Currier McEwen

Arteritis in rheumatoid arthritis

Abstract The clinical and pathologic features of seventeen patients with rheumatoid arthritis and histologically proved arteritis were examined and compared with the findings in fourteen other patients with arthritis who had a negative biopsy. Of the seventeen patients with arteritis, eleven had a necrotizing lesion. The reports of an additional eighty-one patients with arteritis, described in the literature, were surveyed for comparison with those of the present study. Several findings were more commonly associated with the patient with necrotizing arteritis. These included a higher incidence of episcleritis, peripheral neuritis and the serum L.E. factor. The presence of these findings is suggestive evidence of necrotizing arteritis. Subcutaneous nodules and clinically diagnosed pericarditis were noted equally in patients with either type of arteritis but infrequently in the patients with a negative biopsy. No precipitating factors for arteritis were found. Evidence for the suggestion that the use of corticosteroids is related to this complication is not convincing, although more cases of necrotizing arteritis have been reported in the era after cortisone; the data lend some support to the suggestion that in some patients corticosteroid may promote transformation of nonnecrotizing to necrotizing arteritis. The data do not finally answer the question whether arteritis, especially of the necrotizing type, is a fundamental event in the pathogenesis of arthritis or, alternatively, that arteritis and arthritis are diverse manifestations of rheumatoid disease.

Agglutination and inhibition by serum globulin in the sensitized sheep cell agglutination reaction in rheumatoid arthritis

Abstract 1.1. When the euglobulin fraction of serum was employed in the sensitized sheep cell agglutination reaction, over 90 per cent of 133 tests in 108 patients with rheumatoid arthritis gave positive results. Two to 7 per cent of 162 tests in 150 control subjects gave positive reactions. 2.2. Inhibition of agglutination by a variety of serums is demonstrated, and a procedure is described for measurement of inhibition of positive rheumatoid serum by the euglobulin fraction. The serum euglobulin of 105 patients with rheumatoid arthritis failed to show inhibition in 100 per cent of the cases whereas over 96 per cent of the euglobulin fractions of control subjects caused inhibition. 3.3. A positive agglutination test in the serum of a patient with rheumatoid arthritis became temporarily negative soon after intramuscular administration of pooled human gamma globulin. 4.4. The sensitized sheep cell agglutinating factor was demonstrated in the euglobulin fraction in five of seven patients with juvenile rheumatoid arthritis. In no case of adult rheumatoid spondylitis or arthritis with psoriasis tested was agglutination observed.

Diagnostic specificity of synovial lesions

Sections of synovium from 393 operations on diseased joints were re-examined without knowledge of the clinical findings. Specimens were scored for each of 37 histopathologic features. Independently, patients were assigned to one of 10 diagnostic groups after review of all available clinical data. Computer analysis revealed statistically significant differences in the incidence of one or more histologic parameters between the members of all except three of the possible disease pairs. The possibility of exploiting these differences to increase diagnostic precision was examined.

Evaluation of prolonged cortisone therapy in rheumatoid arthritis: A four-year study

Abstract In this report are presented the data collected from observation over a four-year period of seventy-eight patients with rheumatoid arthritis (including nine cases of juvenile rheumatoid arthritis) who were treated with cortisone for intervals varying from a few weeks to almost four years. The patients were examined every four weeks or more frequently. The results have been analyzed to yield information concerning the following: composition of the group according to certain clinical features of rheumatoid arthritis; age and sex distribution; duration and stage of arthritis; duration of cortisone therapy; average daily maintenance dose; functional improvement as measured by four different criteria; relation of duration of therapy to grade of therapeutic response; comparison of certain factors in the groups that exhibited Grade I and Grade III or IV response; behavior of subcutaneous nodules during therapy; appearance or extension of bone destruction despite maintenance therapy and good clinical response; occurrence of undesirable effects including peptic ulcers, fractures and one death from overwhelming sepsis. An attempt is made to determine what effect, if any, cortisone exercises on the natural course of rheumatoid arthritis. The factors which may inadvertently influence or even prejudice results achieved by an agent subjected to clinical trial in this disease are discussed.

Clinical and serologic observations in patients with juvenile rheumatoid arthritis and their relatives

The clinical and laboratory features of 50 subjects with juvenile rheumatoid arthritis are reviewed. The frequency of systemic manifestations is emphasized, but such involvement appears to be of little prognostic significance. Rheumatoid factor was detected in 87 per cent by the sheep cell inhibition test while the more commonly used tests were positive in 29 to 40 per cent. The incidence of positive reactions correlated with subcutaneous nodules but not with any other features of the disease. Serologic and clinical studies of 97 relatives of 28 subjects revealed that 8 per cent had rheumatoid arthritis. Eighteen per cent of all the relatives, and 15 per cent of the asymptomatic ones had positive rheumatoid factor tests. These findings suggest that rheumatoid arthritis in children is similar to the disease seen in adults and is modified only by the response of the less mature subject to an as yet ill-defined stimulus.

Rate of D isappearance and Metabolism of Hydrocortisone and Cortisone in the Synovial Cavity in Rheumatoid Arthritis.

Summary Quantitative assays have been performed on extracts of synovial fluid aspirated from patients with rheumatoid arthritis, following intra-articular injection of cortisone, hydrocortisone, and their acetates. After one hour and 3 hours about 85% and 98% respectively had disappeared. There was no marked difference in rate of disappearance among the 4 compounds. Paper chromatographic analyses of post-injection extracts revealed well localized bands which were not seen in the control fluid from uninjected joints, indicating that metabolites were formed within the synovial cavity.

Spondylitis in Post-Pubertal Patients with Rheumatoid Arthritis of Juvenile Onset

The involvement of the cervical spine in patients with juvenile rheumatoid arthritis was mentioned by Still (1897) as among the earliest manifestations of this disease. Middlemiss (1951) has reported that clinical involvement of the cervical spine, though observed frequently, is not as often seen radiologically. Coss and Boots (1946) found fusion of two or more cervical segments in 11 per cent. of their patients with juvenile rheumatoid arthritis. In an analysis of 61 cases, Barkin (1952) and Potter, Barkin, and Stillman (1954) found clinical involvement of the cervical spine in 70 per cent. of individuals, and obtained radiological confirmation in 54 per cent. The most frequent and outstanding radiological change was narrowing, irregularity, and often fusion of the apophyseal joints of two or more cervical vertebrae. These observations have led us to review the x rays of the spine and sacro-iliac joints of our postpubertal patients with rheumatoid arthritis in whom the disease had begun in childhood. This was done to determine whether it would be possible to utilize the presence of a characteristic type of spondylitis, if found with sufficient frequency in this group, as an aid in the retrospective diagnosis ofjuvenile rheumatoid arthritis in cases in which evidence of the childhood stage of the disease might have been clinically inapparent.

STUDIES ON THE METABOLISM OF ADRENAL CORTICAL STEROIDS IN THE SYNOVIAL CAVITY IN RHEUMATOID ARTHRITIS

The effectiveness of hydrocortisone in suppressing inflammation in rheumatoid joints when injected intra-articularly is well established. Since the synovial fluid of inflamed knee joints can be readily withdrawn by aspiration, an opportunity is presented for direct observation of the chemical alterations produced in the hormone by the tissue on which it is acting. Moreover, this technique makes it possible to follow the metabolism of other steroid substances in vivo by a peripheral tissue, ih both normal and diseased states. Such studies could indicate whether the anti-inflammatory effect of hydrocortisone involves chemical transformation of the steroid or is independent of it. It is well known that, when administered systemically, cortisone and hydrocortisone do not differ greatly in their ability to suppress the inflammatory reactions of rheumatoid arthritis. Upon being injected directly into the synovial cavity, however, cortisone has little or no effect , while hydrocortisone exhibits local anti-inflammatory power. This difference is in contrast to the local effectiveness of both steroids in some other inflammatory conditions. The ineffectiveness of cortisone in the synovial cavity suggests that chemical transformations are involved in anti-inflammatory activity, and that these cannot be adequately effected by synovial tissue when cortisone is injected. I t was hoped, therefore, that a comparative study of the metabolites produced from cortisone and hydrocortisone might throw light on the mechanisms by which their anti-inflammatory activities are exerted.

A statistical approach to the histopathologic diagnosis of synovitis

Synovial tissue from 393 operations on diseased joints were scored for each of 37 histopathologic variables; the patients fell into 10 clinically defined diagnostic categories. The five most populous of these diagnostic groups provided a data set for calculating diagnoses based on histopathologic findings. For each pair of clinical diagnostic categories we derived a linear discriminant function dependent solely on the histopathologic assessments. The functions gave a numerical score for segregating each case into one of the diagnostic categories. The histopathology based diagnoses agreed with the clinical diagnoses in 54 to 78 per cent of the cases. Illustrations of the application of this technique are presented.