specific T lymphocytes (16, 17). Interestingly, Kempkes et al. (18) and Weltzien et al. (19) have also reported conserved TCR usage, especially in the CDR3 regions, by trinitrophenyl-specific murine CTL clones.

Conservation in TCR usage by Hom-CTL is best demonstrated in HLA-A68-restricted T cells from patients MM and CR. They selected not only V gene segments of the same subfamilies (AV4 and BV23) but also nearly identical CDR3s of their ß-chains. Interestingly, the V gene segments (AV20S1 and BV5S1) used by one of the B27-restricted T cell clone, AB1, are closely related to AV4S1 and BV23S1, respectively (AV20S1 is the closest relative of AV4 among all human TCR V{alpha} subfamilies and BV5S1 shares 70% homology with BV23S1 on protein level (10)), suggesting strong selective pressure for AV4, BV23, and related gene products in the homocysteine-specific TCR. It should also be noted, however, that the AV22S1/AJ17S1 {alpha}-chain accounted for >40% of the {alpha}-chain sequences from the MM Hom-CTL line (Table IGo), indicating that a large percentage of T cells in this line were expressing this {alpha}-chain. Although no Hom-CTL with such an {alpha}-chain were successfully cloned, their existence cannot be ruled out. Among all the Hom-CTL lines generated in our laboratory, MM Hom-CTL was by far the most efficient, specific, and stable one that could be kept growing in vitro for several months without losing its specificity (X. M. Gao, unpublished observation). If T cells expressing the AV22S1/AJ17S1 {alpha}-chain were not specific for homocysteine-sensitized target cells, they might have out-grown the homocysteine-specific clones and made the MM Hom-CTL line nonspecific in several weeks. It is interesting that the AV22S1/AJ17S1 {alpha}-chain also contains an R at position {alpha}93 (Table IVGo) (see below).

Another interesting observation from this study is that TCR {alpha}-chains with an R or K residue at {alpha}93 are preferably selected by Hom-CTL restricted by A68 and B8, but not B27. This effect is possibly driven by the complementarity of the respective receptors for antigenic determinant, i.e., homocysteine. It has been shown that the CDR3s are in contact with the antigenic peptide and the rest of the TCR encoded by the V{alpha} and Vß germline sequences interact with MHC (11, 12, 13, 14, 15). Amino acid 88–103 of moth cytochrome c (MCC) is a murine T cell epitope presented by I-Ek (20). The MCC peptide contains a K at position 99, and the {alpha}93 of the specific TCR was always a glutamic acid (E) or aspartic acid (D) (15, 21, 22). When there was a K-E substitution at position 99 of the MCC peptide, however, the E or D at {alpha}93 of the TCR was replaced by a K (21, 22), suggesting that a salt-bridge between TCR CDR3{alpha} and the MCC peptide was crucial for the MHC/peptide/TCR interaction. An analogy can be drawn between this and the T cell recognition of homocysteine/HLA complexes. When homocysteine forms a disulfide bond with peptides bound to HLA Ags such as A68 or B8, the negatively charged carboxyl group of homocysteine would be positioned toward TCR; it could form a salt-bridge with the positively charged side chain of R or K at position {alpha}93 of TCR, thus providing extra binding affinity for the HLA/peptide/homocystine/TCR interaction.

In HLA-B27-restricted Hom-CTL, TCR usage appears to be heterogeneous among different donors, although two B27-restricted T cell clones from patient AB share the same V gene segments (Table IGo). In the direct modification model, B27 is modified by homocysteine through its unpaired Cys67. If so, homocysteine would be buried in the B-pocket of B27, which is responsible for accommodating the R residue at the second position of the bound peptides (23), and become inaccessible from the molecular surface. The directly modified B27 would thus present a new set of peptides (certainly no R at position 2), rather than homocysteine, to Hom-CTL. The fact that the TCR usage by HLA-B27-restricted Hom-CTL is relatively heterogeneous provides supporting evidence for this view. However, concrete evidence for the direct modification model can only come from experiments in which direct labeling of HLA-B27 Ag with homocysteine is demonstrated.

In conclusion, the data presented in this report reveal certain important features of Hom-CTL TCR and also provide valuable information on how homocysteine might interact with different HLA molecules in the cell. It should also be emphasized, however, that the number of subjects included in this study is relatively small (five patients and one healthy individual). It is possible that future studies involving more subjects will reveal a pattern of modest conservation of TCR usage by B27-restricted Hom-CTL. Furthermore, if the HLA-B27 molecule can also be modified by homocysteine via the indirect pathway, it should be possible to find B27-restricted Hom-CTL expressing TCR with certain features similar to that of A68- or B8-restricted T cells (e.g., with an R or K at position {alpha}93). Finally, it would be of importance to determine whether an R or K at position {alpha}93 is an absolute requirement for TCR of Hom-CTL not restricted by HLA-B27. Only analysis of a much larger panel of Hom-CTL lines and clones from more individuals will answer these questions in full.


    Acknowledgments
 
We are grateful to Dr Martin Seifert, Department of Rheumatology, St. Mary’s Hospital, London, for providing blood samples from some of the patients included in this work. We also thank Dr. Paul Boness (John Radcliffe Hospital, Oxford, U.K.) for commenting on the manuscript.


    Footnotes
 
1 This work was supported by The Wellcome Trust, U.K. Back

2 Present address: Prenatal Resources, Swedish Medical Centre, Denver, CO 80110. Back

3 Address correspondence and reprint requests to Dr. X. M. Gao, Department of Biochemistry, Imperial College of Science, Technology and Medicine, London SW7 2AY, U.K. E-mail address: Back

4 Abbreviations used in this paper: AS, ankylosing spondylitis; ReA, reactive arthritis; Hom-CTL, homocysteine-specific CTL; CDR3, third complementarity determining region; AnPCR, anchor PCR; rhIL-2, recombinant human IL-2; BCL, B cell line; MCC, moth cytochrome c. Back

Received for publication September 3, 1997. Accepted for publication December 17, 1997.


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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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