Rheumatoid arthritis patients with peripheral blood cell reduction should be evaluated for latent Felty syndrome: A case report

RATIONALE

Felty syndrome is a rare and life-threatening type of rheumatoid arthritis (RA).

PATIENT CONCERNS

A patient with RA had skin rash and subcutaneous hemorrhage, with a significant decrease in blood hemoglobin (Hb), white blood cell count (WBC), and blood platelet count (BPC).

DIAGNOSES

The patient had a history of RA, splenomegaly, decreased Hb, WBC, BPC, and normal immunological indexes, combined with a series of bone marrow related tests and genetic tests.

INTERVENTIONS

She was given high-doses of glucocorticoids intravenously, followed by oral prednisone and cyclosporine maintenance therapy.

OUTCOMES

Her symptoms were resolved within 2 weeks after the start of immunosuppression. After 2 weeks of discharge, the Hb, WBC, BPC basically returned to normal, and prednisone gradually decreased.

LESSONS

Felty syndrome is a rare complication of RA. Reductions in Hb, WBC, BPC, and subcutaneous hemorrhage should be considered strongly as the possibility of Felty syndrome. Multi-disciplinary diagnosis and related tests of bone marrow and genes are helpful for diagnosis and correct treatment.

Hematological Manifestations among Patients with Rheumatic Diseases

BACKGROUND

Rheumatic diseases have many hematological manifestations. Blood dyscrasias and other hematological abnormalities are sometimes the first sign of rheumatic disease. In addition, novel antirheumatic biological agents may cause cytopenias.

SUMMARY

The aim of this review was to discuss cytopenias caused by systemic lupus erythematosus and antirheumatic drugs, Felty's syndrome in rheumatoid arthritis, and autoimmune hemolytic anemia, thrombosis, and thrombotic microangiopathies related to rheumatological conditions such as catastrophic antiphospholipid syndrome and scleroderma renal crisis. Key Message: The differential diagnosis of various hematological disorders should include rheumatic autoimmune diseases among other causes of blood cell and hemostasis abnormalities. It is crucial that hematologists be aware of these presentations so that they are diagnosed and treated in a timely manner.

[Not Available]

Zusammenfassung. Das Felty-Syndrom ist eine komplizierte und seltene Form der rheumatoiden Arthritis mit Splenomegalie und Neutropenie, das von A. R. Felty im Jahr 1924 erstmals beschrieben wurde und dessen Diagnose klinisch gestellt wird. Das Felty-Syndrom geht mit hoher Entzündungs- und regelmässig hoher Krankheitsaktivität einher. Die Prognose ist aufgrund der hohen Inzidenz von Infekten schlecht. Die Ursache ist noch unklar; diskutiert werden eine chronische Entzündungsreaktion und eine entsprechende individuelle Disposition. Differenzialdiagnostisch müssen maligne Erkrankungen des Blutes ausgeschlossen werden. Die Therapie der Wahl ist Methotrexat, bei fehlendem Ansprechen können andere DMARDs (Disease-Modifying Anti-Rheumatic Drugs) in Erwägung gezogen werden; die Therapie mit Steroiden in der akuten Infektsituation ist kontrovers. Weitere Therapieoptionen wurden bisher nur in kleinen Fallstudien beschrieben. Von TNF-α-Inhibitoren wurde in einer Kleinstudie mit sechs Patienten über Unwirksamkeit berichtet. Der CD-20-Antagonist Rituximab (Mabthera®) hat in einer Studie mit acht Patienten bei der Mehrheit (n = 5) einen Anstieg der neutrophilen Granulozyten gezeigt. Als Wirkmechanismus wird eine Einflussnahme auf Anti-G-CSF-Antikörper diskutiert.

Felty's Syndrome: A Qualitative Case Study

Felty's syndrome is a triad of rheumatoid arthritis, splenomegaly, and neutropenia. This rare disorder is difficult to diagnose and produces many complications. The purpose of this descriptive qualitative case study was to provide a comprehensive, context-bound understanding of one patient's struggle with the condition.

One case of Felty's syndrome efficiently treated with rituximab

Felty's syndrome (FS) is a rare association of rheumatoid arthritis (RA), neutropenia and splenomegaly. Mechanisms of neutropenia in FS are unclear but involve both innate and humoral immunity, impaired granulopoiesis and decreased granulocyte half-life. Several treatments have been used without clear efficiency. We report a patient with FS efficiently treated with rituximab (RTX), the monoclonal anti-CD20 antibody. A literature review of FS treated with RTX was performed.

Diffuse disseminated candidiasis in a patient with Felty's syndrome: a case report

Severe granulocytopenia predispose patients with Felty's syndrome to severe infectious diseases. The following report deals with an occurrence of chronic disseminated candidiasis in a patient with Felty's syndrome who presented with prolonged and severe granulocytopenia. To the best of our knowledge this coexistence has never been described before.

[Corticosteroid resistance thrombocytopenia in connective tissue disorders and vasculitis]

In rheumatic diseases there can appear deteriorations of the thrombocytes number in the sense of increase or decrease of this number.Thrombocytosis has 3 major causes: (1) reactive or secondary thrombocytosis; (2) family thrombocytosis and (3) clonal thrombocytosis. Thrombocytopenia, that is, decrease of the thrombocytes number below 150000/mmc is unusually in rheumatic diseases. Their mechanism of production can be central and peripheral. In the connective tissue disorders and vasculitis thrombocytopenia can has different causes: (1) decrease thrombocytes production; (2) splenic platelets sequestration; (3) peripheral platelets consumption; (4) peripheral immune mediated destruction of platelets. Thrombocytopenia is present in the following rheumatic diseases: systemic lupus erythematosus, antiphospholipid syndrome, rheumatoid arthritis, Felty syndrome, vasculitis. Steroids are the conventional first line therapy for immune thrombocytopenia. Corticosteroid resistance can develop as a result of deteriorations that appear to the any level of pathway action of corticosteroids.

Pathogenesis of neutropenia in large granular lymphocyte leukemia and Felty syndrome

T-cell large granular lymphocyte leukemia (TLGL) is an atypical chronic lymphoproliferative disorder derived from cytotoxic T-cells (CTL). Unlike most forms of leukemia, the pattern of bone marrow infiltration in TLGL may be subtle and the cytopenias are often lineage specific, with neutropenia dominating. Both granulocytic survival and proliferation defects are observed and are mediated by humoral and cell-mediated mechanisms respectively. Splenic production of immune complexes induces a neutrophil survival defect, where as Fas expression by leukemic CTL results in a marrow based proliferation defect. These humoral and cell-mediated pathways induce granulocytic apoptosis through independent intracellular mechanisms which are not mutually exclusive and may be observed concurrently in individual patients with either TLGL or FS. A variety of therapeutic interventions have been utilized in the management of TLGL and Felty syndrome, including methotrexate, cyclosporine A, cyclophosphamide, glucocorticoids, myeloid colony stimulating factors and splenectomy. Their efficacy and mechanisms of action are reviewed.

Longterm outcome of treatment of Felty's syndrome with intramuscular gold: case reports and recommendations for management

OBJECTIVE

To evaluate the incidence, complications, and course of Felty's syndrome (FS) in patients treated with intramuscular (IM) gold.

METHODS

Retrospective chart review of all FS cases (1979 to 2003) was conducted in the Mary Pack Arthritis Centre (MPAC) gold clinic. FS was diagnosed if patients had rheumatoid arthritis (RA; American College of Rheumatology criteria) and persistent leukopenia [white blood cell (WBC) count < 4] in the absence of other known causes of leukopenia. Splenomegaly was not part of the inclusion criteria.

RESULTS

Thirteen patients with FS were identified in the gold clinic population. The mean age at diagnosis of FS was 58.7 years and the mean duration of RA at time of diagnosis was 6.9 years. The weekly dose of gold ranged from 10 mg to 50 mg depending on tolerability. Gold therapy resulted in normalization of the WBC count in 9 of 13 patients. The mean time to normalization of the WBC was 40 weeks. Only one patient with FS had experienced recurrent infectious complications from FS, and this did not recur after gold treatment was initiated. No patient had vasculitis.

CONCLUSION

In our gold clinic population FS is a mild disease and is rarely associated with infectious complications. Gold is an effective treatment of FS.

Felty's syndrome

Felty's syndrome (FS) comprises a triad of rheumatoid arthritis (RA), neutropenia and splenomegaly, occurring in less than 1% of RA patients. Clinically it is characterized by severe joint destruction contrasting with moderate or absent joint inflammation and severe extra-articular disease, including a high frequency of rheumatoid nodules, lymphadenopathy, hepatopathy, vasculitis, leg ulcers, skin pigmentation etc. Recurrent bacterial infections are mostly due to the severe, otherwise unexplained neutropenia. The cause of neutropenia lies in both decreased granulopoiesis and increased peripheral destruction of granulocytes. Recurrent infections may lead to increased mortality. Spontaneous remission of the syndrome also occurs. Over 95% of FS patients are positive for rheumatoid factor (RF), 47-100% are positive for antinuclear antibody (ANA), and 78% of patients have the HLA-DR4*0401 antigen. Some 30% of FS patients have large granular lymphocyte (LGL) expansion. LGL expansion associated with uncomplicated RA is immunogenetically and phenotypically very similar to but clinically different from FS. Neutropenia of FS can be effectively treated with disease-modifying anti-rheumatic drugs (DMARDs), the widest experience being with methotrexate (MTX). Results of treatment with granulocyte colony-stimulating factor (G-CSF) are encouraging, but there is no experience with other biological agents. Splenectomy results in immediate improvement of neutropenia in 80% of the patients, but the rate of infection decreases to a lesser degree.

Salazosulfapyridine-induced remission of Felty's syndrome along with significant reduction in neutrophil-bound immunoglobulin G

Felty's syndrome is characterized by neutropenia, splenomegaly, and leg ulcers in patients with rheumatoid arthritis. The pathogenesis of the neutropenia is an immune-mediated process that involves immune complexes, antineutrophil antibodies, and abnormal white cell kinetics. We prescribed salazosulfapyridine to a 65-year-old woman with this syndrome. The neutropenia improved along with a reduction in neutrophil-bound IgG, demonstrated by flow cytometric analysis. Salazosulfapyridine may be of benefit for the treatment of Felty's syndrome, and flow cytometry can be used to monitor disease activity and therapeutic efficacy.

Treatment of Felty's syndrome with leflunomide

Felty's syndrome (FS) is a rare manifestation of severe rheumatoid arthritis (RA). It is an immune mediated inflammatory process, usually treated with standard disease modifying antirheumatic drugs. We describe a case of severe FS that developed in a patient receiving methotrexate therapy for RA. Treatment with etanercept resulted in severe allergic cutaneous reactions. The patient subsequently responded to treatment with leflunomide. The response included dramatic improvement of leukopenia and neutropenia as well as excellent control of his arthritis. Leflunomide has recently been used effectively for the treatment of RA and may be useful for the management of patients with FS.

Pure red cell aplasia in Felty's syndrome: a case report of successful reversal after cyclosporin A treatment

We describe the first report of a patient with Felty's syndrome who developed pure red cell aplasia, likely not attributable to medication, that was successfully treated with cyclosporin A.

Primary aspergillosis of the larynx in a patient with Felty's syndrome

Herein we report the first case of primary aspergillosis of the larynx in a patient with Felty's syndrome. A 53-year-old man, a florist by profession, with a 12-year history of rheumatoid arthritis and on treatment with steroids, was admitted because of hoarseness, and intermittent fever of 2 weeks' duration. On admission, physical examination and laboratory data showed, among other findings, splenomegalia and neutropenia. At bone marrow examination, normal cellularity with mild dyserythropoiesis was observed. A fiberoptic laryngoscopy showed white plaques on both the true vocal cords. Both culture and microscopic examination of these lesions provided the diagnosis of invasive process by Aspergillus flavus. A computed tomography of the middle ears, paranasal sinuses, and chest was normal. Thus, primary aspergillosis of the larynx and Felty's syndrome was diagnosed, and the patient was successfully treated with granulocyte colony-stimulating factor and systemic antifungal agents. Felty's syndrome, corticosteroid use, and occupational risk probably rendered our patient susceptible to Aspergillus infection.

[Felty's syndrome]

BACKGROUND

Felty's syndrome is a complication of rheumatoid arthritis whereby patients develop neutropenia of varying severity and splenomegaly. The major sources of morbidity and mortality are recurrent local and systemic infections, although some patients remain asymptomatic.

MATERIAL AND METHODS

In this paper two patients with Felty's syndrome are presented.

RESULTS

One patient had recurrent infections. Clinical manifestations, laboratory features and different modalities of treatment are reviewed.

INTERPRETATION

Splenectomy has long been standard therapy, but disease modifying antirheumatic drugs (such as gold salts and methotrexate) and colony stimulating factors should also be considered in Felty's neutropenia complicated with infections.

[LGL syndrome can imitate Felty's syndrome. The diagnosis can be established by a simple test]

The article consists in a discussion of neutropenia caused by large granular lymphocytes (LGLs), illustrated by a review of the literature and case reports of five patients with LGL syndrome and one patient whose clinical characteristics were more consistent with classic Felty's syndrome. Recent years have witnessed advances in our knowledge of clonal expansions of suppressor-type T-cells and their capacity to induce neutropenia. The phenotypes of such cells are CD3+, CD8+ and CD57+. The syndrome is often seen in patients with rheumatoid arthritis, and if they also manifest splenomegaly it may be confused with Felty's syndrome. Appropriate evaluation and treatment of the condition are also discussed, and an attempt made to clarify the confusing terminology.

Treatment of Felty's syndrome with the haemopoietic growth factor granulocyte colony-stimulating factor (G-CSF)

Felty's syndrome (FS) (rheumatoid arthritis with neutropenia and splenomegaly) has a poor prognosis, largely because of the high risk of severe infection. Granulocyte colony-stimulating factor (G-CSF) is an emerging treatment for chronic neutropenia. We prospectively monitored its use in eight patients with recurrent infections or who required joint surgery. Significant side-effects were documented in five, including nausea, malaise, generalized joint pains, and in one patient, a vasculitic skin rash. In two patients treatment had to be stopped, and in these cases G-CSF had been started at full vial dosage (300 micrograms/ml filgrastim or 263 micrograms/ml lenograstim) alternate days or daily. G-CSF treatment was continued in three patients by restarting at reduced dose, and changing the proprietary formulation. G-CSF raised the neutrophil count, reduced severe infection, and allowed surgery to be performed. A combined clinical and laboratory index suggested that long-term treatment (up to 3.5 years) did not exacerbate the arthritis. Once on established treatment, it may be possible to use smaller weekly doses of G-CSF to maintain the same clinical benefit. One of the three patients whose FS was associated with a large granular T-cell lymphocytosis showed a reduction in this subset of lymphocytes during G-CSF treatment.

Use of colony-stimulating factors in the treatment of neutropenia associated with collagen vascular disease

Chronic neutropenia associated with collagen vascular disease is seen principally with Felty's syndrome complicating rheumatoid arthritis. Multiple recent reports document the efficacy of both granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF) in reversing the neutropenia and decreasing the risk of infections in Felty's syndrome. Long-term use of G-CSF appears well tolerated and effective in Felty's syndrome. Of concern, however, have been flares of arthritis and development of leukocytoclastic vasculitis in several patients following the use of colony-stimulating factors (CSFs) in Felty's syndrome. The incidence of these complications of CSF therapy appears to be greater in Felty's syndrome than in other disorders. Future studies will need to address the incidence of these side effects, evaluate strategies to reduce risks, and clarify the optimum use of CFSs in Felty's syndrome.

[Felty syndrome: a therapy-resistant variant of chronic rheumatoid arthritis? 2 case reports and literature review]

Felty's syndrome is a rare but serious extra-articular manifestation of rheumatoid arthritis. Morbidity as well as mortality are increased on account of greater susceptibility to infectious agents. We report on two patients suffering from Felty's syndrome who were successfully treated by cyclophosphamide. A review of the literature with special regard to treatment of Felty's syndrome is given.

Resolution of the neutropenia of Felty's syndrome by longterm administration of recombinant granulocyte colony stimulating factor

Felty's syndrome is characterized by neutropenia, splenomegaly, and recurrent infection in patients with rheumatoid arthritis. We used recombinant granulocyte colony stimulating factor (rGCSF) in a patient with Felty's syndrome and recurrent sepsis. rGCSF induced a statistically significant increase in the patient's absolute neutrophil and total white blood cell counts. During 14 months of followup taking rGCSF, disseminated varicella zoster was the only infectious complication. Except mild thrombocytopenia and a transient flare of arthritis, no serious adverse effects occurred. rGCSF may be a safe and effective therapy for Felty's syndrome in selected patients.

Pseudo-felty's syndrome. Report of a case with no symptoms for at least 15 years

The prognosis of large granular lymphocyte proliferation with rheumatoid arthritis (pseudo-Felty's syndrome) remains uncertain. We report a case with a 15-year follow-up. To date, the patient has not developed lymphadenopathy, splenomegaly, abnormalities in erythrocyte or platelet counts, neutropenia or severe or unexplained infections. This favorable course is not ascribable to an unusual lymphocyte phenotype (CD3+, CD8+, CD57+). A beneficial effect of methotrexate therapy is possible.

Hematologic and cytofluorographic analysis of patients with Felty's syndrome. A hypothesis that a discrete event leads to large granular lymphocyte expansions in this condition

OBJECTIVE

To compare hematologic and cytofluorographic features in Felty's syndrome (FS) patients with and without the large granular lymphocyte (LGL) syndrome.

METHODS

Peripheral blood cells from FS patients and from 2 control groups (rheumatoid arthritis [RA] patients and subjects without symptoms of a rheumatic disease) were analyzed by hematologic and cytofluorographic techniques. A separate assessment of disease activity was performed.

RESULTS

FS patients had reduced lymphocyte and platelet counts, with a parallel reduction in lymphocyte subsets examined. CD4 counts were reduced in all FS patients, including those with the LGL syndrome. Disease activity was lower in FS patients than in RA control patients. Treatment was similar in all patient groups. No direct association was seen between LGL numbers and duration of RA or neutrophil counts in RA groups.

CONCLUSION

Hematologic abnormalities in FS extend beyond neutropenia. Although similarities were seen between FS patients and FS patients with the LGL syndrome (e.g., CD4 lymphopenia), evidence for a gradation from FS to the LGL syndrome was not seen, thus favoring the hypothesis that a "transforming event" is required.

[Inflammatory rheumatism and celiac disease in adults. Coincidence or pathogenic relationship?]

Five adults had inflammatory rheumatic disorders 6 to 20 years before the diagnosis of coeliac disease. It is known that joint inflammation occurs in certain patients with adult coeliac sprue who develop either a specific inflammatory rheumatic disease or an atypical progressive polyarthropathy, sometimes as the first manifestation of the intestinal disorder. The diagnosis of adult coeliac sprue should be entertained in these cases even in absence of major digestive disorders or malabsorption. IgA anti-reticulin antibodies and atrophy of the duodenojejunal villosities are the best indicators for diagnosis. There are two important reasons for making the diagnosis of "asymptomatic adult coeliac sprue". First a gluten-free diet can improve or even cure the inflammatory joint disease, a rare situation which emphasizes the causal relationship between these two diseases. Second, the risk of developing lymphoma (especially in the small bowel) is apparently lower in patients on gluten-free diet. Pathogenesis is unclear. Frequently the two autoimmune disorders simply appear to coincide in the same patient; more rarely, arthritis is a symptom of coeliac disease. The immunological mechanisms probably begin when antigens cross an excessively permeable intestinal mucosa.

[A case of Felty's syndrome with marked thrombocytopenia and severe hypocomplementemia]

Felty's syndrome is diagnosed when a patient shows both splenomegaly and leukocytopenia of various degree during the course of rheumatoid arthritis (RA). The accompanying immunologic abnormalities (e.g., antinuclear antibody, antiplatelet antibody, and hypocomplementemia) also characterize Felty's syndrome, but some authors may regard these abnormalities as a transitional form into overlap syndrome [RA + systemic lupus erythematosus (SLE)]. Here we reported a female case of Felty's syndrome who showed marked thrombocytopenia and severe hypocomplementemia. Thrombocytopenia had been refractory against several forms of therapies including high-dose methylprednisolone. Simultaneously, she had various autoantibodies (i.e., antiplatelet antibody, positive Coombs' test, antithyroglobulin antibody, antimicrosome antibody and anti-RNP antibody). Although she did not fulfill the ARA diagnostic criteria for SLE, the degree of thrombocytopenia as well as that of hypocomplementemia argued in favor of the overlap of SLE in this patient. Low-dose cyclosporin A (CsA) combined with small dose of prednisolone could increase both platelet count and level of complement. Notably, the titers of several autoantibodies dropped after CsA was started. These findings might suggest that CsA could normalize the underlying immunologic abnormalities in this patient. However, the disease activity of RA could not be decreased without a help of low-dose methotrexate.

Flare of arthritis with successful treatment of Felty's syndrome with granulocyte colony stimulating factor (GCSF)

A 58-year-old white male with Felty's syndrome was successfully treated with granulocyte colony stimulating factor (GCSF). GCSF can correct the granulocytopenia of Felty's syndrome and may be a beneficial therapeutic adjunct in patients who have serious infections associated with neutropenia. The patient developed a flare of arthritis concomitant with increased circulating neutrophils following GCSF therapy.

Felty's syndrome treated with rhG-CSF associated with flare of arthritis and skin rash

A patient with Felty's syndrome and rheumatoid arthritis was treated with recombinant granulocyte stimulating factor rhG-CSF (Neupogen) in view of severe neutropenia. He had a prompt rise in his neutrophil count and associated with this a severe flare of his arthritis and a skin rash. rhG-CSF was stopped, his neutrophil count fell rapidly and his symptoms resolved. rhG-CSF and the resulting rise in neutrophil count may be associated with flare of autoimmune disease in susceptible individuals.

Long-term remission of neutropenia in Felty's syndrome after a short GM-CSF treatment

We report a case of Felty's syndrome in which neutropenia was corrected by a short-term treatment with recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF, 5 micrograms/kg/day s.c. for 14 days). Absolute neutrophil counts rose from 0.1 to 2.2 x 10(9)/l and remained > 1.0 x 10(9)/l 8 weeks after discontinuation of the GM-CSF therapy. A flare-up of arthritis and a decrease in platelet counts were observed.

Felty's syndrome: a case presentation

A 64-year-old male patient with Felty's syndrome was treated with antibiotics, Plaquenil (hydroxychloroquine sulfate), and gold salts. In the fourth week of hospitalization, the patient died. Autopsy showed extensive bronchopneumonia, fibrous pleuritis, congestive splenomegaly, mild atherosclerosis, reactive lymphoid hyperplasia, congested passive liver, severe rheumatoid arthritis, and hypercellular bone marrow.

Sequential administration of cyclophosphamide and granulocyte-colony stimulating factor relieves impaired myeloid maturation in Felty's syndrome

A patient with Felty's syndrome (FS) and persistent profound neutropenia developed recurrent infections and sepsis syndrome. No impairment of granulocyte-macrophage colony development was observed in vitro. Marrow morphology revealed an absence of mature neutrophil forms despite administration of granulocyte-colony stimulating factor (G-CSF). However, pretreatment with bolus cyclophosphamide (CY) permitted the growth factor to relieve this impairment of late myeloid maturation and resulted in a brisk, albeit short, burst of neutrophilia. This suggests that immune interference in myelopoiesis can be overcome by growth factor administration if immune activity is adequately dampened by immunosuppressive therapy.

Treatment of neutropenia in Felty's syndrome with granulocyte-macrophage colony-stimulating factor--hematological response accompanied by pulmonary complications with lethal outcome

We report on a 67-year-old man with Felty's syndrome (FS) complicated by recurrent pneumonia and an infected wound, which was not healing in spite of maximal antibiotic and local therapy. Encouraged by previous experience, we treated him with granulocyte-macrophage colony-stimulating factor (GM-CSF). His total leukocyte count rose, but the patient's pneumonia deteriorated. In addition, a previously known chronic obstructive lung disease (COLD) was exacerbated acutely. These complications finally led to his death. Postmortem examination revealed widespread pneumonia with invasive aspergillosis and a peripheral adenocarcinoma in his left lung.

Nonneoplastic hematologic disease

Recent literature on nonneoplastic hematologic disease in the rheumatic disorders has been reviewed, and current concepts on the anemia of rheumatoid arthritis and its treatment have been expanded. The anemia of chronic renal failure and of acquired immunodeficiency syndrome has responded to treatment with recombinant human erythropoietin. Recent studies document that the anemia of rheumatoid disease can also be alleviated with intermittent intravenous or subcutaneous administration of erythropoietin without apparent adverse reaction. However, no improvement is evident in the underlying rheumatoid disease or functional abilities of these patients. Further data are needed to determine the utility of erythropoietin therapy in rheumatoid arthritis and in other rheumatic diseases. Other mechanisms of anemia of rheumatoid disease have been studied, and as the underlying defects become known, other therapies may become available to patients with rheumatoid arthritis and other rheumatic diseases.

Felty's syndrome: favorable response to granulocyte-macrophage colony-stimulating factor in the acute phase

We report a case of Felty's syndrome in which infectious complications due to severe neutropenia could be overcome by short-term treatment with recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF, 7 micrograms/kg/day s.c.). Leukocyte counts rose from 1,050/mm3 at presentation to 4,470/mm3 after 15 days of treatment. A flare-up of arthritis was not noted. Defects in granulocyte function and clinical improvement prior to leukocyte rise suggest that the beneficial effect of GM-CSF is mainly due to an improvement of granulocyte function.

Coexistent Felty's syndrome and palindromic rheumatism

Palindromic rheumatism is a syndrome of intermittent abrupt onset monoarthritis with asymptomatic intercritical periods of variable duration, which commonly evolves into rheumatoid arthritis. Felty's syndrome consists of leucopenia (selective neutropenia) and splenomegaly, usually occurring in longstanding classic rheumatoid arthritis. Felty's syndrome can be confused with the more recently recognised rheumatoid arthritis associated large granular lymphocyte proliferative disease. This paper describes a patient with palindromic rheumatism presenting with Felty's syndrome in whom large granular lymphocyte proliferative disease was ruled out by lymphocyte phenotyping.

Worsening of Felty's syndrome with methotrexate

Images

[Felty's syndrome]

Felty's syndrome (FS) consists of the triad: rheumatoid arthritis (RA), leukopenia and splenomegaly. FS occurs in approximately 1% of patients with RA. In this syndrome, the risk of infection is increased and anaemia, thrombocytopenia and cutaneous ulcers are more frequently observed. The literature is reviewed on the basis of a case history. The pathogenesis is unknown but is probably multifactorial. Cell antibodies, increased occurrence of immune complexes, inhibited neutrophil production, altered neutrophil distribution and reduced neutrophil function have been observed. The main indication for treatment is present if the patient has severe neutropenia (less than 0.1 x 10(9)/l) and repeated infections. Various methods of treatment are available. The most important are: gold, low-dose methotrexate, lithium, methylprednisolone pulse therapy, penicillamine and splenectomy. According to the literature, conventional steroid treatment cannot be recommended.

GM-CSF in the treatment of Felty syndrome

Many therapeutic agents have been tried with variable success in the treatment of Felty neutropenia, but the reports are anecdotal. We now describe the second trial of recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF), in a splenectomized, infected patient with Felty syndrome.