Malignant transformation during immunosuppressive therapy (azathioprine) of rheumatoid arthritis and systemic lupus erythematosus. A retrospective study.
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Biomedical subjects
Publications and source records attributed to K Abendroth.
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In 57 patients with chronic renal failure (CRF) [44 patients on regular dialysis treatment (RDT), 33 renal transplant patients (RT) and 26 normal patients (NP)] and in a further 11 patients with CRF (8 patients on RDT and 17 patients without any renal disease in the post mortem) the vitamin A content of the serum obtained from the tissue of the liver, the stomach, the subcutaneous adipose tissue and the bone were analyzed. The vitamin A content of the serum was increased significantly for all groups of patients in comparison with the control group, but hypervitaminotic ranges were not reached in any case. The vitamin A content decreased depending on the time of dialysis treatment and the period after kidney transplantation. The retinol-binding protein accumulated even more than vitamin A in CRF and RDT. This statement is not in conformity with that of a hypervitaminosis A, of which normal respectively decreased RBP levels are characteristic. The serum prealbumin concentration was near the upper limit of the normal range in all groups of patients. The serum content of beta-carotene in patients with CRF and RDT was raised in comparison with NP and RT patients. As to the vitamin A content of the organs, a distinctive decrease appeared in the liver, so that a marginal supply must be assumed. In the stomach and the subcutaneous adipose tissue no changes, in comparison with the control patients, resulted. Due to renal insufficiency the results indicated an unphysiological situation in the vitamin A metabolism. Connections with disturbances of the fat-household could not be set up.(ABSTRACT TRUNCATED AT 250 WORDS)
In 60 patients with chronic renal insufficiency and 36 dialysis patients an iliac crest biopsy was performed, on the undecalcified bone morphometric determinations were carried out as well as the aluminium deposition was investigated histochemically. Histologically were found in 3 patients normal findings, in 11 patients a fibroosteoclasia, in 23 patients an osteoidosis and in 59 patients a combination fibroosteoclasia and osteoidosis. 3 oft the 60 patients with a chronic renal insufficiency had aluminium depositions in the polyblasts. Of the 36 dialysis patients 19 (55.4%) had a positive aluminium histology: 30.7% of the patients with osteoidosis and 23.7% with a mixed form. There was a positive correlation to the bone and osteoid volume, to the osteoid surface and a negative relation to the activity of osteoblasts, the absorption surface and the activity of osteoclasts. Aluminium depositions on the mineralisation border might be of importance for the changes.
In patients with chronic renal insufficiency and dialysis patients as well as in normal persons determinations of vitamin A in the serum and in the bone were performed and related to the parameters of the bone metabolism and to the histomorphometric investigation of the bone. The vitamin A serum levels were significantly increased in the two groups of patients, however, did not show any differences between the patients with an osteoidosis or the combination of osteoidosis and fibroosteoclasia. There were no correlations to calcium, phosphorus, PTH and to the alkaline phosphatase as well as to the individual histomorphometric data. The vitamin A content of the bone was low and did not show any differences to the normal persons. On the other hand, there were significant relations between the parathormone and the parameters of the regeneration and the absorption of the bones. An additional influence of vitamin A on the bone disturbance, eventually by the activation of the osteoclasts cannot be excluded.
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Immune complexes were precipitated under defined conditions using polyethleneglycol. The precipitation was subjected to the first electrophoresis under nondecomposed conditions for immune complexes. In this way IgG can essentially be separated from the immune complexes which remain in the place where they were applied. In a second electrophoresis, the broken immune complexes were fractionated into IgM and IgG bands. These were analysed for antibody activity by means of hemagglutination and immunofluorescent methods. In serum of 20 rheumatoid arthritis patients, we could detect in the IgM fraction of the immune complexes the rheumatoid factor, an antinuclear antibody, and a new unknown antibody directed against cell plasma membranes of human muscle cells and endothelial cells. The importance of this new antibody in the pathogenesis was discussed.
Sera of 38 patients and 10 blood donors were examined for cytotoxicity against human thymocytes. As method for testing the complement-dependent cytotoxicity the lymphocytotoxicity test was adapted for thymocytes. The sera of blood donors and of patients with non-rheumatic diseases showed no or only a very small rate of cytolysis (3.6%). The rate of cytolysis of sera of patients with arthroses (8.5%) and of collagenoses (14.5%) were below 20%, i.e. still within the limits of normal. The sera of seronegative arthritides (30%) and of patients with rheumatoid arthritis (40%) showed an unequivocally pathological cytotoxicity. The complement-dependent thymocytotoxicity might be coordinated to the clinical arthritis.
Inflammatory changes in the epiphyseal bones in patients with rheumatoid arthritis are demonstrated which correspond to changes in the bone organ far from pannus. They may be the cause for the demineralisation near to joint (first x-ray sign to rheumatoid arthritis). Further from the analysis of immune complexes of patients with rheumatoid arthritis apart from rheumatoid and antinuclear factors and IgM-antibody against plasma membranes was the result. These two findings are new in the description of the pathogenesis of rheumatoid arthritis. Their possible importance for the development of the arthrosis is discussed.
New realisations on the regulation of bone and calcium metabolism by hormones and vitamins, modern methods of the radiologic and morphologico-morphometric diagnostics considerably increased our knowledge about the deminerlising diseases of the skeletal system. The possibilities for diagnostics and therapy resulting from this are restricted in practice by a non-adequate nomenclature. The introduction of the disease group notion "osteopenia" for all demineralising processes and its definition as well as the representation of the differential diagnostics of osteolamacia, fibrosteoclasia and syndrome of osteoporosis as clinical main representatives of osteopenia shall help to prevent diagnostic and therapeutic errors.
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It is reported on an undifferentiated cell leukosis of the type PAS in the 2nd trimenon of a pregnancy. The paralymphoblastosis could well be influenced by a prednisolone monotherapy so that a healthy baby was born. After birth very quickly developed a severe recidivation of leucosis which no more could be influenced therapeutically so that the patient dies on the 10th day after birth. The problems of the therapy of undifferentiated cell leucosis during pregnancy are discussed and possible hormonal protective mechanisms are taken into consideration.
On the basis of instances the problems of the simultaneous use of the notion of osteoporosis for a clinical picture of a disease and a roentgen-morphological symptom is discussed. The described errors of diagnostics avail themselves of the introduction of the notion of osteopenia as initial findings which then further must be differentiated into the defined clinical pictures of osteomalacia, fibroosteoclasia and into the so-called syndrome of osteoporosis. In the nomenclature proposed the radiologists have the main responsibility, since instead of osteoporosis as X-ray-morphological symptom they must propose the clinician the osteopenia with sings for an adequate clinical picture and so compel the clinician to perform the differential diagnosis of demineralisation of the bone as far as possible.
16 patients with a Paget's disease at the age of 51--80 years were treated by synthetic salmon calcitonine in a dosis of 20 mcg (80 MRCU/die). 14 patients could be observed for a longer time. In all cases there was a statically significant decrease of the increased alkaline serum phosphatase. The excretion of hydroxyproline in the collected urine had a decreasing tendency. Other laboratory parameters as calcium, phosphatase and acid phosphatase in the serum and the excretion of calcium and phosphate in the urine were not significant influenced by therapy. The patients felt subjective a clear improvement of the bone pains. After a six month-treatment the dosis was reduced (each 2--7 days 20 mcg salmon calcitonin sc). There was observed a rebehaviour of the subjective symptoms and an increase of the alkaline serum phosphatase, which did not reach the unitial values before the beginning of treatment. Calcitonine is an effective substance for the treatment of an active Paget's disease.
Sixteen patients with Paget's disease of bone aged from 51 to 80 years was treated daily with 20 micrograms (equivalent to 80 MRCU) synthetic salmon calcitonin. Fourteen patients was observed on a long time. In all cases was observed significant reductions in increased serum alkaline phosphatase. The urinary hydroxyproline excretion was also decreased. Other laboratory dates as serum calcium, serum phosphorus, serum acide phosphatase, urinary calcium and phosphorus excretion was not significantly influenced by the therapy. The treatment produced a clear remission of pain. After treatment of 6 months the dose was reduced (2 or 3 injections subcutaneously of 20 micrograms salmon calcitonin weekly). There was observed a recurrence of pain and an increase of serum alkaline phosphatase, but not until the pretreatment values. These results confirm the effectiveness of calcitonin treatment in Paget's disease of bone.
The results reported in this paper clearly indicate the release of osteal antigens of articular connective tissue in response to inflammatory alterations and injuries to the region immediately adjacent to an articulation. Further studies will have to be performed in an effort to find out whether these antigens are of pathological importance and if there is a relationship between the liberation of antigens and the intensity of inflammatory alterations or if the different and often difficult-to-interpret results of the determination of antibodies in the sera of patients with rheumatoid arthritis can be more easily explained by a simultaneous antigen analysis of the corresponding sera.
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