Rheumatoid arthritis with serologic evidence suggesting systemic lupus erythematosusClinical serologic and chromatographic studies.код для вставкиСкачать
Rheumatoid Arthritis with Serologic Evidence Suggesting Systemic Lupus Erythematosus: Clinical, Serologic and Chromatographic Studies By ROBERTF. WILLKENS AND JOHN L. DECKER Fourteen patients with antinuclear activity demonstrable in their serum were studied in detail. All had severe, deforming rheumatoid arthritis with visceral manifestations, and eight had chronic leg ulcers. Serum protein chromatography provided evidence that, in these patients, macromolecular globulins comprised a greater proportion of the antinuclear activity than was true in systemic lupus erythematosus. The factors were considered to be a manifestation of rheumatoid arthritis possibly provoked by chronic bacterial infection. Dece-quatro patientes con activitate antinucleari demonstrabile in le sero esseva studiate in detalio. Omnes habeva sever grados de deformante arthritis rheumatoide con manifestationes visceral, e octo habeva chronic ulceres de gamba. Chromatographia del proteinas del sero provideva evidentia que in iste patientes le globulinas macronucleari comprendeva un plus grande proportion del activitate antinucleari que in patientes con systemic lupus erythematose. Esseva opinate que le factores esseva un manifestation de arthritis rheumatoide, provocate possibilemente per chronic infection bacterial. T HE PATIENT with rheumatoid arthritis whose serum is found to produce L.E. cells defies classification as either rheumatoid arthritis or systemic lupus erythematosus. The American Rheumatism Association criteria for the diagnosis of rheumatoid arthritis (R.A.) exclude those patients with a significantly positive L.E. cell preparati0n.l This exclusion has been interpreted to support the opposite view that the appropriate diagnosis is systemic lupus erythematosus ( S.L.E.) . The difficulty is compounded b y the fact that these patients frequently exhibit visceral manifestations which are uncommon in rheumatoid disease but regularly seen in systemic l u p ~ s . ~ ? ~ Rather than classify these individuals, some authors have simply dealt with them descriptively and labeled them as rheumatoid arthritics with a positive L.E. cell preparation. More frequently the interpetation has been that It i s , in some measure, the inclusion of this type these patients have S.L.E.4*5 o f patient in the diagnostic category of systemic lupus which has produced a modification of the concept of S.L.E. as a more chronic disease than heretofore conceived. While it is recognized that a chronic false positive serologic tests for syphilis, idiopathic thrombocytopenic purpura, or a convulsive disorder may presage the much later onset of frank S.L.E.,such “tagged patients seldom exhibit chronically active disease, which is the hallmark of the arthritic patient considered here. Some authors have preferred to place these individuals in a borderline zone ~~ From the Department of Medicine, University of Washington, Seattle, Wash. Supported in part by Grants A-2663 and ZA-5157 of the National Institute of’ Arthritis and Metubolic Diseases, U.S.P.H.S. 720 ARTHRITIS AND RHEUMATISM, VOL. 6, NO. 6 (DECEMBER), 1963 721 R.A. AND EVIDENCE OF S.L.E. somewhere between the two major disease entities.6 Indeed, the point has been made that a clear distinction between these disorders is little more than a semantic exercise.? Insofar as there is validity in distinguishing among any of the “collagen diseases,” these patients appear to require separate consideration. They are sufficiently numerous in the rheumatic population to have a very pronounced effect upon etiologic, descriptive, or therapeutic studies or analyses of either S.L.E. or R.A. In attempting to answer the question of what these chronic arthritics with positive L.E.cell preparations represented, we have analyzed the clinical course of 14 such patients currently under our observation. They were selected from a much larger group of patients with R.A. on the basis of the demonstration of some form of antinuclear serologic activity as defined below. Their clinical records were analyzed in detail, four postmortem examinations were re-evaluated, and their sera were studied with a series of procedures including anion-exchange chromatography in six instances. The results constitute the body of this report. The data best conformed to the notion that these patients have rheumatoid arthritis. Within this diagnosis these patients were distinguishable by the high frequency of rheumatoid nodules, splenomegaly, leg ulcers, serositis, and high titers of the rheumatoid factor. The antinuclear activity in these patients was distinguishable to some extent from that found in a group of patients with unequivocal systemic lupus. While the reason for the presence of this antinuclear activity remains unknown, it is suggested that it results from the altered immunologic status known to exist in patients with R.A. METHODS Clinical In addition to the patients described below, sera from six patients with active S.L.E. were studied. All were women between 22 and 43 years of age. All had had nondefoming arthritis, fever of unknown origin, serositis, skin involvement and positive L.E. cell preparations. Four had renal disense, including two with the nephrotic syndrome. The diagnosis was substantiated in two cases by postmortem examination. .4ntinuclear Activity ( 1 ) L.E. ceZE preparation. The direct method of Hargraves was used without an anticoagulant, the fibrin being whipped out with a swab stick.8 The indirect method of Davis and Eisensteing was used on sera. The smears were examined by US. (2) DNA-RBC. Desoxyribonucleic acid ( D N A ) obtained from salmon sperm (Nutritional Biochemical Corp., Cleveland, Ohio) was dissolved in phosphate buffered saline (pH 8.0) (PBS) to make a 0.1 per cent solution. Sheep whole blood was drawn into Alsever’s solution and stored for periods up to 10 days at 4 C. When needed, the red cells were washed 3 times in PBS and exposed for 10 minutes at 37 C . to a 1:60,000 solution of tannic acid in PBS.10 They were rewashed 3 times in PBS and suspended at poncentration of 25 per cent in fresh PBS. One volume of this suspension wa5 added to 2 volumes of the 0.1 per cent DNA solution and the mixture incubated for 30 minutes at 37 C. The cells were washed once with PBS and resuspended at 0.20 per cent. All sera were heat inactivated ( 3 0 min., 56 C . ) and absorbed with washed, packed sheep red cells overnight at 4 C. Serial dilutions of the serum or serum fraction to be tested were made up with a final volume of 0.5 ml. in each tube with 1 per cent normal rabbit serum > 722 WILLKENS AND DECKER Table 1.-Phosphate Chamber Number Buger Volumes in Mixing Chambers _____ Volume (ml.) p H 8.0, 0.1M p H 4.6, 0.3M 75 75 0 0 15 60 75 15 75 30 75 0 0 60 0 45 0 75 in PBS. An equal volume of the sensitized cell suspension was added to each tube. Thc tests were kept overnight at 4 C., and resd without shaking. Appropriate controls including tanned cells only, DNA sensitized cells only, and the full system with known negative and known positive sera were run. The method is similar to those described by others.llJ2 (3) AT-RBC. A 1M sodium chloride solution of nncleoprotein, extracted from frozen calf thymus by the method of Chargaff13 was diluted 1:20 with PBS. With vigorous shaking and mechanical disruption, a faintly cloudy suspension resulted. This was incubated for 30 minutes at 37 C. with half the volnine of a 25 per cent suspension of tanned sheep cells in PBS. The cells were then washed ancl handled as described in (2) above. ( 4 ) NP-Lx. This was performed as prescribed by the manufacturer (Hyland Laboratories, Los Angeles ) . (5) ANFZ. Antinuclear fluorescence was demonstrated using normal humin white blood cells. Capi!lary blood smears were de-Hemoglobinized by exposure to 0.1NHCl and washed with saline 3 times. Serum was then layered on the slide which was incubated for 20 minutes at 37 C. The slides were again thrice washed, layered with a 1:5 dilution of horse antihuman gamma globulin conjugated with fluorescein isothiocyanate ( Sylvana Corporation, Orange, N. J . ) , and incubated for 20 minutes at 37 C. The slides were thoroughly washed, mounted in 25 per cent glycerine, and examined using a Leitz microscope, an Osram HBO 200 mercury vapor arc light source, and BG12 barrier (Corning) and 5840 objective ( Leitz) filters. Slides were studied withont knowledge of the clinical pictures by two observers; known negative and positive controls were prepared and examined in each series of tests. Rhseunicitoid Factor The Singer-Plotz latex test (F-I1 LP) was nwd throughout.14 Chromatography Anion-exchange cellulose column chromatography was carried out on diethylaminoethyl cellulose. Three Gm.of absorbent were packed to a height of 25 cni. in a tube of 1.1 cm. internal diameter. Heat inactivated, sheep red cell absorbed serum in 3 ml. amounts was chromatographed. A phosphate buffer gradient elution system was produced with a ninechambered mixing device.15 A total volume of 675 ml. of phosphate buffers was divided into individual chamber volumes as shown in table 1. The runs were carried out at 4 C. and required about 24 hours. A total of approximateIy 150 tubes was collected and combined into five large fractions as diagrammed in figure 1. Our previous experience and the work of others16 has shown that proteins coming off the column early contain primarily 7 s gamma globulins and 723 R.A. AND EVIDENCE OF S.L.E. TUBE NUMBERS Fig. 1.-Schematic diagram of serum partition obtained by anion-exchange chromatography on diethylaminoethyl cellulose. The fraction cutoff points were selected individually after inspection of each diagram. wbsequently albumin. The gamma globulins were in fraction I and the albumins in I1 and 111. Following the albumin, a variety of proteins were eluted including 19s gamma globulins contained largely in fraction V. The fractions were concentrated by negative pressure dialysis using heavy cellophane membranes to a final volume ranging from 2 to 4 ml. The concentrated fractions were dialyzed against PBS overnight at 4 C. prior to testing for antinuclear activity. Recoveries, evaluated on the basis of the total optical densities absorbed and eluted, were in the area of 60-70 per cent. Protein determinations by a biuret method on the concentrated fractions showed values in the range of 0.9 Gm. per rent for fractions I and 11, 0.6 Gm. per cent for fractions 111 and IV, and 0.2 Gm. per cent for fraction V. RESULTS The 14 patients studied are described in tabular form in table 2 with summary data at the bottom. The group consisted of 11 females and 3 males. The average age of onset was 39 years and the mean duration was 15 years. Our experience with them ranged from 1% months to 5 years, and averaged 2.4 years. In the majority the illness was first manifested as a symmetrical small joint disease, although in two the first sign was leg ulcer and in another it was pericarditis. Applying the Steinbrocker criteria the entire group was found to be Stage I11 or IV. With a single exception, all exhibited both small diid large joint involvement with erosive x-ray changes. Notwithstanding thesr changes, w. F 11 .__. F 79 F 70 F 45 F 59 M 67 F 60 F 54 F 35 F 60 F 55 F 56 F 67 M 47 M 41 56 15 9 25 20 20 10 15 6 15 15 8 18 15 10 40 -. Ihration (years) ___ ... .- In-IV 2.8 IV 4 111 2 111 4 IV 4 IV 3 IV 4 IV 4 111 2 I11 2 111 2 1112 Iv2 111 2 111 2 Stage/Class - -. - 11 + 0 0 + -t -1- + + + 0 + + + + - . .- .. 7 - - 6 6.5 ~--. 4.0 8.8 2.6 1.6 5.0 1.9 5.2 0 - 6 - -. 8 0 0 0 0 0 0 T + + + + + + + . -. - 4 ~. 0 0 0 0 0 0 + - - Tbc.. 0 0 0 0 -. + -i + __ . .. Ulcer 1.W .... -. .____ 0 0 0 .t f 0 0 - 0 0 i' + Serositis - 5.8 lcukopenic _ _ _ ~- 0 0 0 0 + + + + 0 0 i t 0 -1- - WBC . Features Clinkal Manifestations - (r1000) -. 7.6 1.5 1.5 9.4 3.7 -SPlc?llOrncxaly __ - Nodules -. - Table P.-CZinicaZ - = Adequate data unobtainable. 'The serositis noted was detected only at postmortem examination. Summary A. W. K. D. M. G. E. T. C. B. I. H. P. M. €3. P. A. R. F. Y.G. M.H. H. K. Y. R. Ser/Age ._ .. ~ 7 0 .t0 0 + + 0 + + 0 + + 0 0 - ~ . - -. Albuminuria -. . - 10 + 0 + + '1 . 0 + .+ 1- + 0 + + Steroid 6 + 0 0 - + 0 0 0 + 0 i + + Gold - Therapy -. -__ - - 4 0 0 0 0 + 0 0 + 0 + 0 0 0 + Death _- _ - U 7. r v) b5: $ E R.A. AKD EVIDENCE OF S.L.E. 725 Fig. 2.-The opening of a fistulous tract overlying the right elbow of Y. G. The tract led to a rheumatoid nodule of long standing. At the time of photography, 5-10 ml. of purulent material had been draining daily for 3 months. over half were well enough to be in Functional Class 2, only five patients being severely incapacitated. Eleven patients had subcutaneous nodules. In addition to the usual olecranon site, several of them had tiny seed-like nodules over metacarpal-phalangeal joints. Three patients (P. A., Y. G., and Y. R . ) showed nodular breakdown, infection and drainage from sites overlying the olecranon, a state described as fistulous rheumatismli (fig. 2 ) . Splenomegaly, apparent in seven patients, was only minimal to moderate in degree but was associated with leukopenia in five. In one patient the duration of splenomegaly was known to exceed 5 years. Most of the leukopenic group showed neutropenia with the polymorphonuclear proportion ranging from 10 to 50 per cent. Serositis was noted historically or on examination during life in four patients. In three the pleura and the pericardium were involved and in the other peritonitis was demonstrated at laparotomy. Clinically there was no evidence of peripheral neuropathy nor pulmonary fibrosis. The leg ulcers, noted in eight patients, initially appeared as hemorrhagic papules or bullae 2 mm. in diameter. With gradual enlargement, the center became white and was surrounded by an erythematous halo; the appearance was that of an infarcted central area (fig. 3). The entire lesion then became WILLKENS AKD DECKER Fig. %-Early phase of recurrent ulceration of right ankle (P. A.). Previous lesion shows as atrophic scar at lower border of photograph. In the recent past the area had showii desquamatioii h i t was clcar of the multiple, circular darkened areas. necrotic and, with removal of the slough, a shallow ulcer crater was apparent. Sucli ulcers often gradually enlarged and coalesced with neighboring lesions to form ii still larger crater (fig. 4 ) . By the time they were 5 to 10 cm. in diameter, they were generally infected with a variety of organisms. Although these ulcers, when seen late, were similar to those associated with venous R.A. AND EVIDENCE OF S.L.E. 727 Fig. 4.-Same area as in figure 3, 2 weeks later. The darkened areas have sloughed leaving multiple, coalescent ulcers. stasis in that they were found over the malleoli and anterior tibia (fig. 5) and recurred readily, the patients failed to demonstrate evidence of peripheral venous disease. In all instances the ulcers were greater than 2 cm. in diameter and their duration exceeded 3 months. Tuberculosis was present in four patients. Two patients were receiving steroids at the time the infection was demonstrated; one never received 728 WILLKENS AND DECKER Fig. 5.-Chronic, 6 cm. skin ulcer (R.Fa), Bone and muscle were exposed but no osteomyelitis was detected. Progressive healing was observed on anticoagulant therapy. steroids. In three the infection was primarily pulmonary while in one of the steroid treated patients the organisms were found in a cervical node biopsy when the patient was being evaluated for fever of unknown origin. Seven patients showed proteinuria but in none was it persistent or profound. In five a combination of chronic renal infection and nephrosclerosis provided adequate explanation. In two patients the albuminuria was not clearly explained, although in one of these the protein was related to congestive heart failure. Four of the patients died and the postmortem findings are summarized in table 3. Special sections of the kidneys were made and these, in addition to myocardial, lymph node, and splenic sections, were studied in detail. No findings compatible with a histologic diagnosis systemic lupus were demonstrated. The reactivity of the sera for rheumatoid factor and antinuclear activity is shown in table 4. Only three patients had rheumatoid factor titers below 1:5120. All but one (M. H.) had definite hypergammaglobulinemia. None had 729 R.A. AND EVIDENCE OF S.L.E. Table 3.-Postmortem - -___ Cause of Death R. F. H. K. B. W. M. G . Rupture of great vein of Galen while on anticoagulant therapy for chronic leg ulcer: prothrombin time 22% 7 days before death. Old and recent myocardial infarctions with congestive heart failure. Gram positive eoccal septicemia originated from chronic leg deer. Rheumatoid arteritis with pseudomonas septicemia origi~ted from extensive decubital ulcers. Findings . _ _ Myocardium __-___ Serous Surfaces Round cell infiltrates. Obliterated perieardium; minimal pleural adhesions. Spleen Kidney -.______ Nephmmicroscopic sclerosis normal Round cell infiltrates with rheumatoid nodule at base of mitral valve. Normal. Chronic, active pencarditis with 200 ml. fibrinous fluid; obliterated pleura. 180 Gm., microscopic normal Nephrosclerosis Minimal pericardial adhesions: obliterated pleura. 250 Gm.. microscopic normal NephTsclerosis Round cell infiltrates. Chronic, active perkarditis: obliterated right pleura; flbrous peritonitis. 330 Gm.. acute arteritia with evidence of sepsis. Acute arteritis. pyelonephritis, and nephrosclerosis. 425 Gm.. Table- 4.--Serum Proteins and Reactivity.__ ______ -___ ..___. Serum Proteins Antinuclear Activity (Gm.%) F-I1 LP Titer P. A. R. F. Y. G. M. H.t H. K . Y. R. B. W.? A. W.t K. D. M. G.t E. T. C. B.7 I. H. P. M.7 40,960 10,240 20,480 40,960 20,480 6.120 40.960 10,240 20.480 10,240 2,560 10,240 640 2,660 L.E. Prep DNA-RBC NP-RBC Gamma -___Total globulin* Direct Indirect titer titer 7.1 6.7 6.4 5.8 6.6 7.7 7.2 8.7 6.4 6.0 8.8 6.1 7.0 : 1.7 3.6 1.9 1.8 $ NP-Lx ANFl - 1.9 2.0 1.7 0.6 l.? 1.6 2.0 2.0 1.3 - 224 - 3684 - - 448 3684 896 448 - ++ t- 3584 896 224 896 3684 448 4- 224 448 - - - *Determined by paper eleetrophoreais and densitometric proportionality. ?These sera were subjected to anion-exchange chromatography. $Not done. reactivity on the venereal disease research laboratory test and cryoproteins were not demonstrable in their sera. The tests for antinuclear activity showed a wide variety of results. The L.E. prep, positive in eight patients, was generally weakly positive even when special methods to enhance sensitivity were used. In only one patient (C. B. ) was the number of cells large and their demonstration easy. In four cases, only one of the six procedures was positive; this was true of DNA-RBC ( B. W. ) , NP-Lx (P. A. and K. D. ), and ANFl (Y.G.) . In three cases (M. G., C. B., and. P. M.)five or six of the procedures were positive. Analysis of the clinical and laboratory data pertaining to these individuals was searched for other dis- 730 WILLKEKS AND DECKER Table 5.--Chromatographic Fraction Activity of Six Dual and Six S.L.E. Sera __.-__ ~ _ _ _ _ _ _ ~ - -- ~~ Number of Dual Sera Positive by Number of S.L.E.Sera Positive by - DNA-RHC F-I1 LP DNA-RBC F-I1 LP I I1 111 2 1 6 0 2 4 0 4 IV 4 6 6 6 6 6 0 0 0 6 6 0 Fraction V _______ tinguishing features. At the time blood was obtained they all had active infections, M. G. had active rheumatoid arteritis and pseudomonas septicemia unresponsive to antibiotics. C. B. and P. M.had active pulmonary tuberculosis complicated in the former by laryngeal disease. However, in two further patients (H. K. and I. H . ) with active tuberculosis at the time of sampling, only an intermediate number of positive tests for antinuclear activity were found. Six serum samples were selected for chromatography because of the presence of DNA-RBC agglutinating activity in the whole sera (see table 4 ) . They also contained large amounts of rheumatoid factor and are therefore referred to as “dual.”The resulting chromatograms and effluent tests for DNA-RBC and F-11-LP agglutinating activity were compared to concurrent, identical experiments on six Sera from patients with active S.L.E. (table 5 ) . The whole sera from these lupus patients was similarly reactive in the DNA-RBC test, but did not contain rheumatoid factor. Antinuclear reactivity was more consistently found in the post-albumin peaks (IV and V ) of the dual sera whereas it was found in both the pre(11) and post-albumin peaks from the lupus sera. In those instances in which pre-albumin antinuclear reactivity was demonstrated in dual sera, it was from the patients with the greatest number of antinuclear factors. The absence of rheumatoid factor from the L.E. sera fractions is another distinguishing feature. The chromatographic fractions from four of the “dual” sera and four of the S.L.E. sera were checked for ANFl activity. These limited results show clearly that the ANFl and DNA-RBC activity are eluted in different fractions. In the S.L.E. sera fraction I always showed ANFl activity, while in the “dual” sera it was found only once. The serum of A. W., a “dual” factor patient, was studied before and after absorption with large amounts of aggregated gamma globulin by the method of Christian.l*The treatment resulted in complete loss of rheumatoid factor and a one tube drop in DNA-RBC activity in the whole serum. On chromatography after absorption, the rheumatoid factor disappeared from fractions 111, IV and V. DNA-RBC activity, originally present in fractions 111, IV and V, persisted only in fraction 111. DISC;USSION Prior to the availability of the L.E. cell preparation there would have been little question of a cliagnosis of R. A. in these patients. The finding of a R.A. AND EVIDENCE OF S.L.E. 731 destructive, deforming polyarthritis developed over a period of 15 to 20 years associated with the presence of rheumatoid nodules would have been irrefutable evidence in support of this conclusion. In recent years an additional bit of evidence has become available; high titers of the rheumatoid factor, in contrast to lower titers, have been reported in only a few conditions other than rheumatoid arthriti~.l~-~2 The question at hand is whether the demonstration of a positive L.E. cell preparation or antinuclear activity should properly alter this interpretation. While these patients demonstrate findings compatible with a diagnosis of rheumatoid arthritis, they also manifest features which serve to distinguish them from the routine case of R. A. Splenomegaly and neutropenia, unusual features of rheumatoid disease, were present in more than half of this group. Serositis, seen in five patients, has recently been noted more frequently as a complication of the rheumatoid disease p r o ~ e s s , 2 3but ~ ~ ~its occurrence must still be considered unusual. The high titer of rheumatoid factor is also of note when it is recalled that the patients were selected on the basis of antinuclear activity. The high frequency of rheumatoid nodules present in more than three-fourths was also noted in Friedman’s study of L.E. cell forming rheumatoids.26: While all of the above features have been mentioned by others as aspects of the “overlap syndrome,”* less has been said of the chronic leg ulcers so common in our series. Study of the development and course of these indolent lesions led to the conclusion that an arterial process was involved, that tissue infarction caused necrosis, and that tissue ischemia coupled with chronic infection resulted in further enlargement of the ulcer crater. Biopsies showed findings of inflammation and repair with other changes interpreted as due to secondary infection. Indeed the presence of infection and chronic tissue breakdown at the site of these ulcers suggested consideration of the antigenic potential of this natural adjuvant-DNA mixture as discussed by Benjamin and Hueston.26In any case, the presence of these relatively circumscribed lesions distinguishes these patients from others with rheumatoid arthritis and their nature distinguishes them from the digital and cutaneous gangrene reported in malignant rheumatoid arthritis?‘ Three major features may be cited as evidence favoring a diagnosis of S.L.E.-the antinuclear activity of the sera, the serositis, and the chronic is also seen in R. A. where it leg ulcers. The serositis, a hallmark of S.L.E., tends to be more chronic, less often associated with fever, and more benign as in our cases.28Classical descriptions of S.L.E. do not include chronic leg ulcers; the concept that they are a manifestation of that disease has developed ~ - ~majority ~ of the since Hargrave’s first demonstration of the L.E. ~ e 1 1 . 2The reports deal with chronically deformed, long-standing rheumatoid arthritics often with splenomegaly and leukopenia-in other words, .the same type of problem under consideration here. The previous diaebses have been based primarily upon the demonstration of antinudear activity, a demonstratiboh which is confirmed here. All of our patients did exhibit some form of antinuclear activity during a part of their course. Of the tests employed, no one method was consistently 732 WILLKENS AND DECKER positive but, in our hands, the ANF1, the direct L.E.prep, and the DNARBC procedures appeared to detect the presence of antinuclear activity more frequently than did the other methods. Nevertheless, in two cases (P. A. and K. D., table 4 ) the only positive procedure was the NP-Lx, a method which has been described as relatively insen~itive.~~ The concept of “sensitivity” is probably illusory in connection with antinuclear factors. Following Robb i n ~ , 3and ~ consistent with our own findings and those of other^?^.^^ it is apparent that one is not dealing with variable amounts of a single factor, but rather with a multiplicity of factors each with its own specificity and each with its own independent quantitative variation. The patients (M. G., C. B., and P. M.) whose sera showed reactivity in most of the tests have developed multiple factors and, in this respect but in this respect only, more nearly parallel our findings in classic S.L.E.38The majority of our patients showed positivity in only one, two or three of the series of antinuclear activity tests. The chromatographic studies on the “dual factor” patients brought out further contrasts. DNA-RBC activity tended to be absent from the earlier fractions (7s globulins and albumin) in the dual patients while present in the S.L.E. group. ANFl activity tended to be absent from fraction I (small globulins) of the “dual sera,” but present in the S.L.E. sera, a finding in agreement with a recent report of Baum and Ziff.*g Taken together these two findings suggest that antinuclear activity in this type of patient is less likely to be found among the smaller molecular early fractions and more likely to be found late in the elution pattern where larger globulins are being removed while true S.L.E. sera tend to show activity throughout the spectrum. In this regard, however, it is to be recalled that absorption of a dual serum (A. W.) with aggregated globulin removed the 19s rheumatoid factor but failed to eliminate the DNA-RBC agglutinating activity, thus confirming the findings of others that the two types of activity are not present in one and the same molecule.40*41 Clinically our patients distinguished themselves from those with S.L.E. in a variety of ways-no skin rash nor alopecia, no oral ulcers nor stomatitis, no unusual degree of reactivity to medications, no bleeding diatheses nor purpura, no episodes of hemolytic anemia, no cytoid bodies nor sun sensitivity, no psychoses and no false positive serologic tests for syphilis. The absence of such findings, however, can hardly be considered conclusive in view of their relative infrequency in S.L.E. The well recognized diffic~lty4~ of making an unequivocal diagnosis of S.L.E. on a histopathologic basis at postmortem examination precludes a flat statement that this disease was not present in our four autopsied cases. Nevertheless the complete absence of hematoxylin bodies, “onion skin” changes of the splenic arterioles, and glomerulitis is noteworthy. Renal disease occupies an important place in the distinction since it is common and a frequent cause of death in S.L.E.43whereas it is essentially never seen in rheumatoid arthritis,44excepting such conditions as amyloidosis and chronic pyelonephritis. The appearance of signs of glomerulitis and particularly red blood cell casts in a patient considered to have R. A. would, indeed, be grounds for questioning the diagnosis. None of our 14 patients, in life or at postmortem, showed such a lesion. 733 R.A. AND EVJDENCE OF S.L.E. In short, we conclude that these patients have rheumatoid arthritis of a severe nature and that, for reasons unknown, such patients are likely to develop circulating factors with antinuclear activity, factors which are generally recognized to be without pathogenetic significance. It seems to us foolish to use the presence or absence of such factors as of diagnostic significance in the clinical syndrome described. The results of recent family studies have suggested that individuals with R. A. are members of families manifesting a state of unusual immunologic rea~tivity.4~ It might be suggested that, as the duration of active disease, the age of the patient, and the degree of involvement advance, serologic antinuclear reactivity, usually of only one or a few types, develops presumably in response to “antigenic stimuli” which are sommon to the normal population. The supervention of chronic infection may be considered to increase the variety or antigenicity of such stimuli, a notion which has been suggested recently in studies of the rheumatoid fa~tor.4~9~7 On this hypothesis, thew patients would be considered to show both “disturbed antibody” and “distiirbed antigen.”48 CONCLUSIONS 1. Fourteen patients with long-standing rheumatoid arthritis characterized by severe articular deformities, subcutaneous nodules, and visceral manifestations are described. Eight had chronic ulcerative skin lesions of the lower extremity. 2. Despite the presence of a variety of antinuclear factors in their sera, they were not considered to have systemic lupus erythematosus. 3. Serum protein chromatography suggested that the antinuclear factors in rheumatoid arthritis were more frequently composed of larger protein molecules than in systemic lupus erythematosus. 4. The antinuclear factors are considered to be a manifestation of rheumatoid arthritis and clinical evidence suggested that chronic infection may have played a role in their development. ACKNOWLEDGMENT The authors acknowledge with thanks the hclp and advice given by Dr Rohert Carp-nter with regard to the fluorescent technics. 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