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Objective: To determine whether there are peculiarities of the POEMS syndrome (a multisystemic disorder associated with polyneuropathy, organomegaly, endocrinopathy of various forms, production of a monoclonal [M] component, and skin changes) in Caucasian patients, especially signs and symptoms absent in other series; and to attempt a reappraisal of the neuropathy and endocrinopathy to find a unifying mechanism., Design: A retrospective, cooperative study compared 25 cases, observed over a 15-year period, with two published series of patients, one of Japanese patients and one of American patients, and with a review of the literature on non-Asian cases. Details were obtained of patients' medical history, physical examination, immunochemical and hormonal testing, roentgenographic examination, computed tomography imaging, and electromyography., Results: The main features of the syndrome found in these patients were those first described in Japan: polyneuropathy, enlargement of the lymph nodes, liver, and spleen, endocrine disturbances, low concentration of the monoclonal component, hyperpigmentation, and hypertrichosis. Three other symptoms were found more frequently than previously reported: skin angiomas, scleroderma changes of the hands, and thrombocytosis. Electromyography and nerve biopsy showed a variety of abnormalities ranging from demyelination to axonal degeneration. Nerve deposits of immunoglobulin were absent. Organomegaly seemed to be heterogeneous. Pathologic findings in the enlarged lymph nodes and spleen were compatible with Castleman's disease. Liver biopsies were usually normal. The endocrine changes were surprisingly diverse, with some observations combining unrelated primary and secondary insufficiencies. No single hypothesis emerged regarding their mechanism. All M components had a lambda-light chain. An IgG M component was found more frequently in solitary lesions. An IgA M component was found more frequently in patients without bone lesions. Sedimentation rate was usually normal. Radiotherapy of solitary plasma-cytomas was followed by dramatic improvement of extramedullary signs and symptoms in all cases., Conclusions: The symptoms, clinical course, and management of the patients reported here were similar to those observed in the literature. This study confirms the existence of a close link between symptoms and lambda-light-chain production. There are indications that a plasma cell growth factor that does not cross-react with interleukin-6 (IL-6) may be involved.

Twenty-four cases of septic arthritis in rheumatoid arthritis patients were compared with 99 cases of septic arthritis in patients without rheumatoid arthritis. In addition, 238 previously published cases of septic arthritis with rheumatoid arthritis were analyzed. Fifteen percent of our patients with septic arthritis had rheumatoid arthritis, which was typically of long duration (mean 15 years), erosive, and seropositive. Fifty-four per cent (28% in the literature) and 9% of patients with and without rheumatoid arthritis, respectively, had pyarthrosis of multiple joints. The knee represented one-third of infected joints and the elbows and wrists were more often infected in patients with than without rheumatoid arthritis. S. aureus was recovered in 80% versus only 60% of patients with and without rheumatoid arthritis, respectively. The source of sepsis was often a skin lesion, in particular at the foot, emphasizing the need for early orthopedic treatment of deformities responsible for skin lesions. Monoarticular infection was more likely to be due to an intraarticular injection. Mortality rate was 17% in patients with rheumatoid arthritis (23% in the literature) versus 7% in patients without rheumatoid arthritis. Staphylococcal infection and infection of multiple joints were associated with higher mortality rates (35% and 49%, respectively). The mortality rate in polyarticular infections has failed to decline over the last 35 years. Initial failure to distinguish septic arthritis from an exacerbation of rheumatoid arthritis contributes to the high mortality rate. The diagnosis of septic arthritis rests on a high index of suspicion. Septic arthritis cannot be ruled out based on absence of local inflammation, fever, or hyperleukocytosis or on presence of inflammation of multiple joints. Joint fluid specimens should routinely be sent to the microbiological laboratory and should be inoculated in blood culture bottles at the least suspicion.

The main biological sign of inflammation is an increase in erythrocyte sedimentation rate (ESR). However it can be falsely normal (polyglobulia, cryoglobulinemia, hemoglobinopathy) or spuriously high in the absence of inflammation (anemia, hypergammaglobulinemia). In cases of doubt, the acute phase reactants (APR) should be measured: C reactive protein (CRP), fibrinogen, haptoglobin, alpha 1 acid glycoprotein. They have different kinetics of variation and various degrees of increase (some--the so called "negative" proteins--actually decrease). Several pitfalls can be avoided if it is remembered that the APR themselves can be modified by causes other than inflammation: low fibrinogen in intravascular coagulation, very low haptoglobin in hemolysis, raised orosomucoide in renal insufficiency and elevated transferrin in iron deficiency. Furthermore liver insufficiency or leakage through the kidney or gut lesions can lower them. In some patients, the observed levels of APR are thus the result of opposite trends. In complex cases, these pathological mechanisms are more apparent on profiles which express the concomitant blood levels of several APR in a normalized or comparative manner. In medical practice, ESR serves first and foremost to detect an inflammatory syndrome. CRP is prominent among the APR because its changes show a great sensitivity, are independant of those of ESR and have a time course fitting closely that of the inflammatory processes. Profiles yield detailed information but rarely provide major evidence in the quest of a diagnosis or the choice of a treatment. Because of their cost they are to be used only in difficult cases.

Longitudinal stress fractures of the tibia are rare: only 16 cases have been published. We report three cases, in two men aged 54 and 70 years and in one women aged 73. The patients had pain when bearing weight on the affected limb. The pain increased over a few weeks. A diagnosis of arthritis of the ankle joint was entertained in 2 cases. Among the three patients, one was suffering from rheumatoid arthritis and had had Ender nails due to fracture of the femoral neck of the same limb. The longest delay for diagnosis was six months. Plain radiographs were normal in two cases. A technetium 99m MDP bone scan showed increased uptake of the whole shaft of the tibia in one patient, on the lower end of the tibia in two others. Computed tomography was performed in two cases and showed the stress fracture. Diagnosis was often delayed because clear changes at plain X-ray examination, periostal reaction often being delayed. Technetium 99m bone scan early showed increased uptake. CT scan showed callus formation and sometimes the fracture itself. MRI has been studied little.

The authors report four cases of POEMS Syndrome with renal involvement. Two had renal failure and mild proteinuria. The two others had hyporeninemic hypoaldosteronism with type IV renal tubular acidosis in the first and hyperkalemia alone in the second. In the two cases, renal biopsy showed mesangial proliferation. Evolution was favourable when the plasma cell proliferation could be checked. In POEMS pathophysiology of renal involvement remains unknown. Soluble factor(s) produced by plasma cells may be responsible for most signs and symptoms perhaps as a result of increased vascular permeability.

The antiphospholipid syndrome produces acute occlusions of arteries and veins. This syndrome can cause a multiple organ systems failure whose outcome is often fatal. The authors report a case of the primary, antiphospholipid syndrome characterized by this fatal outcome, a so-called "devastating" syndrome following pulse steroids. In this patient, the antiphospholipid antibodies had been found after presenting bone-marrow fat necrosis, which led to extensive lesions of knees, hips and shoulders. Damage to the cell membranes in necrotic lesions might have promoted the immune response against phospholipids. The potential risks of pulse doses of steroids in the antiphospholipid syndrome are documented by the present observation, which also suggests that antiphospholipid antibodies should be determined in cases of fat necrosis of all origins.

Infections due to Mycobacterium bovis have become uncommon. We report a case with polyarthritis and cutaneous nodules suggesting a rheumatic disease. This 61 year old male under corticosteroid therapy for asthma developed febrile arthritis of the right wrist and cutaneous nodules that resolved rapidly under treatment with penicillin M and an aminoglycoside. Six months later, he developed arthritis of the right wrist and both elbows, as well as infection of a right hip prosthesis. The left wrist and left knee were then affected concomitantly. The cutaneous nodules recurred. A giant cell granuloma without caseous necrosis was found upon examination of a biopsy specimen from a nodule. Granulomatous lesions with caseous necrosis were seen in a specimen of synovial membrane from the right wrist. Antituberculous treatment ensured resolution of the arthritides and nodules but failed to prevent loosening of the hip prosthesis. Acid-fast bacilli were found in the specimens taken during removal of the prosthesis. After three months, cultures of synovial membrane specimens from the knee grew Mycobacterium bovis.

Epileptic seizures can produce dislocations or fractures of the limbs and vertebral compression fractures. We tried to determine the clinical and radiological features of the latter in 8 patients: 6 men and 2 women including one aged only 41 years. The often multiple compression fractures involved the first thoracic (n = 3) and the intermediate thoracic (n = 3) or lower lumbar (n = 2) vertebrae but, contrary to common osteoporosis, never the thoracolumbar hinge. In 2 cases, the appearance of the fracture and the neurological signs led to surgery. Posterior dislocation of the shoulder was associated with the fractures in 2 cases. Chronic alcoholism (4 cases), anti-epileptic drugs (1 case) or corticosteroids (1 case) might have facilitated a demineralization which was however not obvious on X-ray films. The seizure was a first ever event in 6 cases. In the absence of controls the fracture was considered to be spontaneous. These particularities explain why a metastatic compression fracture was initially suspected in 3 cases, leading to explorations which sometimes were aggressive. In the presence of a suspicious vertebral compression fracture the clinician must consider the possibility of an epileptic seizure, a trauma which is sufficient to explain the fracture, as shown by the complications of electro-convulsive therapy.

The foot is among the sites most often affected in spondyloarthropathies, whose diagnostic criteria include heel pain and sausage-like swelling of the toes. Few studies have systematically analyzed foot manifestations in reactive arthritides. We retrospectively reviewed 143 patients fulfilling Amor's criteria. One hundred five patients (73%) exhibited inflammatory involvement of one (n = 47) or both feet. In 8 cases no other articular sites were affected. Heel pain was reported by 36% of patients (52/143), within the first six months in half the cases. Both heels were painful in 26 patients. Heel pain was plantar in 36 cases, posterior in 7 cases, and bipolar in 4 cases. Roentgenographic calcaneal changes were found in 54 cases overall but in only 31 of the patients with heel pain. Sixteen patients had asymptomatic calcaneitis. Seventeen patients had involvement of the transverse tarsal joint, usually with no other affected joints. Involvement of the subtalar joint was rare (6 cases). Metatarsophalangeal manifestations were found in 44% of patients (64/143) and were symmetrical in 17 cases; 17 patients had changes of the great toe suggestive of gout. Interphalangeal arthritis was seen in 22% (32/143) of cases; in half these cases the first two rays were affected and sausage-like digital swelling was seen in 28 patients (20%). Permanent roentgenological damage was uncommon.

Rheumatoid arthritis (RA) and polymyalgia rheumatica (PMR) are the most common rheumatologic diseases encountered in older patients. However, other disorders including spondylarthropathy and a variety of connective tissue diseases also occur in the elderly. PMR and the RS3PE syndrome seem to occur only in the elderly, although their symptoms may be difficult to differentiate from those of other conditions. Late-onset RA and, above all, late-onset spondylarthritis may have unusual presentations responsible for diagnostic mistakes. Pitting edema is typical of RS3PE syndrome but may also occur in other rheumatic diseases. This symptom seems to be associated with advanced age rather than with a specific cause. Because of these many unusual features, rheumatologic diseases in the elderly are often difficult to diagnose and to differentiate from a variety of other rheumatologic or nonrheumatologic conditions.

This study was designed to investigate the value of biologic evidence of inflammation for the diagnosis of giant cell arteritis. Experienced physicians were asked to evaluate five pairs of medical records based on real cases. In each pair, one case lacked biologic evidence of inflammation. This study offered the opportunity to explore the feasibility of a simplified Bayes model. A blind evaluation obtained by showing the paired case-reports with similar evidence of inflammation in both cases of each pair to 14 specialty physicians yielded a likelihood of diagnosis of +/- 20%. Analysis of the 46 responses to the study demonstrated, despite wide variations, a significantly greater likelihood of diagnosis in the cases with evidence of inflammation. Nevertheless, 17% to 36% of physicians--according to the case-report--ascribed virtually no importance to the ESR. Most of the physicians considered temporal artery biopsy was warranted when the likelihood of diagnosis was greater than 25%. Emergency corticosteroid therapy while awaiting the histologic results was approved by most responders when the likelihood of diagnosis was greater than 65%. The "pre-test" likelihood, calculated assuming that sensitivity and specificity of the ESR are 0.99 and 0.50, respectively, ranged from 0.89 to 0.98 for the case-reports with no evidence of inflammation and from 0.16 to 0.59 for the case-reports with evidence of inflammation In theory, the figures for the two types of case-report should not differ by more than 20%. Use of a low value for specificity (0.05) would improve the fit of values in cases without evidence of inflammation but would increase discrepancies in the other cases.(ABSTRACT TRUNCATED AT 250 WORDS)

An inflammatory disease is sometimes suspected despite a normal erythrocyte sedimentation rate (ESR). When this dissociation is present, the reasons for the lack of ESR elevation, which concern the red cells, the plasma and the laboratory techniques, must be excluded, the reality of the inflammatory syndrome being then confirmed by assay of the inflammatory proteins. However, an inflammatory syndrome is missing in 5 to 10 percent of inflammatory diseases, more frequently in cases of polymyositis or scleroderma, less frequently in those of giant cell arteritis. Little information can be found in the literature, concerning the missing inflammatory syndrome. Does it confer peculiar semeiological or prognostic features? Is the dissociation related to the patient, as would appear in some special cases, or to the disease, as suggested by the small rise of the C-reactive protein in acute episodes of lupus erythematosus? The absence of inflammatory syndrome is a source of diagnostic problems when the symptoms are atypical or when there are no specific signs of the suspected disease. Differential diagnoses, especially non-inflammatory diseases, must then be carefully discussed. Improving our knowledge of the missing inflammatory syndrome would require the creation of this key-word.

Between 1979 and 1990 we have seen 8 patients (7 females) with rheumatoid arthritis (RA) who developed a neuro-muscular involvement while on D-penicillamine (D.P.). Five of them had a drug-induced myasthenia. D.P. withdrawal led to a complete recovery in 1.5 to 5 months. Another patient presented with a myopathy which led to the diagnosis of Grave's disease. She was treated with D.P. for 4 months. D.P. was reintroduced and 5 months later a myasthenic syndrome developed. A thymoma was discovered 1 year later. In the last 2 patients D.P. induced polymyositis which, in one, was associated with features of systemic lupus erythematosus. In the other patient, the evolution was fatal in spite of D.P. withdrawal, high dose steroids and plasma exchanges. A literature survey has shown 150 D.P. induced myasthenia and 38 D.P. induced polymyositis cases.

Cyclosporine A (an immunosuppressive cyclic undercapeptide) acts as an antagonist to prolactin receptors on a breast tumour cell line (MCF7) which is known to express specific prolactin receptors. The competition between cyclosporine A and prolactin to prolactin receptors was demonstrated by measuring the decreased specific 125I-labeled prolactin-binding to prolactin receptors in the presence of increasing concentrations of cyclosporine A. Moreover, cyclosporine A inhibiting effects on the cell growth were investigated in this mammary cancer (MCF) by measuring the cell DNA content with flow cytometry. Our results should prove very useful in understanding the mechanisms of prolactin regulation of DNA synthesis in tumorigenesis of the mammary gland.

The authors reviewed the files of male patients who have been hospitalized over a 12 year period for a rheumatoid-factor negative arthritis beginning after age 50. Polymyalgia rheumatica, psoriasis or crystal-induced arthritis were excluded. The remaining 105 observations were classified according to published criteria in rheumatoid arthritis (RA), reactive arthritis or ankylosing spondylitis (AS). Twenty-nine patients had RA and 29 had AS with equal numbers of axial and peripheral types. Four patients had reactive arthritis, one of them had also AS. Forty-four patients had "unclassified arthritis". Among the latter, 14 were B27 positive, 21 were B27 negative, 9 were not typed. Some features were more frequent in B27+ patients: an assymetrical oligoarthritis of the lower limbs with minimal signs of inflammation at synovial analysis or at synovial biopsy; frequent unilateral edema; marked, constitutional signs; very high ESR. Nine patients, all B27+, met the diagnostic criteria of spondylarthropathy. B27 typing thus appears relevant to the classification of late-onset, seronegative rhumatisms.

IL-6 is now recognized as a growth factor for plasma cells as well as a C Reactive Proteine inducer. This prompted a reappraisal of acute phase reactants in monoclonal gammapathies. Eight acute phase proteins were assayed in patients with multiple myeloma (n = 51), MGUS (n = 17) and Waldenström's macroglobulinemia (n = 5). The CRP level was above 10 mg/l in 27% of all myeloma patients, in 39% of patients with active myeloma, in 4 of 5 patients with Waldenström's macroglobulinemia and in none of the MGUS patients. Fibrinogen, alpha-1-antitrypsin and orosomucoid levels were significantly higher in the myeloma group than in the MGUS group. Differences were not significant for haptoglobin, ceruleoplasmin, transferrin, and alpha-2-macroglobulin. Serial assays in 22 myeloma patients showed that CRP levels were correlated with disease activity. A biologic inflammatory syndrome, defined as a significant variation in two or more acute phase reactants, was demonstrated in 41% of myeloma patients, 18% of MGUS patients, and 60% of Waldenström's macroglobulinemia patients. Active disease was significantly more common among myeloma patients with biologic evidence of inflammation, as compared with myeloma patients without biologic inflammation. These data suggest that similarly to IL-6 acute phase reactants are markers for disease activity in multiple myeloma.

Cyclosporine A (an immunosuppressive agent) decreases Ia lymphoid differentiation marker in female Sprague-Dawley rats with N-nitroso-N-methylurea-induced mammary tumors. Presence of lymphoid differentiation antigens was determined on mammary tumor cells and lymphoid cells from bone marrow, spleen, and peripheral blood by flow cytometric analysis. Quantification of Ia antigen expression was also performed by affinity chromatography and chromatofocusing in mammary tumors. A significant decrease in Ia antigen expression by mammary tumors of animals treated with cyclosporine A was noted with the two different methods. Cyclosporine A acts as an antagonist to prolactin receptors in such hormone-dependent mammary cancer. Our results should prove very useful in understanding the mechanisms of prolactin regulation of Ia antigen in tumorigenesis of the mammary gland.

The authors report four observations of synovial cysts of the psoas bursa. They recall the following from a review of the literature: the relative rarity of these lesions, their physiopathology, their clinical expression, the diagnostic tests available, which at present consist mainly of modern imaging (echography and tomodensitometry), and finally the principles of treatment.

Topical minoxidil, used in the treatment of baldness, has been commercially available since 1987. Its systemic side effects are rare. We observed an as yet unreported "polymyalgia syndrome" in four otherwise healthy males whose sole medication was topically applied minoxidil. They experienced fatigue, weight loss and severe pain in the shoulders and pelvic girdle, suggesting connective tissue disease. Three patients had a transient rise in liver enzymes, while other laboratory analyses remained normal. Tritanomaly was detected in two patients who underwent systematic color vision testing. All symptoms disappeared after withdrawal of minoxidil. Rechallenge was positive once in one patient and twice in another. The mechanism of this side effect remains to be determined.

The defective autologous MLR was studied in Sjögren's syndrome (SS) in relation to Ia+ cells as determined by reactivity with a monoclonal anti-human Ia antibody. By indirect immunofluorescence, the percentage of Ia+ T lymphocytes was increased in nine of 15 patients. There was no correlation with clinical features or drugs. The percentage of Ia+ T cells in the non-T cell preparations was normal. An inverse correlation was found between the percentage of Ia+ T cells and the proliferative response to autologous non-T cells. Removal of Ia+ T cells enhanced both the autologous MLR and the allogeneic MLR. Thus Ia+ T cells contain suppressor cells in the MLR, but this may not be the sole explanation for the defective autologous MLR.

Preliminary Results: The authors have treated 10 children presenting with severe epilepsy with repeated large doses of gamma-globulin. They noted a marked improvement in 7 of the children with respect to behaviour and a disappearance of seizures in 8 with comparable EEG improvement. Four children have been able to reduce their conventional anticonvulsant therapy considerably and 2 others havers received no other medication at all for 8 months. The possibility of an immune disturbance in some childhood epilepsies is thus suggested.

The diagnostic evaluation of the sicca complex in rheumatology depends, on the one hand, upon performing tests and, on the other hand, upon the specific clinical presentations which lead to these tests. The frequency with which the clinical problem is encountered should be taken into account as well as the probability of whether or not the patient does indeed have the sicca complex, and the necessity of making a precise diagnosis. A labial biopsy should be performed when it is necessary to confirm the diagnosis. Schirmer's test is useful to evaluate the ocular component of the sicca complex, which is the only component requiring therapy. In other cases, one examination can follow another in sequence such as salivary nucleotide scanning followed by biopsy and histological examination.

We have studied the synovial and blood lymphocyte populations of 18 patients with rheumatoid arthritis. Two methods have been used: the membrane markers (E rosette, active E, EA, EAC) and lymphocyte electrophoresis. The authors find no significant difference beteween the blood populations of the patients with the PR and that of the controls. On the other hand, the study of the synovial fluid shows a large number of lymphocytes T forming active rosettes having an electrophoretic mobility of about 1,10. In order to explain the presence of lymphocytes with high affinity for sheep red cells, and having a reduced electric charge in the synovial fluid, we propose two explanations: the first one is a selective filtration through the synovialmembrane of a physiological T subpopulation; the second one is a general modification of the lymphocyte membrane in relation with a stimulation or an intraarticular cellular alteration. In the discussion we report the arguments in favour of the two hypothesis.

An association of a familial bisalbuminemia and a benign M component (IgG Kappa) in a healthy woman is described. Any connection between the two abnormalities is unlikely. However this rare association should be known for a better understanding of the striking features of its electrophoretic pattern.

The examination of a patient with Sjögren's syndrome includes evaluation of the eye, the buccal cavity, and a search for certain factors in the blood. Schirmer's blotting-paper test is a good test but is not specific. In addition, a decreased amount of tearing is difficult to interpret after the age of 45. Slit-lamp examination (rose bengal and fluorescein) yields lesions which confirm keratoconjunctivitis due to decreased tearing. The buccal component is difficult to evaluate. A biopsy of the buccal mucosa gives the best results with minimum risk and expense. Nucleotide scanning is sensitive, but less specific. Salivary flow decreases with age. After 60 years of age this decrease can not be interpreted. The chemical composition of tears or of saliva is promising, but it is not yet a part of the usual diagnostic work-up. Of the available laboratory tests, anti-SS-A antibodies and/ or anti-SS-B antibodies are of value, but they are not found consistently.

Cell electrophoresis allows separation of normal human blood lymphocytes into two main groups which are a function of their relative rates of migration, with regard to the reference speed (1 mum.sec.-1V-1.cm): the lymphocytes which have a greater mobility than this value seem to be T-lymphocytes (80,1 per cent for 42 healthy adults); on the contrary, B-lymphocytes have an inferior mobility (19,9 per cent). Two known methods are used for the selection of the lymphoid populations: spontaneous rosetting with sheep's red blood cells, which are characteristic of T lymphocytes, and adherence to nylon wool columns, which is dominant in the case of B-lymphocytes. This method confirms the fact that T-lymphocytes have a rapid migration and B-lymphocytes a slow migration. We have isolated a third population, having neither the T markers, nor the B markers. It has a very homogeneous migration, centered on the two classes 1,05 and 1,10 mum.sec.-1.V.-1.cm.

The mode of action of methotrexate (MTX) in rheumatoid arthritis (RA) is unknown. The hypothesis that its cytostatic effect may be involved has been questioned based on the evidence of several negative results, the most intriguing being its lack of effect on the Lymphoblastic Transformation Test (LTT) and other lymphoproliferations in cultures from patients' samples. Our study demonstrates that LTT evaluation by 3H-thymidine uptake, a standard method, is misleading when applied to MTX-treated cells. At in-vitro concentrations similar to those present in the red blood cells of RA patients, MTX produced an early block in the cell cycle without reducing the cellular uptake of 3H-thymidine. While the explanation of this discrepancy is still open to discussion, it is clear that future studies on the immunological status of RA patients on MTX should not use thymidine uptake for the measurement of the lymphocyte response to mitogens and various stimuli, but must rely on other methods for evaluating DNA synthesis.

A man aged 54 years presented multiple symptoms (acroparesthesia, familial deafness, cardiomyopathy, diarrhea, adenopathy with infiltration of frothy macrophages, pancytopenia with a dense marrow, chronic meningitis, renal failure) associated with intermittent fever, with feverish attacks and a temperature of 40 degrees C, and with a severe biologic febrile syndrome. Fabry's disease was diagnosed only after 3 years of fruitless explorations. The reasons for this delay are analysed and it is suggested than Fabry's disease be added to the list of conditions responsible for fever or for a persistent inflammatory syndrome.

33 patients with scleroderma, xerostomia and xerophthalmia underwent biopsy of 3 to 5 labial salivary glands. Histological and ultrastructural study were systematically performed on the salivary gland specimen. In 27 patients, sclerosis was the main feature: it was an active fibrosis, with numerous secreting fibroblasts and degranulating mast cells. This fibrosis was located around capillaries and excretory ducts. It surrounded the acini, progressively destroying them. Lymphocytes were present but not very numerous. They were not grouped around the ducts but scattered in the fibrosis. 5 patients had similar fibrotic lesions but they also had numerous lymphocytes grouped in focus around excretory ducts as in primary Sjögren's syndrome. It is concluded that in scleroderma, xerostomia and xerophthalmia can be related either to a pure sclerotic process or to a 'common' secondary Sjögren's syndrome.

Signs of ankylosing spondylitis were sought in 11 patients suffering from Behcet's syndrome and followed up in different departments of the Clermont-Ferrand teaching hospital group. Three patients, described in detail, had definite ankylosing spondylitis and 2 had phenotype B27. This prevalence would be greater than that predicted on the basis of data in the literature. This combination is rare but it is felt to be legitimate to seek the other disease when one of these two conditions is diagnosed.

The authors report their experience of myeloscintigraphy summarizing the 120 examinations made during the years 1975 and 1976, in the department of rheumatology of the regional hospital centre of Clermont-Ferrand. The technique uses serum labelled with technetium 99 introduced by the lumbar route. Schematically 3 pathological patterns can be determined : complet block, segmental block, and partial block. The examination is particularly reliable at the dorsal and high lumbar levels, where only one "false negative" was found, and even that debatable. In this situation it has a valuable role in regard to both the presence and the level of a compression. In the cervical and low lumbar levels, its reliability seems definitely inferior, especially in the case of lateral disc herniations. Tolerance has always been excellent whatever the age of the patient. We have thus an investigation that is simple and well tolerated, and its valuable role in the early detection of myelo-radicular compressions should assure it a place of choice alongside other methods of paraclinical investigation of the spinal canal.

The electrophoretic mobility of circulating lymphocytes has been studied in normal human subjects after immunization by tetanus toxoid. The mean migration speed was shown to increase, particularly two and three days after secondary immunization. This increase appeared to be due to the elevation of percentage of T cells migrating at 1.20 and 1.35 micrometer. sec.-1v.-1 cm. (active rosettes-forming cells), with a decrease of the percentage of B cells and T lymphocytes migrating at 1.10 micrometer. sec.-1v.-1 cm. The return to the anterior status was observed between day 4 and 8 after immunization.

This atypical form of spondylarthritis was described after studying 11 patients. The latter are males over 50 years old, with minimal or no axial involvement, asymmetrical oligoarthritis of the lower limbs, few cells in the synovial fluid and a fibrous synovium upon biopsy. In contrast, their general condition is greatly affected, with an elevated erythrocyte sedimentation rate and unexplained edemas suggesting diverse non-rheumatological diseases. Bilateral sacroiliitis appeared in 6 patients and 5 developed ankylosing spondylarthritis.

Cell electrophoresis enables the separation of the lymphocytes in normal human blood into two principal groups, as a function of their migration speed in relation to 1 mum.sec -1..v-1.cm. In 42 healthy adults, 19,9 % of the lymphocytes have a slower migration, and 80,1 % a faster migration than the reference speed. Two known methods are used for the selection of the lymphocytic populations : spontaneous rosetting with sheep red blood cells, a property of the T lymphocytes, and the adherence to nylon wool columns, which is dominant in the case of B lymphocytes. The cells which do not form spontaneous rosettes, and the cells adhering to nylon wool columns have above all a slow migration. On the contrary, cells which do not adhere to nylon columns have a fast migration. These arguments are in favour of the T nature of the rapid migrating lymphocytes, and of the B nature of the slow migrating lymphocytes.