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Peripheral T cell subset modifications induced by steroid pulse in a case of Still's disease.

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Peripheral T cell subset modifications induced by
steroid pulse in a case of Still’s disease
To the Editor:
Several authors have proposed the use of large
intravenous pulses of steroids as therapy for adult (1) or
juvenile (2) rheumatoid arthritis.
In order to assess the possible effect of such therapy
on biologic parameters, we performed a sequential analysis
of peripheral lymphocyte subsets on a 14-year-old girl with
known Still’s disease since she was 5 . Several classic
therapies had provided short-lived remissions only, and a
pulse of synthetic corticosteroid therapy was decided upon
when a relapse occurred. Methylprednisolone was injected
intravenously (1 gm/m2 over 1 hour), at a time when the only
other drug prescribed for the patient was acetylsalicylic acid
(3 gm/m*/day).
Peripheral blood lymphocyte subsets were evaluated
before she received the pulse, as well as 2 and 13 days after.
A classic indirect immunofluorescence technique was used
to label Ficoll-isolated lymphocytes with the following
monoclonal antibodies: OKT3, OKT4, OKT8 (Ortho, Raritan, NJ) and Leu 7 (Becton-Dickinson, Mountain View,
CA.). Fluorescein isothiocyanate conjugated sheep antimouse Ig (Institut Pasteur Production, Paris) was used as
second-step reagent. Labeled cells were counted using an
Olympus microscope equipped with a Ploem system of
Before the pulse, significant abnormalities were observed among the patient’s T cell subsets, as indicated by an
inverted OKT4/OKT8 ratio (0.7). Leu 7-positive cells were
extremely rare (1%). Two days later, the percentage of
OKT3+ cells was lowered, while the OKT4/OKT8 ratio had
reversed to 1.2 (Figure IA). At day 13, this reversion was
still present, and even improved (1.6), while the percentage
of O K T 3 t cells had resumed its initial value. By this time,
numerous Leu 7-positive cells (27%) also had appeared.
These results are even more interesting when absolute numbers are considered instead of percentages. Figure
IB clearly shows that the steroid pulse induced a dramatic
decrease in the total number of T cells, as well as in T cell
subset numbers. This important lymphopenia was not completely restored by day 13, although the number of T cells
had significantly improved.
‘This observation of a dramatic T cell decrease after a
steroid pulse is similar to that recently reported by Myones
et al(3). However, those authors had observed a short-lived
decrease of the OKT4/OKT8 ratio. 5 hours after injection of
30 mg/kg methylprednisolone, and initial features were resumed in their patients by day 2. The modifications induced
Day 2
Day 13
Day 0
Day 2
Day 13
Figure 1. A, Percentages of OKT3+ (0).OKT4+ (A),OKT8+ (W, and Leu 7-positive (V) cells among the peripheral lymphocytes of a patient
with Still’s disease before, 2 days after, and 13 days after treatment with methylprednisolone pulse. B, Same results as in Figure l A , but
expressed in absolute numbers.
by steroid pulse in our patient appeared more consistent, and
might explain in part the medium- to long-term efficiency of
such treatments. These results also suggest that sequential
studies might prove useful to assess the possible efficiency of
a pulse, as well as to determine the best protocol to use for a
G. Faure, MC
M. C. Bene, PharmD
FacultP de Mtdecine
P. Bordigoni, MD
Hcjpital d’Enfants
Vurtdoerrvre les Nancy
Liebling MR, Leib E, McLaughlin K, Blocka K, Furst DE.
Nyman K, Paulus HE: Pulse methylprednisolone in rheumatoid
arthritis. Ann Intern Med 9491-26, 1981
Miller JJ 111: Prolonged usc of large intravenous steroid pulses in
the rheumatic diseases of children. Pediatrics 65:989-994. 1980
Myones HL. Silverman ED. Miller JJ 111: The transient naturc of
megadose steroid pulses on the distribution of circulating lymphocyte subpopulations (abstract). Arthritis Rheum (suppl)
26:S34, 1983
ately decreased hemolytic complement activity (42 CHSO
unitshl), and a normal C3 level. Antibodies against granulocytes wete also demonstrated (1 : 100 titer). Staphylococcal
bacteremia was present. After antibiotic (oxacillin and gentamicin) and high-dose prednisolone (2 mgikg) therapy, her
granulocyte count returned to normal (leukocytes: 7,100/
mm3, granulocytes: 839%).the erythema and swelling disappeared, and she remained afebrile. Two subsequent exacerbations have been recorded: thyroiditis that resulted in
thyroid hypofunction (1981), and polymyositis requiting
high-dose corticosteroid therapy (1982). She is now in remission without corticosteroid treatment, with a constant, moderate leukopenia between 2,900 and 3,600, and an absolute
granulocyte count exceeding 1,500/mm3.
This report indicates that severe neutropenia in SLE
may cause bacterial invasion. In such cases (except for
cytotoxic drug-induced neutropenia) both antibiotic and
high-dose corticosteroid therapy are recommehded.
Peter Gergely, MD, DSc
Setnmelweis University
Buda#est, Hungury
Severe neutropenia in systemic lupus erythematosus
Shopping bag syndrome
TO the Editor:
Leukopenia is common in active systemic lupus
erythematosus (SLE). Besides a decrease in circulating
lymphocytes, there is also a granulocytopenia in leukopenic
patients (Michael SR, Vural IL, Bassen FA, Scaefer L: The
hematologic aspects of disseminated [systemic] lupus erythematosus. Blood 6: 1059-1072, 1951), the cause of which is
not entirely understood. Yamasaki et al have reported a very
likely explanation for this occurrence (Yamasaki K , Niho Y,
Yanase T: Granulopoiesis in systemic lupus erythematosus.
Arthritis Rheum 26516-521, 1983).
The suppression of granulocytopoiesis, however,
seldom results in severe neutropenia. Among 212 patients
with definite SLE, we have found only 1 instance of a
transient episode of severe granulocytopehia with concomitant pyogenic infection.
The patient, a woman born in 1920, had suffered
from SLE since 1969. The diagnosis was based on both
clinical criteria, which included arthritis and pleuritis, and on
laboratory findings: positive antinuclear antibody (ANA),
lupus erythematosus (LE) cell phenomenon, and leukopenia. She did fairly well receiving dexamethasone (2 mg) on
alternate days until 1979. In November 1979 she was admitted to the Second Department of Medicine with a high-grade
fever and facial erythema and swelling (cellulitis). She had
leukopenia (1 ,700/mm3), granulocytopenia (7% granulocytes), an elevated erythrocyte sedimentation rate, positive
ANA (above 1 : loo), positive LE cell phenomenon, moder-
To the Editor:
I would like to point out to my colleagues a “new”
observation that has emerged in the south Florida area. The
local supermarkets have instituted the use of plastic shopping bags which have supplemented the usual brown paper
bag that we have all been used to seeing. These new plastic
bags are carried by a small handle and can be easily gripped
by either the entire hand or several fingers. The bags,
weighted down with various groceries, are grasped at the
handle, and the entire force is put on these fingers.
We have been seeing increasing numbers of flexor
tendinitis of the fingers, bicipital tendinitis, capsulitis of the
shoulders, and pain over the forearm and lateral epicondyle
of the “tennis elbow” variety. What happens is that as these
bags are lifted in and out of the trunk of the car the entire
weight is thrust upon the outstretched arm, quite contrary to
when we used to bend forward and hold the bag with 2
hands. These symptoms are being seen in patients of all ages
with various underlying diagnoses, but I think that those
who are prone to these problems are finding that the use of
these newer plastic shopping bags is aggravating the symptoms.
For want of a better term, we might label this the
“shopping bag syndrome.” I guess we can call it progress of
some sort, another spinoff of the “age of plastic.”
Sheldon Zane, MD
North Miami Beach, FL
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pulse, subsets, steroid, periphery, induced, modification, case, disease, stil, cells
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