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Vasculitis Mast Cells and the Collagen Diseases.

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Arthritis and Rheumatism
Journal of the qmerican Rheumatismassociation
VOL. IV, NO. 1
Vasculitis, Mast Cells and the Collagen Diseases
Purpura and necrotizing vasculitis complicate high dose adrenocortical therapy
in rheumatoid arthritis. Pathological
changes in five cases are summarized.
Tissue mast cells are. concentrated
around blood vessels and store heparin,
histamine, hyaluronic acid and in some
species, serotonin. These pleuri-potential
cells upon “trauma” yield these potent
biological substances which may act as
prime movers in the idammatory reaction. Association of these cells with
adrenocortical steroids, fibrogenesis and
anaphylaxis is further evidence that
they play a role in the panangiitic reaction of hypercortisonism.
Purpura e vasculitis nectotisante rende
complicate le us0 de therapia a alte
doses de steroides adrenocortical in
arthritis rheumatoide. Es summarisate
le alterationes pathologic incontrate in
cinque casos. Mastocytos del tissu es concentrate circum le vasos de sanguine e
effectua un thesaurisation de heparina,
histamina, acido hyaluronic, e-in certe
species-de serotonina. Quzndo le mastocytos, que es pluripotential, es “traumatisate”, illos libera le mentionate biologicamente potente substantias que alora
pote ager como promotores primari del
reaction idammatori. Le association de
iste cellulas con steroides adrenocortical, fibrogenese, e anaphylaxe supporta
additionalmente le these que illos ha un
rolo in le reaction panangiitic de hypercortisonismo.
HE PURPOSE OF THIS PRESENTATION is to propose an hypothesis.
By this method it is planned to present certain facts and relationships and
from these draw certain inferences which may lead to a better understanding
of one of the iinlfying aspects of the so-called collagen vascular diseases. This
discussion will center around the pathological changes in and about the blood
vessels of patients with rheumatoid arthritis which some observers consider to
be the site of the primary pathological Jesion in this illness.lP2 The line of
reasoning and steps leading to the development of this new concept will be
considered in the same chronological fashion as it has evolved in our group.
Some of the evidence which will be used to fabricate this thesis will be factuil;
Thb paper was presented aa the Stephen Walter R a n s a Alemoth1 Lecture at Nmthm..vtem Uniuers& Medical School, Chicago, Illinois, November 4, 1959.
From the Department of Medicine, Section of Rheumatic Diseases, University of Colorack School of Medicine, Dentm, Colorado.
much is circumstantial and an earnest effort will be made to keep these differences clear and distinct.
As is well known, the cause and cure of rheumatoid arthritis is unknown.
The need for fresh, new, unorthodox and untried approaches to this problem
is clearly evident. No one can possibly predict what new routes are going to
lead to the discovery of the ultimate cause of rheumatoid arthritis. It is also
cIearly evident that we are going to have to explore some entirely untried
avenues if we are to make headway against this stubborn and destructive
foe. In this endeavor, evidence will be presented to support a new concept of
pathogenesis of the primary vascular lesion of rheumatoid arthritis.
Subcutaneous hemorrhages: About two years ago, our attention was first called to the
occurrence of ecchymotic areas on the hands and forearms of patients attending the
Arthritis Clinics at the Colorado General Hospital. The frequency with which these skin
hemorrhages were being encountered appeared to be greater than either of us had
been accustomed to seeing in arthritis patients and we began to study the particular group
of individuals. It soon became evident that these subcutaneous hemorrhages were developing in patients with rheumatoid arthritis who had been maintained on one or another of
the adrenocortical steroids or corticotropin for long periods of time and were in a state
of hyperadrenocortisonism. At the time the first patients were studied many of them
were receiving 20 to 30 mg. of prednisone or prednisolone daily. Today we would consider these rather excessive doses of the two steroid drugs. Figure 1 contains several
illustrations of these subcutaneous hemorrhages which were noted to develop with only
minor trauma in patients on long-term steroid therapy.
Fig. 1.-Hemorrhagic lesions in the skin of the upper extremity of four patients
with rheumatoid arthritis (A,B,C,D). Each patient had iatrogenic hypercortisonism
from long-term cortiwteroid therapy.
Fig. 2.-(A) Dry gangrene of right leg and foot of patient (A. M. CoIorado
General Hospital #117986) a 55 year old female with rheumatoid arthritis of 14
years’ duration. She had received adrenocortical steroid therapy for eight years and
was in a hypercortisone state when this vascular occlusion occurred. (B) Mediumsized artery from the amputated extremity showing an organized thrombus partially occluding the lumen with fibrosis extending through the wall into the adventitia.
An analysis was made of 109 patients attending the Arthritic Clinic at the Colorado
General Hospital; it was found that this type of vascular skin lesion was present in 40
per cent of the group and formed the basis of a report in 1958.3 At about the same time,
other published reports appeared which indicated a similar incidence; Boland4 found
34 per cent among 70 patients and DenkoK reported 20 per cent in 75 patients. Efforts to
Fig. 3.-Microscopic section from myocardium. (Patient A. M., Colorado General
Hospital, # 117986.) Acute necrotizing rrteritis with extensive infiltration of lymphocytes, mononuclear cells and proliferating fibroblasts involving the adventia.
demonstrate the cause of this hemorrhagic tendency revealed no measurable defect of
the intravascular clotting factors. By using a negative pressure suction apparatus, no
hemorrhages were produced, indicating that there was no defect in the integrity of the
capillary wall.
At this point our attention was focused upon the possibility that the defect responsible
for these purpuric lesions was an abnormality in the extravascular hemostasis. In other
words, was the cause for the hemorrhage a failure to quickly close the rent in the capillary continuity, thus permitting a macroscopic hemorrhage to occur? We shall return to
this line of thinking a little later.
Vasditis in steroid-treated patients: Another event growing out of experiences with
adrenocortical steroid therapy in the long-term management of patients with rheumatoid
arthritis served to focus attention again to the vascular system. In 1957 one of us ( C . J. S.)
was asked to see a female patient, age 67, with rheumatoid arthritis who had been on
continuous adrenocortical steroid therapy for three years. She complained bitterly of
burning pain and numbness in the toes and feet and tips of the fingers. Soon afterward
she was admitted to a Denver hospital with purplish-black fingertips, and the skin over
the shins was necrotic. She died after a few weeks in the hospital and at autopsy was found
to have a difhse polyarteritis-nodosa-like vasculitis. During the next several months, we
observed two other patients both on high dose long-term adrenocortical steroid therapy
who died, and at autopsy showed similar diffuse vascular changes which had the pathological characteristics of polyarteritis nodosa except that the lesions were distributed
evenly along the length of the vessel. T h e observations in these three cases and an exhaustive review of the literature concerning the vascular lesions in rheumatoid arthritis formed
the basis of a recent report by Drs. Johnson, Lubchenco, Valentine, Holt and Smyth.6
Since that report, two additional patients with rheumatoid arthritis on high doses of
adrenocortical steroids have been observed. In one patient there was extensive dry
Fig. 4A.-Left hand showing gangrene of the fingertips in a 61 year old male.
(Initials C. T., Denver Veterans Administration Hospital, #40791) Rheumatoid
arthritis for eight years and continuous adrenocortical therapy ranging from 20 to
40 mg. per day for two years.
Fig. 4B.--Small arteriole from the submucosa of the intestine of the above patient
obtained at autopsy. There is fibrinoid necrosis of the entire thickness of the vessel
waII with mononuclear and lymphocytic cellular exudate in the adventitia.
gangrene of the right lower extremity (Fig. 2A). At autopsy there were occlusions of large
vessels in this extremity (Fig. 2B). In the liver, kidneys, myocardium and lungs there
was a generalized polyvasculitis of the periwteritis nodosa type (Fig. 3). .knother patient
developed necrosis of the fingertips (Fig. 4A).The autopsy studies revealed a widespread
acute necrotizing arteritis in all visceral organs (Fig. 4B). Many vessels showed residual
fibrosis, hyaline degeneration and marked intimal thickening.
Doctors Kemper, Baggenstoss and Slocumb? approached this problem by reviewing
the frequency of arteritis at the hlayo Clinic and reviewed all cases with the diagnosis of
rheumatoid arthritis that came to autopsy through 1954. Of the 52 cases carefully studied,
14 had received cortisone and 38 had not received any. They observed that no cases with
polyarteritis were recorded among the 38 who had not received steroids, whereas there
were 4 cases with such diffuse vascular lesions among the 14 that had received cortisone.
2 of these 4 showed other features of chronic hypercortisonism.
Widespread necrotizing arteritis is well known in cases of rheumatoid arthritis in
which the patients had not received corticotropin. However, the occurrence of this
nsmotizing angiitis or panmesmhymal reaction is much more pronounced and appears
with a greater frequency and severity in patients with chronic hypercortisonism. Less
severe forms of this entity than those illustrated above are now frequently recognized.
The presence of peripheral neuritis and the skin lesions are the most common clinical
manifestations of this condition. A gradual reduction of the dose of adrenocortical
steroids is, in our experience, usually accompanied by a gradual disappearance of the
symptoms due to this reaction.
Our interest in this presentation is to suggest an explanation of the mechanism for the production of this diftuse panangiitic or polyarteritis noclosa-like
lesion. The observations of our own group and those of others point to the
production of or the marked accentuahon of a lesion which is both perivascular
or adventitial as well as mural and intramural in location.
Let us now turn back to the first cases which were described, those with
subcutaneous hemorrhages which developed upon minor trauma. What are
the structures immediately surrounding the small blood vessels which might
be involved in the extravascular clotting of blood? Our attention has been
drawn to a group of cells located immediately outside the capillaries, venules
and arterioles. They were first described by Paul Ehrlich in 11177 when he was
a medical student.8 Their demonstration depends upon special metachromatic
stains. He proposed the name "Mastzellen" or mast cells which means "wellfed cells." They are not seen in the usual hematoxylin and eosin stained and
formalin-fixed tissues because the granules have an avidity for basic dyes, and
it is this reaction which characterizes these cells. They, therefore, escape attention in the usual study of tissue sections.
Numerous studies of these cells in various species have shown that they
have a particular tendency to cluster fairly close to blood vessels. Riley, in a
comprehensive study of the mast cell in the rat and cattle, demonstrated their
close relationship to the great and small blood vessels and pointed out that
their number was determined largely by the extent to which the blood vessels are equipped with an adventitial coat of mesenchymnl cells (Fig. 5).4"
The perivascular location of the mast cells is illustrated in the book on Heparin
by Jorpes (1946, p. 64).b4 A similar arrangement of mast cells in the aclventia
of blood vessels was also depicted by Ehrlich.8 Staernmler,"B QuenseP and
Fig. 5.-In most tissues the mast cells lie predominately around arterioles and
capillaries. Tissue spread of uterine fringe from a rat. Toluidine blue (X-108). Reprinted by permission, from Riley, J. F.: The Mast CeUs, E. and S. Livingstone Ltd.,
Edinburgh, 1959.
S ~ n d b e r ghave
~ ~ each made detailed studies of the mast cells in man and all
have noted the tendency for these cells to aggregate into groups around the
blood vessels.
Distribution of the n u t cell: The mast cells are interesting from several
other viewpoints. They are described as being most commonly found in the
following tissues in the higher vertebrates including man: kin,^^*^^ ciliary
body,-’zp4isynovial membrane,22.*1*42.4*
gastro-intestinal t r a ~ t , 4 ~cardiovas+~~,~~
pericardium and lung^.^".^^ It was this distribution of the mast cells in the loose connective tissues of certain structures
and organs, especially about blood vessels, which suggested a possible relationship between these ubiquitous cells and the so-called “collagen diseases.” If
one may be permitted to draw an inference - it is these tissues with the high
mast cell content that are the site of many of the changes one encounters in
the connective tissue diseases.
One of the particularly provocative observations concerning mast cells
especially in view of the skin hemorrhages and vascular changes which ‘are
a part of hypercortisonism is the action of cortisone upon the mast cell. AsboeHansen of Copenhagen in 19521° presented evidence that in human patients
the mast cells of dermal connective tissue decrease in numbers and become
degranulated when exposed to the action of ACTH and cortisone ( Fig. 6 ) .
These observations led this long-time student of the mast cell to consider
Fig. 6.- (A) Normal mast cell. Granules evenly distributed throughout the
cytoplasm. (B) Mast cell from human skin influenced by cortisone. Vacuolation and
conglomeration of granules. (C) Mast cell from human skin influenced by cortisone.
Granules distributed in major and minor clusters and lumps, staining orthochromatically or metachromatically. Magnification approximately 3000 x. Reprinted by
permission from Asboe-Hansen, G.: The Mast Cell. Cortisone Action on Connective
Tissue. Proc.Soc.Exper.Biol.&Med. 80:677, 1952.
them to be the target organ of the adrenocortical steroids. and he has designated the mast cells as the peripheral transmitters of hormonal influences at
the connectizje tissue
F. Bloom" reported a marked reduction in the number of mast cells in a
mastocytcma in dogs following the administration of cortisone. At the same
time he found that the hyaluronic acid of the ground substance was reduced.
G. Bloom'' treated a child 10 months old with urticaria pigmentosa, a rare
dermatological condition characterized by luge numbers of mast cells, with
subcutaneous injections of cortisone in doses of 12.5 mg. daily for nine days.
Biopsy specimens obtained from this child after cortisone treatment showed
vacuolization and disruption of mast cells with a release of the cellular granules.
KelCnyi15administered ACTH to rats, and 24 hours following the injection
of 60 units he observed swelling and degranulation of the mast cells. He considered that the morphological chants corresponded to the initial changes in
the mast cells seen immediately following lccal X-ray irradiation.
Several other authors (Baker and Whitaker, 1950; Taubenhaus, Taylor and
Morton, 1952; Zachariae and Moltke, 1954) have pointed out that cortisone as
well as hydrocortisone act directly upon the mast cells.
Other substances known to degranulate or disintegrate mast cells are
colchicine.'J nitrogen mustard,'> roentgen therapy*4*1f'
and the potent pharmacolcgical substance which is also a histamine liberator, compound 48/80.'17
An interesting avenue of future investigation would be to study the effect of
other drugs ( gold, salicylates, chloroquine, iproniazid, reserpine, hydralazine,
'Compound 48/80 is a potent histamine liberator and a condensation prodiict of pmethoxyphenethylmethylnlnine with formaldehyde.
phenylbutazone) and physical agents ( heat, massage, and ultra-sound ) commonly used in or possibly related to the rheumatic disorders to determine to
what extent they alter mast cell morphology and function.
There is conflicting infcrmation pertaining to some of the functions of the
mast cells (Fig. 7). From the standpoint of function they first received special
attention when Jorpes9 demonstrated that they were ;he source of heparin.
There is general agreement today that they contain heparin. Also it has been
firmly established by Riley and his co-WC)rkers16,%"'2a~~o
and by 0thers*9~2'~~5
mast cells are rich in histamine. Asboe-HanserP proposed that they secrete
hyaluronic acid. Benditt et a1.l') produced evidence that mast cells contain
serotonin ( 5-hydroxy-tryptamine or 5 HT) . By direct analysis of mast cells
isolated from rat peritoneal fluid it was shown that they contain approximately
0.7 mg. of serotonin per cu. mm. of cells. Studies by Parratt and Westz1 have
shown that much of the serotonin as well as histamine in the skin of the rat
is contained in tissue mast cells. The finding of serotonin in the mast cells of
some species is a point which may have far-reaching implications in the pathophysiology of connective tissue and in the pathogenesis of collagen diseases.
Sjoerdsma and associates"* were unable to demonstrale serotonin in the skin
... - . ..
Controverr i a l
I955(1 9 )
R at*+
e t a 1 , 9 5 7 m h um a n G 0
and W e s t .
Fig. 7.-The potential role of mast cells in this dynamics of connective tissue is
related to the chemical substances (heparin, histamine, hyaluronic acid and possibly serotonin) which they either synthesized or store.
from a patient with urticaria pigmentosa, a tumor rich in mast cells, and in
two normal individuals. They did find large amounts of serotonin irr three
human carcinoid tumors. These tumors arise from the chromafEn cells of the
gastro-intestinal tract and patients with metastatic carcinoid tumors excrete
excessive amounts of 5-hydroxyindoleacetic acid, a metabolic product of serotonin. Lembeck has previously demonstrated the presence of large amounts of
serotonin in a carcinoid tumor.2‘;Some of the additional possible links between
tissue mast cells and connective tissue diseases were recently summarized in
an editorial in Arthritis and Rheumatism.“+
There are several bits of circumstantial evidence which have stimulated our
interest in the possible relationship of serotonin to some of the changes seen
in the connective tissue diseases. The reasons for believing that serotonin or a
related derivative of tryptophane may be implicated in the collagen diseases
are as follows:
(1) In the malignant carcinoid syndrome there is frequently a marked
fibroblastic proliferation of the subendocardium and valves of the right side of
In these instances there are metastases to the liver and ii high
concentration of serotonin reaches the heart through the hepatic vein and
bathes the interior. The maximum content of serotonin is present in the blood
only during this brief passage from the liver to tlie right side of the hcwt to
the lungs. This has been suggested as the reason for the subendocardial, and
the tricuspid and pulmonary valvular fibrosis being localized in the right
side of the heart.29Changes in the left side of the heart are not seen in the
carcinoid syndrome and it is postulated that the high concentration of monoamine oxidase in the lungs inactivates the serotonin before it reaches the left
side of the heart. In a recently reported case with malignant carcinoid in
whom there was a patent foramen ovale, there was fibrosis of the valves on the
left as well as the right side of the heart?” This observation lends support to
the concept that the valvular lesions are the result of the high serotonin content of the blood.
(2) The number of cases of connective tissue diseases occurring in patients
with the carcinoid syndrome seems higher than would be expected from
chance alone. Olson and Gray3‘ commented that the incidence of arthritis i s
Table 1.-Reports
of Carcinoid Syndrome and Connective Tissue Diseases
Sjoerdsma et 31.82
Jaiiies and MacI>onald4’
Heilmeyer et al.5fi
Zarafonetis et al.“!
Carcinoid Cases
8 (autopsied)
21 (reviewed)
Connective Tissue Chanses
2 Rheumatoid arthritis
4 “Joint involvement”
6 “Joint involvement”
1 Rheumatic symptoms
1 Rheumatoid arthritis
1 Finger swelling around
and between joints
I Scleroderma
1 Scleroderma
increased in this disease. In a report of four cases with malignant carcinoid
by Sjoerdsma et a1.,s2 two were thought to have rheumatoid arthritis. MacDonald33 has reported “joint involvement” in four of eight carcinoid patients autopsied at the Mallory Institute of Pathology. One of his cases showed marked
thickening of the skin of the fingers, toes and face. These changes suggested
those occurring in scleroderma or dermatomyositis. Sauer and his associatess4
studied 8 patients with the carcinoid syndrome at the Mayo Clinic and one had
rheumatoid arthritis. An analysis of the joint findings among 12 patients
personally studied and 67 from literature reviewed by Thorsonq5 indicated
that articular and periarticular changes are not an uncommon feature of this
syndrome. He found 13 cases with swelling, stiffness and pain referred to
joints and/or sudden localized edema of the hands or face. Three of these
patients had only joint manifestations and three had joint manifestations as
well as localized edema. Seven had localized edema but no joint symptoms.
One of his own cases ( E . Pa.) had finger swelling related to severe flush
episodes and located not only around the joints but also between the joints.
The association of scleroderma with malignant carcinoid was reported in
195836and 1959.0D
( 3 ) Dermal fibrosis in rats has been produced by the repeated injection of
serotonin creatinine sulfate.37The daily injection of 8 mg. for 72 consecutive
days produced marked thickening of the dermis, a decrease of hair follicles
and thickening of the epidermis. These changes simulate the proliferation of
collagenous and fibrous tissues within the dermis seen in human scleroderma.
( 4 ) The similarity in chemical structure of 5 HT and its metabolic product,
5-hydroxy, 3-indole acetic acid to the primary growth hormone in plants,
3-indole acetic acid, may be pertinent. The closely related structures of serotonin, 5-hydroxyindoleacetic acid and indoleacetic acid are shown in Figure 8.
It does not seem unlikely that these substances might participate in similar
enzymatic reactions with the basic aniine serotonin better adaDted for the
alkaline pH of animal fluids and indoleacetic acid for the acidic juices of
plants .6’J
(5) The striking clinical effect produced after iniecting serotonin into and
around the joints of patients with rheumatoid arthritis and svstemic lupus
erythematosus renorted by Scherbel and Harrisonae and ScherbeP is additional evidence of the possible role of serotonin in this disease. In normal hdividuals, they demonstrated that serotonin produced a transient swelling and
Fig. 8.-The similarity of structural formulae of serotonin, 5-hydroxyindole acetic
acid and indole acetic acid the plant growth hormone is immediately apparent.
erythema which disappeared within 30 minutes, while in the rheumatoid
patients the response was exaggerated and lasted from two to eight hours.
The reaction was characterized by diffuse p a h and erythema with swelling
over the dorsum of the hand, which spread rapidly into the forearm and to
all of the fingers. About five minutes after the injection, cyanosis occurred in
all of the fingers and became progressively more severe during the next ten
minutes and persisted for periods ranging from one to two hours.
This exaggerated reactivity to the extravascular injection of serotonin could
be blocked by the intravenous injection of two of the serotonin antagonists ( a )
2-bromo-d-lysergic acid diethylamide and (b) Hydergine.* Less marked but
similar responses follow the injection of histamine.
They interpreted these exaggerated vascular reactions to the decreased
activity in the tissues of one of the tissue enzymes, umine oxiidase, one of the
enzymes responsible for the conversion of serotonin to 5-hydroxyindoleacetic
There are good grounds for believing that hypersensitivity has much to
do with the mechanism of tissue damage in systemic lupus erythematosus and
perhaps rheumatoid arthritis.lVs0 The mast cells may be a link in the chain of
immunological events which results in the vascular lesion of these and allied
connective tissue diseases. That the mast cells were directly influenced by an
antigen-antibody reaction was demonstrated by Stuarts1 in 1952 who observed
the disruption and degranulation of mast cells in rabbits, guinea pigs, dogs
and mice subjected to anaphylactic shock induced by hen's egg albumin. Another study which related the tissue mast cells to the local hypersensitivity reaction was reported by Carter, Higginbothan and Dougherty.62 They injected
homologous and heterologous antigens in previously sensitized mice and
found that within five minutes after the injection of horse serum there was an
explosive degranulation of mast cells. These results were considered to clearly
demonstrate the hyper-reactivity of sensitized tissues to an otherwise relatively innocuous agent. Additional reports by Mota and Virgman,BSHumphrey and
M ~ t a and
, ~ ~Motaea have shown that mast cell alterations are produced by
several antigen-antibody systems.
These phenomena in experimental animals have not been reproduced in
man. but similar studies in humans may prove a fruitful avenue of approach to
exnlain the immediate vascular reactions in serum sickness and perhaps the
delayed vascular responses of the other rheiimatic diseases.
If we return again to the two clinical observations with which this discussion
was started, how do the known facts explain the skin hemorrhages and increased frequency of vasculitis observed in patients with hypercortisonism?
The proposed scheme for the participation of the mast cells in the dynamics
of the connective tissue is shown in Figure 9 which has been adapted from
'A mixture of three hydrogenated ergot alkaloids-Sandoz
Adoptad from Ri1.y.
I V S V (4 0 )
Fig. 9.--Riley has proposed a scheme for the participation of the mast cells in
the local perivascular events of the connective tissues. Components of the ground
substance, derived originally from the fibroblast, are stored in altered form and released following “trauma” to re-enter the cycle via mesenchymal cells. The relationship to collagen fibrogenesis and scar formation is shown.
Hiley.4O To illustrate the part played by the mast cell in the local events of
the connective tissue, let it be assumed that there is some trauma (mechanical,
chemical, thermal or biological) at the point of the arrow on this chart. It
will be noted that these events are illustrated as taking place about a capillary
shown as an endothelially lined space extending horizontally across the diagram. The mast cells are situated in the pen-capillary area and, when stimulated promptly, release their metachromatic granules into the ground substance.
In the case of long-term steroid therapy, these cells may have been constantly stimulated to produce, among other things, heparin. The arthritic
patient with hypercortisonism who receives a minor skin injury may have an
ineffective extravascular clotting mechanism because the pericapillary area of
the ground substance is constantly heparinized.
The products of the mast cell or their degradation products or some combination of these may set off a chain of events which we recognize as chronic
inflammation. One of the first events is the production of acute water-rich
edema and the presence of the histamine will cause capillary dilatation and
further accumulation of fluid. These free granules form the free chemotrophic
substance and round cell invasion soon follows. Fibroplasia and recognizable
collagen begins to take shape to regenerate and repair. In chronic inhnmation
the mast cell population further increases and an end point is reached with
the formation of an avascular scar tissue composed largely of collagen fibers.
Serotonin may enter the picture as the stimulating substance for the pro-
duction of fibrils. The presence of heparin in the ground substance may also
play a role in the formation of collagen fibers. Collagen fibers have been
shown by Morrione"2 to form in vitro by the action of heparin on solutions of
collagen and may be effective in inducing collagen fiber formation when
present in concentrations as low as 1:80,000.If the stimulus for production
of the perivascular inflammatory reaction is continued over a long period,
the ultimate end result is the chronic perivascrilar inflammation and scar.
More facts are needed for a final evaluation of the role of the mast cell
in the connective tissues, but at present there appears to be some evidence
that it plays a part in the deposition of fibrils and scar formation in the connective tissue diseases. Mast cells are known to be in high concentration in
certain tissues. They have been shown to either store or synthesize potent
biological materials. They can be looked upon as prime movers in the chain
of events we know as the inflammatory reaction. Beyond this much remains
to be explained. Many of these observations must, at present, remain speculative, but it is hoped that these ideas will stimulate others to study the relationship of the mast cells and their products to the connective tissue diseases.
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Charley 1. Smyth, A.B., M.S., M.D., Associate Professor of
Medicine, Director, Arthritis Clinic, Uniiiersity of Colorado
School of Medicine.
Oren B. Gum,Ph.D., M.D., Assistant Professor of Medicine,
Unioersity of Colmudo School of Medicine.
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mastr, vasculitis, disease, collagen, cells
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