Incidence of macrocytic anaemia in rheumatoid arthritis

Gastrointestinal and hepatic manifestations of rheumatoid arthritis

Rheumatoid arthritis (RA), characterized by inflammation of the synovium and surrounding structures, has a prevalence of 0.5-1%. Rheumatoid vasculitis (RV) is an inflammatory condition of the small- and medium-sized vessels that affects up to 5% of patients with RA with intestinal involvement in 10-38% of these cases. Clinically apparent RV of the gastrointestinal (GI) tract, while rare, is often catastrophic, resulting in ischemic ulcers and bowel infarction. Vasculitis of the colon may present as pancolitis clinically similar to ulcerative colitis. Rectal biopsies that include submucosal vessels are positive for vasculitis in up to 40% of cases. Abnormal esophageal motility in RA may result in heartburn and dysphagia. Chronic atrophic gastritis may be associated with hypergastrinemia and hypo- or achlorhydria, promoting small bowel bacterial overgrowth. RA is the most common cause of secondary amyloidosis with GI symptoms in 22% of affected patients. Although amyloid is usually found in the liver, it is rarely evident clinically. Felty's syndrome occurs in less than 1% of patients with RA and is characterized by neutropenia and splenomegaly. The liver may be involved with portal fibrosis or nodular regenerative hyperplasia. Liver histology is abnormal in 92% of RA patients at autopsy, although the changes are usually mild without associated hepatomegaly. Drug-induced liver disease may occur with aspirin, sulfasalazine, and methotrexate. Significant liver damage is rare if the drug is discontinued or the patient is properly monitored. RA can affect both the GI tract and the liver; changes are usually mild except with RV.

Vitiligo, rheumatoid arthritis and pernicious anemia

A patient with a 46-year history of vitiligo who also presented rheumatoid arthritis and pernicious anemia is described. Meticulous physical examination excluded further systemic or cutaneous involvement. The immunological workup revealed a low CD4 cell percentage with T cells mostly composed of CD8 cells, a discrepancy between the high percentage of cumulative CD4 + CD8 cells and the measured CD3 proportions, very low NK cytotoxicity toward K562 cells, and almost negligible responses to PHA, Con A and PWM mitogens. The results point to severe T and NK cell functional defects. The pathogenetic significance of these data is discussed.

Occurrence of autoantibodies against intrinsic factor, H,K-ATPase, and pepsinogen in atrophic gastritis and rheumatoid arthritis

The occurrence of autoantibodies against intrinsic factor, H,K-ATPase, and pepsinogen was analysed by means of enzyme-linked immunosorbent assay in three groups of sera. Group 1 comprised sera from 14 rheumatoid arthritis patients with normal acid secretion; group 2, sera from 18 rheumatoid arthritis patients with reduced acid secretion; and group 3, sera from 11 patients with pernicious anaemia or achylia. Groups 1 and 2 were rheumatoid factor-positive, and group 3 was negative. Intrinsic factor autoantibodies were low in groups 1 and 2. In group 3, 9 of the 11 sera (82%) scored positive. The highest titres of H,K-ATPase and pepsinogen autoantibodies were found in groups 2 and 3. Only one serum in group 1 scored positive against H,K-ATPase, and two against pepsinogen, whereas corresponding values were 11 (61%) and 7 (39%) in group 2, and 10 (91%) and 6 (55%) in group 3. Autoantibodies against H,K-ATPase from a pool of patient sera recognized both the alpha- and beta-subunits of the enzyme. The present results support the hypothesis of an autoimmune disease overlap between non-organ-specific rheumatoid arthritis and organ-specific pernicious anaemia.

The pathogenesis of anemia in rheumatoid arthritis: a clinical and laboratory analysis

Principal concepts concerning the anemia of RA are summarized in Tables 7 and 8. These concepts have been validated by our analysis of 93 anemic RA patients and by our review of the literature. The fact that anemia in RA may have one or more etiologies, occasionally in the same patient, mandates a reasoned approach to the analysis of anemia in every RA patient in whom it may occur. In particular, iron deficiency is common and determination of bone marrow iron content via an aspirate may be required for a definitive diagnosis. In those RA patients with anemia of chronic disease, the best therapy remains control of the underlying disease, most commonly with second line drugs and/or corticosteroids. The place for recombinant erythropoietin in the therapy of this anemia has not been defined; one specific role for erythropoietin may be in the preparation of RA patients for elective surgery, particularly hip arthroplasty, where correction of the anemia may either obviate the need for transfusion or may allow for donation of blood for purposes of autologous transfusion perioperatively. The pathogenesis of the anemia of chronic disease, as seen in RA anemia, is not completely understood. Inflammatory mediators, particularly the cytokines, appear to be important factors in the impairment of erythropoiesis. The mechanism by which these cytokines impair erythroid progenitor growth and hemoglobin production in developing erythrocytes is an important area for future study.

Upper gastrointestinal manifestations in rheumatoid arthritis patients: intrinsic or extrinsic pathogenesis?

Apart from the complication of gastrointestinal vasculitis it is not known whether the upper gastrointestinal (UGI) tract has any special disease characteristics in rheumatoid arthritis (RA). However, oesophageal motility disorders have been reported in 30% of RA patients. Hypergastrinaemia has been found in 23-43% of RA patients, usually in combination with a decreased gastric acid output. Another finding suggestive of a decreased secretory state, namely a decreased level of pepsinogen A, was found in RA patients with the sicca syndrome and in patients with active disease. The risk for peptic ulcer disease with regard to nonsteroidal anti-inflammatory drugs (NSAID) is possibly higher in RA patients than in patients with other rheumatic diseases. These findings suggest that in RA patients intrinsic factors play a role in the pathogenesis of the oesophageal motility disorders, in hypergastrinaemia and hypopepsinogenaemia and the related decreased gastric secretory state, and possibly in the increased susceptibility to NSAID-related ulcers. However, there are also indications that oesophageal motility disorders, hypergastrinaemia, and NSAID-related ulcers in RA are the result of extrinsic factors, mainly the use of NSAIDs. The effects of NSAIDs and gold compounds on infection with Helicobacter pylori, a possible pathogenetic factor in ulcer disease, is discussed. It is clear that the discussion about intrinsic and extrinsic factors as a cause of the UGI manifestations in RA remains an intriguing but difficult subject for further studies.

Sjögren's Syndrome Associated with Vitamin B(12) Deficiency

Three patients showing Sjögren's syndrome in association with macrocytic anemia due to vitamin B(12) deficiency are described. Antibodies to parietal cells, intrinsic factor and salivary protein were investigated; positive test results were obtained in different combinations. Addisonian pernicious anemia as well as vitamin B(12)-malabsorption because of anti-intrinsic factor antibodies in gastric juice and/or malabsorption due to changes in the intestinal wall induced by Sjögren's syndrome are possible etiological factors. A case of Sjögren's syndrome associated with positive anti-parietal cell antibodies and histaminerefractory achylia is also reported. The concurrence of these two diseases known to be associated with autoimmune responses suggests the possibility of similar pathogenesis.

Sulphasalazine for rheumatoid arthritis: toxicity in 774 patients monitored for one to 11 years

Sulphasalazine is being used increasingly to treat rheumatoid arthritis, though its long term safety profile has not been established in this condition. The incidence and nature of adverse effects occurring in 774 patients with rheumatoid arthritis treated with sulphasalazine for periods ranging from one to 11 years were therefore noted. Altogether 205 of the patients stopped treatment permanently due to an adverse effect. One hundred and fifty six (76%) of these events occurred within three months and few beyond the first year. Most events were trivial and were self limiting after withdrawal of the drug; of the potentially more serious adverse effects, 33 (66%) occurred within three months of treatment. None of the patients died or suffered lasting ill effects. It is concluded that adverse effects of treatment with sulphasalazine are generally seen within three months; though regular monitoring is desirable during that period, thereafter few worrying problems occur.

IMMUNOLOGICAL DISTURBANCES IN MYASTHENIA GRAVIS WITH A REPORT OF HASHIMOTO'S DISEASE DEVELOPING AFTER THYMECTOMY

Images