Alopecia in systemic lupus erythematosus. Relation to disease manifestations

Alopecia was observed in 40/74 (54%) patients with systemic lupus erythematosus (SLE). Patients with alopecia had a significantly higher rating for cutaneous manifestations, Raynaud's phenomenon and muscle tenderness, and most of these signs correlated with the magnitude of alopecia. There was no difference between patients with or without alopecia for arthritis, nephritis or central nervous system manifestations. Alopecia correlated with disease activity index but did not correlate with various specific measurements of disease exacerbation.

Close association of HLA-B51 and B52 in Israeli patients with Behçet's syndrome

Epidemiological data, family history, clinical data, and HLA typing were studied in three groups of patients with Behçet's syndrome: six Israeli Ashkenazi Jews, 29 non-Ashkenazi Jews, and three Israeli Arabs. HLA-B51 and B52 were present in 24/38 (63%) and 8/38 (21%), respectively, of the patients compared with 13/151 (9%) of the control group for both cases, a relative risk of 18.2 and 2.8 respectively. The syndrome was found in six of the 34 families. Ninety five per cent of the affected family members were either B51 or B52 positive. Eleven of the 14 families (79%) chosen for study contained a close relative of the proband who had recurrent oral ulcers. All the relatives with ulcers, except for one, were B51 or B52 carriers. Recurrent oral ulcers in the patients with Behçet's syndrome began a few years before other manifestations of the syndrome occurred. Our findings suggest that (a) HLA-B51 and HLA-B52 are primarily associated with Behçet's disease of Israeli patients; (b) the familial occurrence of this syndrome is high and occurs predominantly in the B5 positive group; (c) recurrent oral ulcers may be the first symptom of Behçet's syndrome, appearing early in life; HLA analysis can provide the clue for a correct diagnosis; (d) ulcer recurrence is common among members of a family containing a patient with Behçet's syndrome.

[Sulfasalazine in rheumatoid arthritis]

Sulfasalazine (SLZ) is now a second-line treatment in rheumatoid arthritis (RA), as well as in psoriatic arthritis and ankylosing spondylitis. 54 patients with active RA were treated with enteric coated SLZ (2 g daily) in a 24-week open study. Clinical and laboratory parameters of disease activity were monitored initially and thereafter at 2-week intervals for the first 2 months, and then at 4-week intervals until the end of the 24-week study. There was significant clinical improvement at the end, as shown by scores for joint pain (Ritchie), grip strength and morning stiffness (p less than 0.0001, less than 0.0001 and less than 0.01, respectively, by paired t test). Clinical improvement was accompanied by significant decrease in erythrocyte sedimentation rate and increase in hemoglobin (p less than 0.002 and less than 0.016, respectively). There was improvement in some cases as early as 3 weeks after starting therapy. The drop-out rate was significant: 19/54 (35%), most (13) due to side-effects, mainly gastrointestinal; none of the side-effects were serious. Our results, similar to those of other studies, indicate that despite the high rate of side effects, SLZ is an effective, second-line drug for RA.

The effect of local deep microwave hyperthermia on experimental zymosan-induced arthritis in rabbits

The effect of local deep microwave hyperthermia (LDMWH) on normal and Zymosan-induced arthritis has been evaluated in 12 rabbits (24 joints). LDMWH, four treatments to each joint (twice weekly for a period of 2 wk), was generated by an antenna operating at 915 MHz for 60 min, reaching an intraarticular temperature of 42.5 +/- 0.5 degrees C. A surface cooling system was used with the microwave apparatus. Two weeks after the last treatment, all animals were sacrificed. The application of LDMWH on normal joints induced a limited proliferation of the synovial lining cells with a minimal perivascular infiltration of mononuclear and neutrophil cells. However, no histologic damage to the skin, muscles, bone, cartilage or bone marrow adjacent to the heated joints could be noted. Induction of Zymosan arthritis (2 wk before LDMWH) was characterized by pannus formation and granulomatous reaction accompanied by fibrinoid deposits and disseminated necrotic foci in the synovial intima. The LDMWH treatment on the examined arthritic joints brought about a reduction in the degree of granulomatous reaction concomitant with the appearance of some fibrocytes and fine collagen fibrils. These findings suggest that LDMWH can be safely applied, even repeatedly, without morphologic evidence of damage to any normal mesenchymal tissue. Moreover, it reduces the inflammatory process in experimentally induced synovitis.

Antiproteinuric effect of captopril in a patient with lupus nephritis and intractable nephrotic syndrome

A 22 year old woman presented with lupus nephritis, hypertension, and intractable nephrotic syndrome. Albumin and furosemide given intravenously was ineffective. Captopril administered in a daily dose of 62.5 mg was associated with a reduction in proteinuria from 28 g/24 hours to 11.5 g/24 hours over 10 weeks, resulting in a weight reduction of 16 kg. This was achieved with relative preservation of renal function. Captopril should be considered in the treatment of intractable proteinuria in patients with lupus nephritis, or when cytotoxic drugs are refused, because of its efficacy and relative safety. Captopril should, however, be used as an adjunct and not as a substitute for standard treatment.

Effect of weather conditions on rheumatic patients

In a one month prospective study of 62 rheumatic patients--16 with rheumatoid arthritis (RA), 24 with osteoarthritis (OA), 11 with inflammatory arthritis, 11 with fibromyalgia joint pain--swelling and everyday activity was compared with changes in daily weather conditions. In most patients weather changes increased arthritic symptoms. Women were more sensitive to weather than men (62% v 37%). Pain was affected positively by barometric pressure and temperature in RA, by temperature, rain, and barometric pressure in OA, and by barometric pressure in fibromyalgia. These results support the belief of most rheumatic patients that weather conditions significantly influence their day to day symptoms.

Serum cobalamin and transcobalamin levels in systemic lupus erythematosus

PURPOSE

The purpose of this study was to assay serum cobalamin levels in patients with systemic lupus erythematosus (SLE) as there are few case reports on the association of pernicious anemia and SLE.

PATIENTS AND METHODS

Serum cobalamin levels were assayed in 43 female SLE patients by a radio-dilution assay using purified intrinsic factor.

RESULTS

Cobalamin levels were found to be significantly lower in the SLE group compared with a normal control group, eight of whom (18.6%) had serum cobalamin levels equal to or lower than 180 pg/mL (mean: 129.25 +/- 40.05 pg/mL). None of the SLE patients had been found to have pernicious anemia. The transcobalamin II level and unsaturated vitamin B12 binding capacity, but not the cobalamin level, were positively correlated with SLE activity.

CONCLUSION

Our results may indicate a subtle cobalamin deficiency in SLE patients without pernicious anemia.

Treatment of articular effusions with local deep microwave hyperthermia

Local deep microwave hyperthermia (LDMWH) may be considered as a therapeutic tool for joint diseases because it has the advantage of heating the target organ e.g. synovium, while sparing the adjacent tissues, as demonstrated in animals. The effect of this new microwave device has been evaluated on seven rheumatoid arthritis patients with knee effusion. The hyperthermia apparatus consists of a 915 MHz power source with a cooling system to the skin. LDMWH was operated for one hour, twice a week for two weeks. Intra-articular knee temperature reached the level of 40.6 +/- 1.1 degrees C within 15 minutes, raised to 41.2 +/- 0.7 degrees C after 30 minutes and to 41.3 +/- 0.9 degrees C at one hour. The skin temperature over the heated knee joints remained at 24.3 +/- 1.1 degrees C during treatment. All patients noted a sensation of warmth in the treated knee. Aspiration of synovial fluid was performed before and immediately after each treatment. Walking time was improved (p = 0.04) and significant decrease in pain (p = 0.01) was noted following treatment. Synovial fluid leukocyte count and prostaglandin E2 level, knee circumference and range of motion did not change. Severity of pain, walking time, knee circumference and range of motion remained stable in the six weeks following the last hyperthermia application. No adverse reaction could be observed. These results suggest LDMWH to be safe and successful as an adjuvant treatment of chronic inflammatory joint effusions.

Adult onset Still's disease

Three patients with adult onset of Still's disease are presented. Common early findings were: septic fever, polyarthralgia, leukocytosis, neutrophilia and elevated sedimentation rate. All of them had abnormal liver function tests which returned to normal values following corticosteroid therapy. It is proposed that hepatic abnormalities in adult onset of Still's disease reflect the basic disease process.

Evaluation of disease activity in rheumatic patients by leucocyte adhesiveness/aggregation

Previous work has shown that leucocyte adhesiveness/aggregation (LAA), as measured by the leukergy test, correlates well with disease severity in rheumatic patients. As LAA is probably a manifestation of the acute phase reaction various components of the acute phase reaction were measured in order to identify the best marker of disease activity. In addition to LAA, the following variables were measured in 79 patients with various rheumatic diseases and in 10 controls: white blood cell and platelet counts, erythrocyte sedimentation rate, haptoglobin, fibrinogen, C reactive protein, albumin, globulin, caeruloplasmin, alpha 1, alpha 2, beta, and gamma globulin, and haemoglobin concentrations. Patients were graded according to the state of their disease as mild, moderate, or severe. The extent of leucocyte adhesiveness/aggregation in peripheral blood proved to be the best laboratory variable for the grading of disease activity. Correct grading was obtained in 63% of the patients by means of the LAA, compared with 48% with C reactive protein, 41% with caeruloplasmin, 40% with haptoglobin, and 32% with haemoglobin. It is suggested that LAA of the peripheral blood during inflammation may be used as a reliable marker of disease severity.

Massive hemoptysis complicating Behçet's syndrome: the importance of early pulmonary angiography and operation

A 16-year-old patient with Behçet's syndrome had massive hemoptysis due to a ruptured aneurysm of a segmental artery of the left lung. Emergency left lower lobectomy was performed. The patient is well 12 months after operation. There have been no further episodes of hemoptysis.

Deep heat in the treatment of inflammatory joint disease

There is now a growing body of clinical evidence suggesting a therapeutic approach to cancer and prostatic hypertrophy by using hyperthermia. It is proposed that such a hyperthermic modality can produce thermal synovectomy in inflammatory arthritis. Heating the joint cavity up to 42 deg C can inhibit the enzymatic effect of collagenase, oxygenase, and other enzymes playing a role in the inflammatory process. If this hypothesis is correct, therapeutic intervention using hyperthermia may offer hope for the treatment of isolated inflammatory joint diseases.

HLA antigens in patients with Heberden's nodes

Tissue typing was performed on a group of 51 patients with Heberden's nodes (HN) (45 Ashkenazic and 6 non-Ashkenazic Jews). The frequency of HLA-DR2 was higher (P = 0.03) in the Ashkenazic patients than in the Ashkenazic controls. However, the association was not significant after correction for the number of tested alleles at that locus. In the second part of the study, HLA typing was performed on subjects from a family with multiple HN occurrences. Of the 13 family members typed, 9 had HN: 6 of these had the haplotype A2, Bw35, DR2. We conclude that the development of HN may be influenced by genetic factors. Our results may suggest an association between HN and HLA-DR2 in Ashkenazic Jews.

Heating rabbit joint by microwave applicator

Heating the joint to high temperatures using a microwave device may inhibit metabolic activity of the synovial tissue and enable higher penetration of antiinflammatory drugs into the joint cavity. To measure the temperature distribution of local thermotherapy, the hind joints of eight rabbits were heated by a 915 MHz microwave power source, using a special applicator. Temperatures of 44.0 +/- 2.8C, 36.1 +/- 3.8C, 39.6 +/- 2.3C, and 35.2 +/- 1.5C were measured after heating in the joint cavity, cartilage, muscle, and skin, respectively. The only significant increase in the temperature was recorded in the heated joint cavity (p less than 0.01). This new microwave device can be a therapeutic tool in treating joint diseases because of its advantage of heating the target organ only, eg, synovium, while sparing the adjacent tissues.

Juxta-articular adiposis dolorosa associated with rheumatoid arthritis. Report of 2 cases with good response to local corticosteroid injection

Juxta-articular adiposis dolorosa, i.e., painful fatty deposits around the joint may occur in postmenopausal obese women. The association of the syndrome with osteoarthritis has been described. The present report describes 2 women suffering from rheumatoid arthritis with painful fatty deposits around the knees. Both responded to local injection of corticosteroid. The possible pathogenesis of the source of pain is discussed.

An epidemic of suicide attempts by burning in a psychiatric hospital

Three patients attempted suicide by burning in one ward of a psychiatric hospital in a period of less than 1 month. No such attempts had occurred there in the previous 9 years. The three patients were schizophrenics with depressive features who occupied the same room in the ward. It seems reasonable to suggest that at least the choice of method and the timing of these suicide attempts were influenced by imitation. Hospital staff should be especially aware of the influence of imitation in suicide in order to avert such undesired epidemics.

Clinical manifestations and laboratory data of subacute cutaneous lupus erythematosus

Nine patients with subacute cutaneous lupus erythematosus (SCLE) are described, all of whom had systemic involvement of the disease although usually milder than in systemic lupus erythematosus. None of the patients had renal disease or died of SCLE.

Transcutaneous electrical nerve stimulation in experimental acute arthritis

Transcutaneous electrical nerve stimulation (TENS) is applied for the relief of various types of pain, including rheumatoid arthritis and osteoarthritis. This study evaluated the influence of TENS on intraarticular (IA) temperature and pressure and synovial tissue of inflamed rabbit joints. Four hours after induction of acute bilateral hind joint arthritis by single intraarticular injection of urate crystals, the knees of 14 anesthetized rabbits were fixed at 90 degrees between femur and tibia. TENS was supplied from an electrical stimulator to the left knee joint while the other joint was unstimulated as a control. A microprobe needle for temperature measurement was inserted into the knee joint. Intraarticular pressure was recorded by polygraph connected to an IA needle. Readings were carried out at 10-min intervals three times before and four times after 5 min of TENS. A significant increase in IA temperature from mean 36.2C to 36.6C and significant reduction of IA pressure (mean decrease of 0.8 mmHg, from 2.5 mmHg to 1.7 mmHg) were found in the stimulated joints, which also showed a reduction of synovial fluid volume and total leukocyte count in comparison to the controls. While the nonstimulated synovial membrane showed massive leukocytic infiltration with neutrophilic exudate and fibrin clot in the intraarticular cavity, the stimulated synovial membrane demonstrated moderate homogeneous leukocytic infiltration through all layers, with absence of inflammatory exudate in the intraarticular cavity. These results suggested that the analgesic effect of TENS on arthritis may be partially attributed to decrease in IA synovial fluid pressure, volume, and leukocyte count. Therefore, TENS may be useful for reducing pain from inflammatory arthritis.

Immunologic alterations in MRL/lpr mice after chronic dimethyl sulfoxide administration

Dimethyl sulfoxide (DMSO) in 1 and 2% concentration was added to the drinking water of 30-100 day MRL/lpr mice. In comparison to control mice, the DMSO treated mice had a 78% increase in their response to exogenous IL-2 and a 64% increase in production of IL-2. Con A stimulated cells had a net help effect in the untreated mice, which was suppressed from 82-26% after DMSO treatment. There was no marked change in Thy 1.2, Lyt 1 and Lyt 2 percentages after treatment. The anti-DNA decreased from 29.0 +/- 17.0% to 13.2 +/- 7.8% after DMSO treatment. We conclude that chronic DMSO administration to MRL/lpr mice can induce immunologic alterations with possible clinical implications.

Early recognition of tuberculous arthritis, assisted by CT scan and closed needle synovial biopsy

A patient with chronic monoarthritis erroneously diagnosed as osteoarthritis, in whom a high index of suspicion for tuberculosis, assisted by CT scan and closed needle synovial biopsy led to the relatively early and correct diagnosis and treatment of tuberculous arthritis is presently reported.

Use of macrophage inhibition factor and mast-cell degranulation tests for diagnosis of cloxacillin-induced cholestasis

Cloxacillin-induced cholestasis was diagnosed with the help of the macrophage inhibition factor and mast-cell degranulation tests. The simultaneous occurrence of both immediate type as well as cell-mediated hypersensitivity to the drug suggested that a defect in the histamine-induced suppressor cells may underly this cloxacillin-induced allergic reaction.

Pneumonectomy in pulmonary mucormycosis complicating Behçet's disease

A 37 year old man with Behçet's disease who was maintained on prolonged corticosteroid therapy, developed diabetic ketoacidosis and pneumonia. Secondary infection with mucor intervened with abscess formation cured by pneumonectomy. The association of Behçet's disease and mucormycosis has not been previously reported, although diabetes mellitus was almost certainly the predisposing cause. Surgical treatment offers the best chance of survival in similar cases.

Localized polyarteritis nodosa: cases involving the lower extremities and the breast

Two patients with cutaneous polyarteritis nodosa with nodules in the lower extremities and another patient with an unusual presentation of polyarteritis nodosa involving only the arteries of the breast are reported.

Bleeding due to thrombocytopenia in acute leukemias and reevaluation of the prophylactic platelet transfusion policy

Prophylactic platelet administration is indicated at counts below 20 X 10(9)/l. The bleeding tendency and severity were compared between thrombocytopenic patients with acute-lymphocytic leukemia (ALL) and acute non-lymphocytic leukemia (ANLL) in the ranges of 10-20 X 10(9)/l platelets, while prophylactic platelet administration was given only below 10 X 10(9)/l. The bleeding tendency for ALL was quite similar at platelet counts above or below 10 X 10(9)/l. The bleeding tendency was significantly lower (p less than 0.001) when the platelets were above this level in ANLL patients. When the thrombocytopenia was caused by chemotherapy, the bleeding was significantly lower in both types of leukemia above 10 X 10(9)/l (p less than 0.05 for ALL, p less than 0.001 for ANLL) as compared with lower counts. When the thrombocytopenia was caused by leukemia, the bleeding tendency was similar in both types of leukemia and at all platelet counts (below 20 X 10(9)/l). Fever, not associated with sepsis, augmented the bleeding severity of patients with ANLL. Stable or rising counts of platelets were associated with significantly lower bleeding tendency above 10 X 10(9)/l only in ANLL patients. The decision for prophylactic platelet administration at counts below 20 X 10(9)/l should be guided by the type of the leukemia (ALL vs. ANLL), the cause of thrombocytopenia (chemotherapy vs. leukemia per se), the trend of the platelet counts, presence of fever and patient's age (below or above 18 years).(ABSTRACT TRUNCATED AT 250 WORDS)

High levels of a common anti-DNA idiotype (16/6), a genetic marker for SLE

Six out of 8 healthy first-degree relatives of a patient with systemic lupus erythematosus (SLE) had very high serum levels of a common anti-DNA idiotype (16/6). In this family an additional sister developed SLE, and all members were heterozygous for C4 deficiency. Measurements of common autoantibody idiotypes may contribute to the understanding of the genetics of autoimmune diseases. They might be found useful in detecting healthy subjects prone to the development of an overt clinical state.

Parameters which can differentiate patients with "idiopathic" from patients with lymphoma-induced liver granulomas

Part of the "idiopathic" liver granulomas prove finally to be caused by infection, sarcoidosis, or malignancy. We looked for the initial admission parameters which may differentiate the idiopathic from the malignancy related granulomas. Patients with idiopathic granulomatous hepatitis had smaller spleen than of lymphoma related granulomas (2.15 +/- 2 versus 9.5 +/- 4.8 cm below the costal margin, p less than 0.01), smaller liver (2.61 +/- 2 cm versus 6.5 +/- 4.0 cm, p less than 0.05), a lower percent of eosinophils (2.3 +/- 1.4 versus 6.2 +/- 3.5%, p less than 0.05) and unlike patients with lymphoma, their fever did not persist beyond 4 wk (p = 0.03). Indeed, if the fever remitted spontaneously, it was likely that a benign condition was responsible for the granulomas (p less than 0.025). If fever persisted (4 wk), a liver or a spleen extending more than 4 cm below the costal margin and 4% eosinophils were attributed 1 point each; a score of 2 points had a specificity of 80 and a 100% sensitivity in detecting patients with lymphoma related liver granulomas. It is concluded that the size of the liver and spleen, the percentage of eosinophils, and the persistence of fever may differentiate between patients with idiopathic- versus lymphoma-related granulomatous hepatitis.

Imipramine for the treatment of fibrositis: a therapeutic trial

Twenty fibrositic patients were treated with imipramine 50-75 mg/day. Only two patients responded favourably. Nineteen patients stopped therapy during the initial three-month period: 14 of them due to lack of response, while two of these concomitantly disclosed side effects. The additional five patients stopped therapy mainly due to side effects, while only one of them improved with therapy. One patient, only, improved and adhered to therapy for more than three months.

Detection of cross-reactive anti-DNA antibody idiotypes in the serum of systemic lupus erythematosus patients and of their relatives

Two common cross-reacting anti-DNA antibody idiotypes designated 16/6 and 32/15, previously identified in the serum of patients who have systemic lupus erythematosus, were found in 24% and 7%, respectively, of 147 first-degree relatives. These findings imply that high-frequency germ-line genes exist among lupus relatives, as well as patients. These dominant or public anti-DNA antibody idiotypes are not likely to be pathogenic factors, but are probably a genetically associated phenomenon.

Amphotericin B causes aggregation of neutrophils and enhances pulmonary leukostasis

The influence of amphotericin B (AmB) on the aggregation of polymorphonuclear leukocytes (PMN) was examined by means of in vitro aggregometry as well as in an in vivo model of pulmonary leukostasis (PL). The AmB caused a dose-dependent aggregation of PMN that was partially blocked by addition of serum to the drug prior to its reaction with the PMN. No aggregation of PMN was seen after the addition of nystatin, a similar polyene antibiotic. In vivo studies were conducted in rabbits, where PL was induced by an intravenous infusion of zymosan-activated plasma (ZAP) or phorbol myristate acetate (PMA), and the degree of resulting leukostasis was expressed as the number of PMN per high power field (HPF). Animals in the control group had 6 +/- 3 PMN/HPF. This number increased to 12.4 +/- 5.6 when ZAP was infused and postmortem examination was performed 1 h later and to 17.4 +/- 4 if the examination was performed after 24 h. These numbers increased more than twice when AmB (1 mg/kg) was infused together with the ZAP. Increased PL after the infusion of ZAP and AmB was not attenuated by prior administration of methylprednisolone (30 mg/kg) to the animals. Infusions of AmB per se caused no significant PL but did cause increased pinocytosis in the pulmonary endothelium. Enhancement of PL by AmB was also examined in a model of PMA-induced PL.(ABSTRACT TRUNCATED AT 250 WORDS)

Nailfold capillary microscopy in essential mixed cryoglobulinemia: a report of several cases

Nailfold capillaries were examined in eight patients with essential mixed cryoglobulinemia. Two patients disclosed marked abnormality. These patients had no Raynaud phenomenon. Four patients with Raynaud phenomenon disclosed normal capillary patterns. Thus, microvascular pathology in essential mixed cryoglobulinemia is not related to Raynaud phenomenon.

The leukergy test in rheumatic diseases. New implications for an old test

In order to assess the value of the leukergy test in which leukocytes aggregate in citrated whole blood, we examined 65 patients with various rheumatic conditions. In addition, plasma samples from 40 patients were examined for neutrophil aggregation activity in vitro. Results of the leukergy test were found to be in very good correlation with disease activity (P = 0.0001), whereas no increased neutrophil aggregation activity was found in the 40 plasma samples examined. The value of the leukergy test in assessing patients with rheumatic disease and its theoretical etiopathogenic role in these diseases are discussed.

Absence of correlation between liver metastases and unexplained fever episodes

An accepted, although debatable explanation for fever of unexplained origin (FUO) in cancer patients is the presence of liver metastases. This controlled study was aimed to determine whether FUO is more common in patients with liver metastases (Group A) as compared to those without evidence of spread to the liver (Group B). One hundred forty-five patients were studied in each group. Fever of unknown origin was experienced by 45 patients of Group A (31%) and 39 of Group B (26.9%). The duration and the fever characteristics were comparable in both groups. There was no relationship between the extent of the liver metastases and the incidence of FUO. That FUO was not caused by the presence of liver metastases per se, is deduced also from the remission of fever in 18 preoperative episodes after the resection of the primary tumor only, in spite of the persistence of the liver metastases. The type of fever and its duration was similar in patients with or without liver metastases. Thirteen severe infectious conditions were missed by the premature adoption of the convenient diagnosis of "fever due to liver metastases." Indomethacin, administered to normalize the fever incorrectly attributed to the liver metastases, obscured four of the above infectious conditions, with a fatal outcome. The authors conclude that the existence of "fever due to liver metastases" as an entity is not supported by the current study, and that the premature adoption of this diagnosis further compromised the outcome of patients with liver metastases and unexplained fever.

Unexplained episodes of fever: an early manifestation of colorectal carcinoma

The possibility that fever may be an early manifestation of colorectal carcinoma was examined. Of 92 consecutive patients, 28 had preoperative fever. In four patients the fever was the presenting symptom of the colonic tumor, and in another six patients it preceded gastrointestinal complaints by 1 week to 4 months. Fever was thus the earliest manifestation of colorectal carcinoma in 10.8% of the patients. In 13 of the 28 patients the fever could not be explained by the intraoperative findings. We suggest that transient bacteremia may be a common but frequently overlooked manifestation of colonic cancer. Prognosis of the patient may be improved by alertness to the possibility that an episode of unexplained fever may be the first, and sometimes the only, manifestation of colorectal carcinoma.

Systemic lupus erythematosus six years following chemotherapy for malignant lymphoma

A 62-year-old woman who developed systemic lupus erythematosus 6 years following chemotherapy for malignant lymphoma is reported.

Hodgkin's and non-Hodgkin's lymphomas masquerading as "idiopathic" liver granulomas

Three patients presented with liver granulomas and fever. An intensive investigation was initially negative. Corticosteroids were administered with dramatic clinical improvement. Ten months to 3 years later, upon tapering the corticosteroid dose, the initial manifestations reappeared. In two patients Hodgkin's lymphoma was discovered and in a third histiocytic lymphoma. Thus, the diagnosis of lymphoma should be considered in patients with idiopathic liver granulomas, fever, and hepatosplenomegaly without lymph node enlargement, who respond initially to steroid administration but relapse upon tapering the dose.

Massive hemoptysis as a presenting sign of benign lymphocytic angiitis and granulomatosis

We report a patient with massive hemoptysis due to benign lymphocytic angiitis and granulomatosis complicated by reactivated tuberculosis. There was remarkably good response to treatment with chlorambucil, corticosteroids and antituberculous drugs.

Polymyalgia rheumatica and temporal arteritis in a married couple

A husband suffering from temporal arteritis and his wife afflicted with polymyalgia rheumatica are reported. The possibility of the existence of an environmental factor rather than a genetic etiology is discussed.

Spherulite crystals in synovial tissue of a patient with recurrent monoarthritis

Frozen, unstained sections of synovial tissue of a 38-year-old man with recurrent monoarthritis and hyperuricemia were studied. Negatively birefringent crystals in a spherulite form were detected by using a compensated polarized light microscope. It is postulated that in some cases of gout the first stage of crystallization is in the spherulite form.