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Healing of joint erosions in rheumatoid arthritis.

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hepatomegaly, splenomegaly, and a tumor in the left submandibular angle. Both parotid glands were enlarged. A
monoclonal IgA band was observed in the serum (IgG 677
mg/dl, IgA 3,471 mg/dl, and IgM 74.5 mg/dl), and free
monoclonal K light chains were detected in the urine. Results
of bone marrow aspiration and biopsy remained normal.
Lytic bone lesions were not observed in a radiographic
examination. A thoracoabdominal computed tomography
scan did not reveal lymphadenopathy. The submandibular
tumor biopsy disclosed plasma cell infiltration.
Ultrastructural studies of these cells (Figure 1A)
revealed features consistent with plasmacytes, including
well-developed rough endoplasmic reticulum containing
highly electrodense granular matter. Mitochondria were
occasionally found around the plasmacyte nuclei, which
were large and irregular, and contained thick aggregates of
chromatin (Figure 1B). A diagnosis of plasmacytoma was
made and local radiation therapy (4,200 centiGrays) was
Monoclonal expansion of plasma cells in the salivary
gland was established by immunoperoxidase staining on
frozen gland tissue sections using rabbit anti-human IgA and
anti-rc chain antisera (Behringwerke AG, Marburg, FRG)
and a mouse anti-human K chain monoclonal antibody (Dakopatts, Copenhagen, Denmark). Plasma cells bearing A
chains, T lymphocytes, and nonsecreting B cells were not
found in the tissue samples when tested with anti-human A
chain antibody (Dakopatts), anti-CD3 (Ortho, Heidelberg,
FRG), and anti-CD19 (Coulter, Krefeld, FRG) monoclonal
antibodies, respectively (Figures 1C and D).
Extramedullary plasmacytoma has been reported in
a wide variety of tissues (5). However, its appearance in the
submandibular salivary gland has not been previously described. Most monoclonal gammopathies in primary SS
involve the IgM class (6,7). In contrast, our patient with
primary SS developed an IgAK extramedullary plasmacytoma of the submandibular salivary gland. Thus, these data
suggest the existence of a pathogenetic mechanism(s) responsible for extramedullary B cell differentiation a n d o r
proliferation in SS patients. The elucidation of such a
putative mechanism(s) warrants further study at the cellular
and molecular levels.
Jose L. Villanueva, MD
Javier Rivera, MD
Jose L. Ogea, MD
Consuelo Ortega, MD, PhD
Antonio Lopez-Beltran, MD, PhD
Jose Peria, MD, PhD
Manuel Santamaria, MD, PhD
Reina Sofia Hospital
Cordoba University School of Medicine
Cordoba, Spain
1. Moutsopoulos HM, Chused TM, Mann DL, Klippel JH, Fauci
AS, Frank MM, Lawley TJ, Hamburger MI: Sjogren’s syndrome
(sicca syndrome): current issues. Ann Intern Med 92:212-226,
2. Tala1 N , Sokoloff L, Barth WF: Extrasalivary lymphoid abnormalities in Sjogren’s syndrome (reticulum cell sarcoma, pseudolymphoma, macroglobulinemia). Am J Med 43:50-67, 1967
3. Diaz-Jouanen E, Ruiz-Arguelles GJ, Vega-Ortiz JM, Villareal G,
Alarc6n-Segovia D: From benign polyclonal to malignant monoclonal lymphoproliferation in a patient with primary Sjogren’s
syndrome. Arthritis Rheum 24:850-853, 1981
Kassan SS, Thomas TL, Moutsopoulos Hhf, Hoover R, Kimberly RP, Budman DR, Costa J , Decker DL, Chused TM:
Increased risk of lymphoma in sicca syndrome. Ann Intern Med
89:888-892, 1978
De Couteau WE, Katakkar SB, Skmnides L, Hayton RC, Somerville EA: Sjogren’s syndrome terminating as a myeloproliferative disorder. J Rheumatol 2:331-335, 1975
Walters MT,Stevenson FK, Herbert A, Cawley MID, Smith JL:
Urinary monoclonal free light chains in primary Sjogren’s syndrome: an aid to the diagnosis of malignant lymphoma. Ann
Rheum Dis 45:21&219, 1986
Moutsopoulos HM, Costello R, Drosos AA, Mavridis AK,
Papadopoulos NM: Demonstration and identification of monoclonal proteins in the urine of patients with Sjogren’s syndrome.
Ann Rheum Dis 44:lWI 12, 1985
Healing of joint erosions in rheumatoid arthritis
To the Editor:
In recent open studies of cytotoxic therapy for rheumatoid arthritis (RA), improvement in the radiographic
appearance of the hands and feet in selected patients has
been reported (1-3). The most prominent feature observed
has been “filling in” or recortication of marginal joint
erosions, a phenomenon equated with “healing.” According
to McCarty and Carrera (l), this phenomenon had not been
previously reported in RA.
We would like to add a word of caution in the
interpretation of “healing erosions.” In the progression of
joint damage in RA, remodeling of the articular surfaces may
be a late finding, and it has been characterized as a stage V
lesion in the Larsen scoring system (43). In association with
this remodeling, there may be apparent resolution of marginal erosions.
An example of joint erosions that resolved in association with joint remodeling is seen in 1 of our patients, a
male truck driver with seropositive, nodular RA. In the
initial radiographs of his hands, there were large subchondral
bone cysts and marginal erosions. A view of the right index
finger is shown in Figure 1A. In the 3-year interval between
the 2 radiographs shown, the patient received tolmetin and a
short course of parenteral gold (total dose 535 mg). In the
second set of radiographs, many of the bone cysts had “filled
in” with new trabecular bone. In addition, there was remodeling of several eroded joints, as illustrated by the metacarpal joint of the right index finger (Figure 1B). In the latter
joint, the distal articulating surface had become both broader
and more concave compared with its appearance 3 years
earlier. This remodeling of the distal articulating surface
produced an appearance of joint space widening and resolution of marginal joint erosions.
We would argue that examples of erosions that
recorticate or “fill in” should be clearly distinguished from
examples of joints in which erosions resolve in association
with joint remodeling. In the example provided by McCarty
and Carrera (1) and reported as a novel finding, no joint
remodeling is evident. However, in the example provided by
Weinblatt et a1 ( 2 ) , joint remodeling has occurred in a
manner similar to that seen in our patient. To what extent the
changes seen in our patient and that of Weinblatt et a1
represent healing with recortication or simply joint remod-
A, Initial radiograph,
showing marginal erosions in both the metacarpophalangeal and the proximal interphalangeal
joints. A large subchondral cyst is present in the distal metacarpus. A large portion of the
endosteal cavity of the middle phalanx is occupied by a cyst. B, After 3 years, extensive bony
remodeling of the metacarpophalangeal joint has occurred, resulting in enlargement and
deepening of the distal articulating surface. The large subchondral cyst in the metacarpus has
been largely replaced by trabecular bone. There is increased bone mineralization in the
proximal phalanx compared with the earlier radiograph. The changes resulting from bony
remodeling of the joint have produced an appearance ofjoint space widening and “filling in” of
marginal erosions.
Figure 1. Serial radiographic views of the patient’s right index finger.
eling is difficult to assess. Thus, care should be taken in the
interpretation of healing in severely damaged joints.
Pierre J. Moeser, MD
Alan N. Baer, MD
State University of New York at Buffalo
Buffalo, N Y
1. McCarty DJ, Carrera GF: Intractable rheumatoid arthritis: treat-
ment with combined cyclophosphamide, azathioprine, and hydroxychloroquine. JAMA 248: 1718-1728, 1982
2. Weinblatt ME, Trentham DE, Fraser PA, Holdsworth DE,
Falchuk KR, Weissman BN, Coblyn JS: Long-term prospective
trial of low-dose methotrexate in rheumatoid arthritis. Arthritis
Rheum 31:167-175, 1988
3. Kremer JM, Lee JK: A long-term prospective study of the use of
methotrexate in rheumatoid arthritis: update after a mean of
fifty-three months. Arthritis Rheum 3 1577-584, 1988
4. DeCarvalho A, Graudal H, Jorgensen B: Radiologic evaluation of
the progression of rheumatoid arthritis. Acta Radiol Diag 21:
115-121, 1980
5. Larsen A, Dale K, Eek M: Radiographic evaluation of rheuma-
toid arthritis and related conditions by standard reference films.
Acta Radiol Diag 18:481491, 1977
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joint, arthritis, erosion, healing, rheumatoid
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