Seppo Sutinen

Open lung biopsy of patients with rheumatoid arthritis

SummaryIn order to shed light on the histological changes occurring in the lungs of patients with rheumatoid arthritis (RA), we scrutinized an open lung biopsy file of 199 patients and selected the patients with RA. The histopathological patterns observed were: pulmonary rheumatoid nodules (4 cases, including one with rheumatoid pneumoconiosis); usual interstitial pneumonia (UIP) (2 cases); desquamative interstitial pneumonia (2 cases); bronchiolitis obliterans with patchy organizing pneumonia (2 cases); follicular brochiolitis (1 case); organizing pneumonia always associated with bronchiolitis (3 cases); granulomatous reaction (3 cases); obliterating vasculitis (3 cases); granulomatous vasculitis (1 case); lymphoid hyperplasia (2 cases); and localized pulmonary fibrosis (1 case). The clinical data and laboratory findings for the histopathological groups overlapped and did not properly predict the anatomical picture. Both patients with UIP died of lung disease. Otherwise the prognosis in the series was good.

Treatment of noninsulin‐dependent diabetes mellitus with enzyme inducers

Although treated adequately with antidiabetic drugs, diet, exercise, and education, patients with noninsulin‐dependent diabetes mellitus (NIDDM) may develop resistance to treatment. In NIDDM hepatic microsomal enzyme activity is reduced and since postreceptional glucose metabolism is influenced by these enzymes, we treated the subjects with enzyme‐inducing drugs. These inducers (phenobarbital and medroxyprogesterone acetate) when added as adjuvant therapy to sulfonyl urea regimen, reduced blood glucose and plasma insulin, and increased microsomal enzyme activity (as indicated by increased antipyrine metabolism). A trial with placebo did not alter serum glucose levels. Body weight fell and serum aminotransferase levels were normalized. These changes were reflected by reduction of liver fat content (determined by light microscopy), by increased surface density of smooth endoplasmic reticulum, and by repairation of the plasma cell membrane of hepatocytes, as seen in electron micrographs. Activation of postreceptional events in hepatocytes may thus be a new approach in the treatment of therapy‐resistant type II diabetes.

High concentrations of chromium in lung tissue from lung cancer patients.

The pulmonary chromium content was determined by plasma atomic emission spectrometer (DCP‐AES) from 53 lung cancer and 43 control patients, and compared with smoking habits, severity of emphysema and occupational history. The chromium content from the lung cancer patients was higher than that from the smoking (P < 0.025) or nonsmoking control patients (6.4 ± 4.3, 4.0 ± 4.0, and 2.2 ± 0.6 μg/g dry weight, respectively). A positive correlation between the pulmonary chromium and smoking time (P < 0.025) and the severity of emphysema (P < 0.001) was found in the control but not in the cancer patients. The difference in the pulmonary chromium content was greatest between those lung cancer and control patients who were light smokers or had mild emphysema. This group of lung cancer patients included subjects with occupational exposure to chromium. The possibility of occupational cancer should be considered especially with light smokers. The grade of emphysema and metals such as chromium accumulating from tobacco could serve as objective indicators of smoking.

Rheumatoid arthritis as a cause of cardiac compression. Favourable long-term outcome of pericardiectomy

SummaryIn order to clarify the significance of rheumatoid arthritis (RA) as a cause of cardiac compression, we scrutinized pericardiectomy files of 47 patients over a ten-year period at two university hospitals in Finland. Five patients with RA were found. All the patients with RA were men with seropositive disease and subcutaneous rheumatoid nodules. Two of the patients had pulmonary fibrosis, one had cutaneous vasculitis and three had had rheumatoid pleurisy. There was a mean delay of 10 months from the first cardiac symptom to the diagnosis of cardiac compression, the most common misdiagnosis being primarily a liver disease. On the basis of clinical and operative data, four out of the five patients had constrictive pericarditis and one had an effusive-constrictive form of the disease. The histopathological findings in all cases were consistent with chronic fibrosing pericarditis. A follow-up of seven to seventeen years of four patients has not revealed any signs of recurrent pericardial disease. Our results demonstrate that RA is an important aetiological factor for cardiac compression. The long-term outcome of this manifestation seems to be good after pericardiectomy.

Detection of antigens in lung biopsies by immunoperoxidase staining in extrinsic allergic bronchiolo-alveolitis (EABA)

Open lung biopsy specimens of 14 patients with extrinsic allergic bronchiolo-alveolitis (EABA) were studied by immunoperoxidase staining with avidin-biotin-complex method using nonconjugated antisera to Micropolyspora faeni, Thermoactinomyces vulgaris, Aspergillus fumigatus, and Aspergillus umbrosus. Antigenic intracellular material was found in macrophages and giant cells of granulomas in the lung tissue of 8 patients. This finding supports the hypothesis which suggests that macrophages and T-lymphocytes contribute to the tissue injury in EABA.

Calcium Microemboli and Microfilters in Valve Operations

Fatal microemboli occurred in 3 of 100 consecutive patients having aortic valve replacement; 2 occurred during perfusion before the microfilter era, and 1 occurred intraoperatively despite the use of in-line filters. In all 3 patients cerebral symptoms were present immediately postoperatively, and each died of severe brain damage. On postmortem examination cerebral calcium microemboli were verified in only 2 patients, although the brain of each patient contained minute infarctions. However, calcium particles were found in the kidneys of all 3 patients. Thus the kidneys proved to be the best place for detection of calcium emboli on postmortem examination. Although the microfilters currently available effectively prevent microemboli during extracorporeal circulation, the surgeon should be aware that embolization can also occur immediately after discontinuation of perfusion. The means of protecting the patient from this are discussed.

Rheumatoid pneumoconiosis in a dolomite worker: A light and electron microscopic, and x-ray microanalytical study

A 46-year-old woman suffering from rheumatoid arthritis developed numerous round opacities at the apex of the right lung 11 years after an exposure to dolomite . Resected lung showed discrete nodules, 0.8-2 cm in diameter, with central necrosis surrounded by palisading fibroblasts and a prominent inflammatory zone. A large number of birefringent dust particles were seen in the necrotic centres and around the nodules. By electron microscopy the particles were dense, mostly elongated and lamellar, varying from 0.005 to 3 microns in width, and from 0.1 to 6.5 microns in length. Energy dispersive x-ray microanalysis of the dust particles gave elemental spectra with high spikes of silicon, aluminium and potassium, and minimal magnesium, calcium, iron and titanium. According to chemical analysis, the original dolomite consisted almost entirely of magnesium and calcium carbonates and only of traces of silicon, aluminium and potassium. Apparently the human organism can better eliminate calcium and magnesium carbonates than silicon, aluminium and potassium.

Weights of the body and cardiac ventricles in pulmonary emphysema

We analysed statistically the association of emphysema, determined on inflation fixed specimens, with the weights of the body and heart, and of the cardiac ventricles, weighed separately, in 170 male and 86 female adult autopsies. The cases were grouped according to the cause of death into cardiovascular, cancer and other deaths. In men the body weight was inversely proportional to the severity of emphysema, but no association existed between the body weight and the cause of death. In male cardiovascular deaths the total heart weight, total ventricular weight and the weight of the left ventricle with the septum were also inversely proportional to the severity of emphysema while this was not true in the other deaths. In male cardiovascular deaths a decrease, and in the other deaths an increase, of the weight of the free wall of the right ventricle was associated with an increasing severity of emphysema. In all male deaths, however, the left to right ratio decreased with an increasing severity of emphysema. Thus, pulmonary emphysema is associated both with a general atrophy, including the myocardium, and a mainly relative right ventricular hypertrophy. An absolute right ventricular hypertrophy, however, seems to accompany emphysema only in the absence of other major cardiovascular diseases.

Bronchiolo-Alveolitis with Pulmonary Basal Lamina Injury in a Rheumatoid Patient during Gold Treatment

A 47-year-old housewife presented with nonproductive cough, progressive breathlessness and intermittent fever during gold treatment, originally prescribed for seropositive polyarthritis, which later fulfilled the criteria for systemic lupus erythematosus (SLE). An open lung biopsy showed abundant interstitial edema with mononuclear inflammatory cells and some eosinophils, and slight bronchiolitis. The picture was nonspecific but suggestive of hypersensitivity pneumonitis. Electron microscopy revealed splitting and local disappearance of the basal laminae of the alveolar capillaries, venules and alveolar epithelium. This injury was confirmed by immunohistochemical staining for type IV collagen and laminin, the major components of basal laminae. In most macrophages there was lysosomal electron dense granular material, i.e. aurosomes, which gave the spectrum of gold in electron microprobe analysis. After the gold treatment was stopped the pulmonary symptoms gradually decreased during several months and no permanent lung disease remained. Whereas the pulmonary manifestation could have been due to her underlying disease we discuss in this study the possibility of its being gold induced.

Lysosomal Gold Accumulations in Pulmonary Macrophages

Although soluble gold has been widely used in the treatment of rheumatoid arthritis, little is known about the distribution of gold deposits in extra-articular tissues. In the synovial lining cells and articular cartilage, the morphology of lysosomes containing gold, the aurosomes, is well documented. Because gold may cause pulmonary injury, the morphology and distribution of gold deposits in pulmonary tissue should be recognized. We found morphologically typical aurosomes with electron-dense membranes and granules, giving the spectrum of gold in electron microprobe analysis, in the interstitial and alveolar macrophages in the open lung biopsies of 3 patients who had received gold treatment but not in 12 patients who had not received gold treatment. In contrast to previous studies, aurosomes were not found in the endothelial cells.