Elam C. Toone

Aortitis and aortic regurgitation associated with rheumatoid spondylitis

Abstract Aortitis and aortic insufficiency were found in eight patients during the course of examinations made in 265 patients with rheumatoid spondylitis. There was no evidence of syphilis in any of the eight patients, a questionable history of rheumatic fever in one, and evidence of peripheral rheumatoid arthritis in five. Rheumatoid spondylitis was diagnosed on the basis of typical roentgen changes in the sacroiliac joints, and aortic insufficiency by a diastolic murmur heard over the aortic valve area and along the left sternal border by at least two observers. In addition to the diastolic murmur of aortic insufficiency and the wide pulse pressure, the following cardiac manifestations were noted: left ventricular enlargement, first degree A-V block, left bundle branch block, Wenckebachs phenomenon, substernal pain suggestive of coronary insufficiency, pericarditis and congestive heart failure. Pathological examination showed the following types of lesions in the two cases: (1) dilated incompetent aortic valves; (2) shortened, thickened aortic valve cusps with rounded margins but with no evidence of fusion; (3) a dilated aorta with the intima wrinkled, thickened, and covered with pale non-calcified plaques; (4) patchy destruction of the elastica of the media with replacement by fibrous tissue; (5) endarteritis obliterans of the vasa vasorum of the tunica externa associated with perivascular infiltration and fibrosis; and (6) absence of any significant damage to the other valves of the heart. These changes were most prominent at the base of the aortic valve cusps and the ascending portion of the aorta. In one case the gross changes extended to the level of the renal arteries. The findings in these two cases and a review of those previously reported indicate a specific relationship between rheumatoid spondylitis and this type of aortitis.

Effect of cortisone in the long-term treatment of rheumatoid arthritis: Observation of thirty-five patients over a three-year period

Abstract 1.1. At the end of three years, eleven cases (31.1 per cent) of an original group of thirty-five patients with rheumatoid arthritis treated with cortisone have been benefited sufficiently to continue the drug. None of these patients suffered any serious adverse reaction. 2.2. Five deaths occurred in the series, four of which were probably directly or indirectly the result of cortisone. In one instance death occurred twenty months after the drug had been discontinued. 3.3. Adverse or toxic reactions of a nature and severity sufficient to discontinue treatment developed in ten cases. In two of these, however, it was doubtful that the cortisone was entirely responsible. 4.4. Minor adverse or toxic reactions were encountered often and in a variety of forms. Many miscellaneous clinical conditions developed in this group during the course of cortisone treatment and were always a source of considerable apprehension and concern on the part of both the physician and the patient. Many of these had no direct or indirect relationship to the treatment, and it was important to evaluate these situations correctly. 5.5. Cortisone has a definite but limited use in the maintenance management of rheumatoid arthritis. It should not be used routinely but only after other measures have been adequately tried.