The spleen in Felty's syndrome: a histological, morphometrical, and immunohistochemical study

A histological study employing morphometrical and immunohistochemical methods was performed in 3 spleens removed because of Felty's syndrome (FS). A comparison was made with control spleens and with spleens removed from patients with idiopathic thrombocytopenic purpura (ITP) or autoimmune hemolytic anemia (AIHA). In FS, the spleen is enlarged, mainly due to expansion of the red pulp. The sinuses are enlarged, too, and contain many macrophages. 2 of our specimens showed many hyperplastic germinal centers; the 3rd contained no germinal centers. Only in the former cases did splenectomy lead to an increase in the number of circulating granulocytes. Immunohistologically, FS spleens differed from the control, the ITP, and the AIHA spleens. The results have provided further evidence indicating that the pathogenesis of granulocytopenia in FS differs from that of autoimmune hematocytopenias, and have given rise to the hypothesis that, in FS, the spleen is the site of interaction between immune complexes and granulocytes.

Clonal proliferation of large granular lymphocytes in rheumatoid arthritis

Some patients with chronically elevated large granular lymphocyte (LGL) numbers have rheumatoid arthritis (RA). Since these patients also may have neutropenia and splenomegaly, their symptoms resemble those of patients diagnosed as having Felty's syndrome (FS). We studied the immunophenotypic and genotypic characteristics of mononuclear cells from patients with RA and neutropenia to better determine the extent of heterogeneity in this condition. Four patients had markedly increased numbers of LGLs, which expressed HNK-1 antigen and IgG Fc receptors. In contrast, the remaining 8 patients, who had FS, had normal LGL counts, and surface marker studies showed normal numbers of HNK-1 and IgG Fc receptor positive cells. Clonal rearrangement of the T cell receptor beta chain gene was demonstrated in all 4 patients with excess LGLs, whereas a germline configuration of this gene was present in all 6 FS patients in whom this was studied. These results suggest that there are diverse groups among patients with RA and neutropenia. Since prognosis may differ, it is important to recognize that some patients who are considered to have Felty's syndrome may have a clonal proliferation of LGLs.

High dose intravenous gamma globulin for Felty's syndrome

High dose intravenous gamma globulin (IV-IgG) was given to 5 patients with Felty's syndrome. The neutrophil count did not change with IV-IgG therapy and no side effects were encountered. We conclude that neutropenia in Felty's syndrome is not comparable to autoimmune hemocytopenia with respect to the response to IV-IgG.

[Biological screening of immuno-mediated marrow insufficiency by means of the CFU-GM assay]

We studied in agar growth behaviour of bone marrow granulocyte-macrophage progenitor cells (CFU-GM) in 16 patients with marrow failure in order to discriminate patients with cells inhibiting granulopoiesis both in bone marrow and peripheral blood. Our experimental design was based on: a) agar culture of bone marrow cells before and after treatment with antilymphocyte globulin (AGL); b) agar co-culture of marrow cells with autologous lymphocytes from peripheral blood. ALG treatment of marrow cells determined CFU-GM growth increase in 4 out of 10 patients; in the same patients co-culture with autologous lymphocytes showed a significant inhibition of CFU-GM growth. The growth enhancement induced by ALG treatment "in vitro" associated with growth inhibition in the coculture suggests the existence of a lymphocyte population suppressing the granulopoiesis both in bone marrow and peripheral blood. With this work we propose an experimental model in order to discriminate marrow failure based on cell-mediated suppression of CFU-GM growth in patient susceptible of immunosuppressive therapy with ALG.

Felty's syndrome presenting without arthritis

A patient with splenomegaly, severe granulocytopenia and a strongly positive rheumatoid factor test initially had no clinical evidence of rheumatoid arthritis. Leukopenia responded to splenectomy and did not recur during one year of follow up. Symmetrical metacarpophalangeal joint swelling developed after nine months. This case emphasizes that arthritis may occasionally be a late and minor manifestation of Felty's syndrome.

Pasteurella multocida septicaemia complicating Felty's syndrome: A case report

A patient with Felty's syndrome complicated by septicaemia due to Pasteurella multocida is presented. Disease caused by this organism is unusual in humans and its occurrence in the absence of trauma, as was the case in our patient, even more so.

Portal hypertension in Felty's syndrome

Idiopathic portal hypertension, usually with esophageal varices, minimal but definitely abnormal liver tests and subtle or no changes on percutaneous liver biopsy has been reported in only a few patients. A case associated with Felty's syndrome in a 65-year old woman with a 44-year history of rheumatoid arthritis is reported in which the liver tests and liver biopsy were normal. Portal hypertension, varices and a patent portal venous system were documented. No surgical procedure was undertaken and she has done well in the 18 months since these studies were performed. A conservative approach is probably warranted in such cases.

Felty's syndrome

An unusual case is presented in which a patient complained of oral ulceration and soreness of the mouth and throat. The results of clinical and laboratory investigations are reported and it was concluded that these oral symptoms were associated with Felty's Syndrome. After treatment of oral infection and a dental clearance the patient was virtually symptom-free for five months. The patient had a relapse and was admitted to hospital for treatment of overwhelming infection. Splenectomy was performed without sustained benefit and the patient died six weeks later.

Splenectomy for Felty's syndrome. Clinicopathological study of 27 patients

The major clinical and pathological features and the long-term follow-up of 27 patients with Felty's syndrome who were treated with splenectomy for sever granulocytpenia and for acute, chronic, or recurrent infection were studied. Granulocyte counts rose within days in most patients, although slow responses and transient granulocytopenia did occur; only 12% of the patients had persistent or recurrent granulocytopenia. Infections resolved promptly in 77% of the patients, more slowly in the remainder, and only one patient had new problems of infection after aplenectomy. Splenic enlargement, present in all but one case, was attributable to expansion of the sinusoidal pulp. The most substantial pathological features of immune stimulation included germinal center hyperplasia and prominent clusters of plasma and preplasma cells within sinuses.

Noncirrhotic portal hypertension in Felty's syndrome

A case of Felty's syndrome with nodular regenerative hyperplasia of the liver, presinusoidal portal hypertension, and bleeding esophageal varices is reported. Increased splenic blood flow may be a contributing factor to the development of the regenerative nodules. The portal hypertension is postulated to be a result of intrahepatic vascular compression.

Nodular, non-cirrhotic liver associated with portal hypertension in a patient with rheumatoid arthritis

A patient with rheumatoid arthritis developed portal hypertension and died from bleeding oesophageal varices. The liver was small and showed a nodular, non-cirrhotic pattern similar to that described by Blendis et al (1970 and 1974) in association with Felty's syndrome. This appears to be the first report of a patient with this liver lesion associated with rheumatoid arthritis in the absence of Felty's syndrome. The liver lesions described here are compared with partial nodular transformation and nodular regenerative hyperplasia; in spite of some differences it is not proven that these are distinct entities and further study is required to settle this question.