In vivo LE cell formation in synovial fluid

Lupus erythematosus cell in body fluids: A case report and review of literature

The diagnosis of systemic lupus erythematosus (SLE) has undergone radical change after the development of serological techniques. The in vitro demonstration of lupus erythematosus (LE) cell has less significance for the diagnosis of SLE in the present scenario. Although over the years, the spontaneous in vivo occurrence of LE cell in numerous body fluids as an initial presentation of SLE has been documented. The report of the presence of the LE cell can not only aid in the further workup of the patient but also suggest the involvement of a particular organ or body cavities by SLE. The morphology and mimickers of the LE cell should be cogitated and meticulous search of such cells should play an important role in the evaluation of body fluids. In our case, the patient presented at emergency with pericardial tamponade and cytological evaluation of the pericardial fluid demonstrated in vivo presence of LE cells. The serological work-up then confirmed the case to be SLE. This report and review of literature wish to highlight the fact that this cell still plays a significant role even in the era of immunoassays.

Synovial fluid cells in systemic lupus erythematosus: light and electron microscopic studies

Joint fluid findings in systemic lupus erythematosus (SLE) have been described in only a few series and systematic electron microscopic study of the synovial fluid (SF) cells has not been reported. We describe the evaluation of 17 SF in patients with SLE with routine analysis and electron microscopy. Joint effusions had a wider range of leukocyte counts than often appreciated, with counts varying from 875 to 39,250 cells per mm3. LE inclusions were seen in eight fluids and have been shown to contain chromatin-like filaments by electron microscopy. There was little associated electron dense immunoglobulin-like material. Tubuloreticular structures (TRS) found in seven SF were mostly in mononuclear cells including some LE cells. The known association of TRS with alpha interferon and viral infections may have important implications for pathogenesis.

Diagnostic value of synovial fluid microscopy: a reassessment and rationalisation

This study is in two parts. In the first synovial fluid from 1892 patients with 14 different arthropathies was examined microscopically. Crystals of different types were identified and the disease distribution of these and various cell types, including several not previously reported in synovial fluid, have been described. These features have been used to derive a series of microscopic diagnostic criteria for each arthropathy. The criteria have been used in the second part of the study to examine synovial fluids from 200 patients without knowledge of any clinical diagnosis. Cytological and clinical diagnoses were compared at the end of the study. Matching diagnoses were made in 71 (35.5%) and a short list of differential diagnoses (based on cytological criteria), which included the clinical diagnosis, was made in a further 43 (21.5%). Of the rest, 63 (31.5%) were correctly described as inflammatory or non-inflammatory and in five (2.5%) no diagnosis could be made. Only in seven cases (3.5%) was an inaccurate (false positive) cytological diagnosis made. The results indicate that synovial fluid microscopy is a potentially more important diagnostic screening test in rheumatological and orthopaedic practice than it would at first appear from published reports.

Synovial fluid characteristics and the lupus erythematosus cell phenomenon in drug-induced lupus. Findings in three patients and review of pertinent literature

The characteristics of synovial fluid obtained from 3 patients with drug-induced lupus erythematosus are described. Two patients had "inflammatory" counts of synovial leukocytes, in the range of 2,500-39,000/mm3, with mononuclear predominance in 1 patient and neutrophil predominance in the other. The third patient had "noninflammatory" fluid, with mononuclear predominance. Lupus erythematosus cells formed in vivo were observed in the synovial fluid of 2 of the patients. Biopsy of the synovium of 1 patient showed nonspecific chronic inflammatory changes. Our findings in these patients with drug-induced lupus are indistinguishable from those previously described in patients with idiopathic lupus erythematosus.

Anti-Sm and anti-DNA antibodies in paired serum and synovial fluid samples from patients with SLE

Antibodies to nuclear antigens (ANAs) are frequently found in the serum of patients with connective tissue diseases (CTDs). Particularly systemic lupus erythematosus (SLE), and have been implicated in the immune-complex mediated pathogenesis of these diseases. In this study we have compared the occurrence of precipitating ANAs in paired samples of serum and synovial fluid from patients with different CTDs. Of the 30 patients examined 3 had precipitating ANAs in their serum only, 1 in the synovial fluid only, and 3 had antibodies in both serum and synovial fluid. Precipitating ANAs in synovial fluid were found in 3/6 patients with SLE, 1 patient with RA/Sjogren's syndrome overlap, and one patient with RA/SLE overlap. Of the other 15 patients with RA, 2 had precipitating antibodies only in their serum. Two of the SLE patients had anti-Sm antibody, one in serum only and the other in both serum and synovial fluid. Detection by ELISA of class specific anti-Sm antibodies in serum or synovial fluid paralleled the occurrence of antidenatured DNA antibodies when both specificities occurred together. One SLE patient did show evidence in synovial fluids of elevated concentrations of specific antibody classes to individual antigens; however, elevated levels were more frequently found in serum. Local production of ANAs does not, therefore, appear to be a feature of synovial fluids from SLE patients.

Cytologic examination of synovial fluid

Cytologic study of synovial fluid has been relatively neglected both by cytologists and rheumatologists. Currently identified implications of cytologic findings include definitive diagnoses of a variety of joint diseases such as those due to malignancies, infections, or pathogenic crystals. Diagnoses can also be strongly suggested, for example, by visualization of lupus erythematosus cells formed in vivo. Immunocytochemistry is being explored for diagnostic and pathogenetic implications. We propose that complementary techniques used in our cytology and rheumatology laboratories may provide new insights into the clinical significance of cellular changes in joint fluids.

Drug-induced lupus erythematosus with in vivo lupus erythematosus cells in pleural fluid

Pleural involvement in drug-induced lupus erythematosus is not uncommon. Lupus erythematosus cells were found in vivo in the pleural of an elderly patient who had received procainamide (Pronestyl) hydrochloride (2 gm daily) for nine months. Patients who initially have pleural effusions while receiving drugs capable of inducing lupus erythematosus should have the fluid analyzed for lupus erythematosus cells to help clarify the cause of the effusion.