Effect of corticosteroid treatment on hemopoiesis in vivo and in vitro in a patient with Felty's syndrome

We have studied the CFU-GM and BFU-E in vitro growth in a neutropenic and anemic patient with Felty's syndrome, either before or one and three months after steroid therapy when neutrophils and erythrocytes returned to normal. Both CFU-GM growth and CSA production were found to be low before therapy, and prednisone was shown to raise them to normal levels. The in vitro growth of BFU-E and the production of BPA by T lymphocytes of the patient were significantly lower than normal when studied before therapy. However, the T lymphocytes incubated in vitro with hydrocortisone regained their ability to stimulate the BFU-E growth. After prednisone therapy both BFU-E growth and BPA production by T lymphocytes returned to normal. Possible pathogenetic mechanisms of impaired granulo- and erythropoiesis in Felty's syndrome are discussed. The in vitro study with hydrocortisone can help to identify steroid-sensitive patients.

Improvement of pneumonia and arthritis in Felty's syndrome by treatment with granulocyte-macrophage colony-stimulating factor (GM-CSF)

A 63-year old man with Felty's syndrome and pneumonia of unknown origin was treated with GM-CSF. Granulocyte counts increased and arthritis-related symptoms improved under GM-CSF. Pneumonia was treated effectively with antibiotics only during or after GM-CSF application. This suggests, that antibiotic-resistant infections can be treated effectively in patients with Felty's syndrome when granulocyte counts are raised by GM-CSF.

Felty's syndrome: response to low dose oral methotrexate

We describe a case of Felty's syndrome with persistent severe neutropenia below 200 granulocytes/mm3, splenomegaly and repeated infections. The patient did not respond to treatment with intramuscular gold salts and lithium carbonate. After 2 months of oral methotrexate administration, 7.5 mg weekly, clinical improvement was notable: she remained afebrile, neutropenia disappeared and splenomegaly regressed. This clinical and laboratory improvement persisted 5 months later. Moreover, accidental discontinuance of the drug and later readministration supported the evidence that the improvement was due to methotrexate.

Felty's syndrome without concomitant arthritis: a variant

A young female patient who had documented seropositive rheumatoid arthritis and was treated consecutively with aspirin, diclofenac, and gold salts was admitted years later for severe neutropenia. On examination she had, in addition, fever, positive rheumatoid factor, reversible swan-neck deformity of the fingers but otherwise normal joint findings. The patient responded to prednisone therapy. This case would appear to be a most unusual variant of Felty's syndrome.

Reversal of neutropenia with methotrexate treatment in patients with Felty's syndrome. Correlation of response with neutrophil-reactive IgG

We evaluated the clinical and hematologic response to methotrexate (MTX) in 4 women with Felty's syndrome (FS) who had had neutropenia for 1-3 years. Since immune complexes or antineutrophil antibodies are implicated in the pathogenesis of the neutropenia of FS, we also measured both direct and indirect levels of neutrophil-reactive IgG. All 4 patients showed a prompt and dramatic increase in neutrophil counts within 1-2 months of starting MTX therapy. In 3 patients, the symptoms of arthritis also improved; in the fourth patient, arthritis worsened. Recurring infections ceased in 3 patients. Neutrophil-reactive IgG levels, which were elevated in all patients prior to treatment, decreased toward normal while the patients were receiving MTX therapy. We conclude that MTX is effective in treating the neutropenia of FS, in part by lowering neutrophil-reactive IgG.

A phase I study of therapy with recombinant granulocyte-macrophage colony-stimulating factor administered by IV bolus or continuous infusion

Sixteen patients with primary or secondary bone marrow failure were treated with recombinant human granulocyte-macrophage colony-stimulating factor (rGM-CSF) given as either an intravenous bolus or by continuous infusion. The dose range studied was from 15 micrograms/m2/d to 960 micrograms/m2/d. Administration of rGM-CSF on a bolus schedule failed to elicit a hematologic response, but resulted in side effects of epigastric distress and eructation in over 30% of administered courses. Administration of rGM-CSF by continuous infusion resulted in a dose-dependent increase in the total leukocyte, granulocyte, and eosinophil counts. The mean maximal rise in granulocyte count was 8.5-fold. After cessation of therapy, blood counts returned to near baseline in most patients by 7 days. A 36 percent decrease from baseline in mean serum cholesterol level was observed in the continuous infusion group, but not in patients receiving rGM-CSF as an IV bolus. Fever, fatigue, and bone pain were dose-limiting in the continuous infusion group at a dose of 240 micrograms/m2/d. The maximally tolerated dose was 480 micrograms/m2/d. No life-threatening toxicities were observed in either group. Our data demonstrate that continuous infusion rGM-CSF is biologically active and non-toxic at a dose of 120 micrograms/m2/d in patients with bone marrow failure.

Felty's syndrome: long-term followup after treatment with auranofin

Five patients who had Felty's syndrome were treated with auranofin, 6 mg/day, for a period that ranged from 4 months to 2 years. All patients experienced both an improvement in articular symptoms and a normalization of the leukocyte count. Auranofin appears to be an effective treatment for Felty's syndrome, and to have a lower degree of toxicity than parenteral gold.

[Treatment of Felty's syndrome accompanied by agranulocytosis using high-dose corticoids. 3 cases]

Three cases of severe Felty's syndrome (neutrophils 80/mm3 in 2 cases and 800/mm3 in one) with enlarged spleen (1 case) and leg ulcer (2 cases) were treated with high doses of corticosteroids (methylprednisolone 1 g by intravenous infusion over 3 hours, on 3 consecutive days). In all 3 patients a dramatic result was obtained, the granulocytes returning to normal values in 24 to 48 hours. In 2 cases, an early relapse (1 month) required a second course in high dosage; after a follow-up of 36 and 8 months respectively, the number of granulocytes remains stable under prednisone 5 to 10 mg/day. The third patient was improved by one single course of infusions and remains stable after 18 months. It must be noted that one patient had previously been treated with plasma exchange and another with corticosteroids without any significant result.

Reversal of depressed neutrophil superoxide production in Felty's syndrome after gold therapy

Six patients with Felty's syndrome were reevaluated after a course of chrysotherapy. In 5 patients, white cells and absolute neutrophil counts had returned to normal. In 4 of these, there was significant concomitant improvement in neutrophil function as assessed by the ability of cells to generate superoxide radicals.

Treatment of Felty's syndrome with low-dose oral methotrexate

Recent studies of methotrexate in the treatment of patients with rheumatoid arthritis have precluded patients with neutropenia. We present a patient with rheumatoid arthritis complicated by severe neutropenia and recurrent infections, who was treated with low-dose methotrexate, orally, for 30 months. The patient experienced symptomatic improvement and a significant increase in granulocyte count, and the dosage of steroids was reduced. Low-dose oral methotrexate may be a therapeutic option in select patients with Felty's syndrome.

Parenteral gold therapy in the Felty syndrome. Experience with 20 patients

Most of the patients with the Felty syndrome suffer from such complications as fevers, infections, cutaneous ulcers, and vasculitis. Unfortunately, there are no therapeutic interventions that are predictably beneficial. We report our experience with 20 patients who received parenteral gold therapy for 2 to 114 months (mean, 23.6 months). All had complications of the Felty syndrome. On parenteral gold therapy, 60% had a complete response, 20% had a partial response, and 20% were unresponsive by preselected criteria. No serious complications were encountered. We think that parenteral gold therapy should be considered early, before other agents, in the treatment of this condition.

Lithium carbonate therapy in severe Felty's syndrome. Benefits, toxicity, and granulocyte function

Lithium carbonate was administered to six patients with severe Felty's syndrome, five of whom had problems with infection. Two patients had granulocyte increments that persisted after therapy was discontinued; in one of them problems with infections resolved. In another patient a transient granulocyte rise accompanied treatment. There was no response in three patients. Granulocyte function was measured in three patients during treatment. It was normal except for subnormal hexose monophosphate shunt activity in two patients. Although serum lithium levels were less than 1.5 mmole/L, serious toxic effect occurred in one patient and significant side effects in the other five. These results support a short trial of lithium carbonate therapy in patients with severe symptomatic Felty's syndrome. Potentially beneficial granulocyte increases occur in a minority of patients only, however, and side effects and toxic effects are common.