MUSCLE LESIONS IN RHEUMATOID ARTHRITIS* · ANNALSOFTHERHEUMATIC DISEASES Case 13.-A 60-year-old...

MUSCLE LESIONS IN RHEUMATOID ARTHRITIS*BY

M. HORWITZFrom the Department of Clinical Medicine, University of Cape Town

Recently certain pathological investigations haveindicated that there is frequently widespread involve-ment of the neuromuscular system in rheumatoidarthritis, and it has been suggested that this may beresponsible for the prominent neuromuscularclinical features of the disease.

Curtis and Pollard (1940) were the first to describethe non-articular lesion which was common to alltheir eleven cases of rheumatoid arthritis, inxcludingfour cases with " Felty's Syndrome ". In everyone of their eleven cases these authors found smallperivascular infiltrations of lymphocytes in themuscles.

Steiner and others (1946) performed musclebiopsies on seven cases of rheumatoid arthritisand demonstrated inflammatory nodules in eachof the cases. The nodules were situated in theperimysium and in the endomysium, rarely in theepimysium. The nodules consisted of collectionsof lymphocytes and plasma cells and the authorstermed the lesion " nodular polymyositis ". Similarlesions were encountered in the muscles of two caseswhich were examined at autopsy. The size of thenodules varied from very small ones (consisting of"twenty or less lymphocytes ") to large ones visibleto the naked eye in the stained sections. They alsonoted definite arteritis and peri-arteritis in the smallmuscular vessels in some of their cases. In additionto the nodular inflammatory lesions they noted theoccurrence of various stages of degeneration andatrophy of the muscle fibres and considered thatthese degenerative changes, when present, werealways secondary to the inflammatory changes. Thelesions were found in muscles which were notadjacent to affected joints, and were present evenin long-standing cases of rheumatoid arthritiswhich were " seemingly burnt-out ". They sug-gested that these findings were specifictorheumatoidarthritis.These results were soon confirmed by other

investigators. Gibson and others (1946) noted thepresence of these nodular inflammatory lesions by

biopsy in each of eleven cases of rheumatoidarthritis. De Forest and others (1947) foundsimilar characteristic lesions in twelve out of sixteenmuscle biopsies. Clawson and others (1947)demonstrated these characteristic lesions in seven-teen out of forty-four deltoid muscle biopsies.Desmarais and others (1948) reported the resultsof muscle biopsies on a further fifty-six cases oftypical idiopathic rheumatoid arthritis. Thirty-four of these cases showed round-cell foci and blood-vessel changes. Like Steiner and others, theynoted " positive " biopsies in cases which appeared" burnt-out ", in cases without muscle wasting,and in muscles remote from affected joints. Bunimand others (1948) stated that they found the..charac-teristic small nodules in the " large majority " ofthe muscle biopsies performed on twenty-five casesof typical rheumatoid arthritis.

It thus appears, when these results are analysed,that " positive " muscle biopsies (with " nodularmyositis ") occurred in 40 to 100 per cent. of casesof rheumatoid arthritis. If the results are totalledit appears that, on the average, approximately60 per cent. of muscle biopsies in rheumatoidarthritis reveal the characteristic lesions describedby Steiner and others (1946).

Morrison and others (1947) examined the musclesof fourteen cases of rheumatoid arthritis at autopsyand encountered varying sizes of inflammatorynodules in eight instances.

Results of Muscle Biopsy in Thirty-four Cases ofRheumatoid Arthritis

Muscle biopsy was performed under localanaesthesia with 2 per cent. procaine on thirty-fourcases of chronic rheumatoid arthritis. The deltoidmuscle was selected in thirty-three cases and thegastrocnemius in one case. The cases were typicalexamples of " idiopathic " chronic rheumatoidarthritis, the durations varying from one year toforty-five years. The size of an average piece ofmuscle removed by biopsy was approximately 1*8cm. in length, 0-6 cm. in breadth, and 0-6 cm. in

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* Extracted from a thesis accepted for the degree of M.D.,University of Cape Town.

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MUSCLE LESIONS IN RHEUMATOID ARTHRITISthickness. The biopsy specimens were fixed incorrosive sublimate and embedded in paraffin wax.Three sections were cut from each specimen andwere stained' with haematoxylin and eosin.

Attention was chiefly focused on the inflam-matory changes in the muscles. It was sometimesdifficult to distinguish with certainty betweendegenerative changes in the muscles and changesresulting from the trauma of removal. As theinflammatory changes, not the degenerative ones,are those which have been regarded as probably ofdiagnostic value in the disease, the degenerativechanges are mentioned more briefly.

Characteristic inflammatory lesions were foundin fourteen cases (40 per cent.) in the series. Themuscle biopsies were " negative " in the remainingtwenty cases.A single focus was present in six cases; two to

seven foci were found in the other eight cases.

THE FOURTEEN "PosriIVE" BIoPSIES

The results of the microscopic examinations ofthe sections of the fourteen " positive " biopsiesare tabulated and illustrated below.

Case 1.-A 51-year-old man had rheumatoid arthritisfor three years. Two large oval nodules consistingof about 100 cells each and one small nodule consistingof about 40 cells were present in the endomysium andwere perivascular in distribution. The cells werepractically all lymphocytes.

Case 2.-A 60-year-old woman had rheumatoidarthritis for seven years. One small nodule consistingof about fifty lymphocytes was situated in the endo-mysium on the edge of the section.

Case 3.-A 61-year-old woman had rheumatoidarthritis for twenty years. One nodule consisting ofabout fifty small round cells (chiefly lymphocytes witha few plasma cells) was found in the perimysium.

Case 4.-A 66-year-old woman had rheumatoidarthritis for five years. Very extensive lesions werepresent in the muscle. Three tiny blue foci were visiblein the section on naked-eye examination, varying in sizefrom a pin-point to a pin-head. Microscopically, foursmaller foci could also be detected. The nodulesconsisted of small round-cells, chiefly lymphocyteswith a few plasma cells, but in one focus plasma cellswere the prominent cells. Scanty eosinophils were presentin the nodules. The shape of the nodules varied:some were oval, others elongated, and several werefusiform. One nodule was very large and replaced alarge area of muscle (Fig. 1). It was situated in theendomysium, and collections of cells straggled outfrom the main nodule between the adjacent musclefibres. A few small portions of muscle fibre wereisolated in the centre of this large nodule. A secondnodule was about half the size of this large nodule,

while an oval-shaped third nodule (Fig. 2) was aboutone-third the size of the large nodule. This latternodule was closely related to a few small blood vessels(Fig. 2). The remaining smaller nodules each consistingof about 100 cells were present in the endomysium andwere perivascular in distribution. The blood vesselwas usually situated near the end of the nodule, not inits centre.

Case 5.-A 40-year-old woman had rheumatoidarthritis for five years. Extensive lesions were presentbut not to quite the same degree as in Case 4. Fourof the five nodules present could be identified in thesections with the naked eye. The nodules were situatedin the endomysium. Only one of the five nodules wasperivascular in distribution; the others were not relatedto any blood vessels. They were chiefly spindle-shaped(Fig. 3). In one area the cells could be seen surround-ing the muscle fibres in transverse section (Fig. 4). Thesize of the nodules varied. The smallest nodule consistedof about a hundred cells, while the largest containedseveral hundred. Lymphocytes comprised the vastmajority of the cells in each case. The muscle fibresoften showed fragmentation at the sites of the muscularinfiltration.

Case 6.-A 35-year-old man had rheumatoid arthritisfor eight years. One irregularly-shaped perivascularnodule consisting of about seventy-five lymphocyteswas present in the perimysium.

Case 7.-A 39-year-old woman had rheumatoidarthritis for six years. Two small nodules, each con-sisting of about forty-five small round-cells, were situatedin the endomysium.

Case 8.-A 57-year-old woman had rheumatoidarthritis for eight years. Six small nodules. each con-sisting of about forty to sixty small round cells, werepresent in the endomysium. The nodules were peri-vascular in three instances.

Case 9.-A 44-year-old man had rheumatoid arthritisfor twelve years. Two large triangular perivascularnodules, each consisting of about two hundred cells,were present in the perimysium. The cells were chieflylymphocytes, but a few plasma cells were also present.An occasional arteriole in other parts of the sectionshowed some slight perivascular infiltration with aboutten to fifteen lymphocytes, and scanty round-cell infil-tration was present between some muscle fibres.

Case 10.-A 39-year-old man had rheumatoid arth-ritis for two years. Six small nodules, consisting ofthirty to forty small round cells, were distributed peri-vascularly in the endomysium and in the perimysium.

Case 11.-A 47-year-old woman had rheumatoidarthritis for one year. One perivascular nodule con-sisting of eighty small round cells and three smallernodules, each consisting of thirty to forty cells werefound.

Case 12.-A 46-year-old man had rheumatoid arthritisfor eight years. One paravascular spindle-shapednodule consisting of about eighty lymphocytes waspresent in the endomysium.

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260 ANNALS OF THE RHEUMATIC DISEASES

FIG. I.-Case 4. Very large inflammatory nodule, consisting chiefly of lymphocytes.It is situated in the endomysium, and linear collections of cells extend betweenadjacent muscle fibres. A large part of the muscle is replaced by the " nodular

myositis ". (Haematoxylin and eosin, x 130.)

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FIG. 2.-Case 4. A large focus consisting of small round cells replaces part of themuscle. Small blood-vessels are present at one edge of the focus. (Haematoxylin and

eosin, x 130.)

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MUSCLE LESIONS IN RHEUMATOID ARTHRITIS 261

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FIG. 3.-Case 5. Spindle-shaped focus of lymphocytes in endomysium. (Haematoxylinand eosin, x 130.)

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FIG. 4.-Case 5. Collections of lymphocytes seenencircling muscle fibres in transverse section. (Haema-

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ANNALS OF THE RHEUMATIC DISEASES

Case 13.-A 60-year-old woman had rheumatoidarthritis for one year. A small irregularly-shapedcollection of about forty small round cells was seenencircling a muscle fibre.

Case 14.-A 70-year-old woman had rheumatoidarthritis for four years. One small paravascular noduleconsisting of about forty-five small round cells waspresent in the perimysium.

DiscussionThe results of the deltoid muscle biopsies were

" positive " in approximately 40 per cent. of thethirty-four cases examined. These findings thusconfirm the reported incidence of the inflammatoryfoci and nodules in the muscle in rheumatoidarthritis. The incidence encountered in this seriesis lower than that noted by most of the investigators,but corresponds closely to the results recorded byClawson and others (1947) in their forty-fourbiopsies.A striking feature was the ease with which the

inflammatory nodules could be recognized andidentified. They appeared in sharp contrast to thesurrounding muscle fibres, and could be easilydetected. In two instances (Case 4, Figs. 1 and 2;and Case 5), the nodules were sufficiently largeto be visible in the stained sections on naked-eyeexamination.The nodules varied in size from small foci con-

sisting of approximately thirty small round cellsto very large nodules visible macroscopically.Fig. 2 illustrates the appearance of such a very largenodule, whilst Fig. 4 illustrates a smaller collectionof cells. The shape of the nodules varied. Somewere round, others triangular, others oval, otherselongated, and others spindle-shaped. The edgessometimes " tailed off " between adjacent musclefibres (Fig. 1). The nodules were encountered inthe endomysium and in the perimysium. Theywere often perivascular or paravascular in situation,but some nodules occurred without any obviousrelation to a blood vessel.The cells consisted mainly of lymphocytes, with

a variable number of plasma cells and a few eosino-phils in some nodules. The muscle fibres at theedges of the larger nodules often showed atrophyand fragmentation. In some nodules muscularremnants could still be recognized. However,there was no close parallelism between the degreeof inflammatory change and the degree of muscularatrophy.There was no close relationship between the

finding of " positive " muscle biopsy and the degreeof " activity " of the arthritis. Case 9, for example,was clinically " burnt-out ", and had a normal

sedimentation rate, yet two large inflammatorynodules were seen in the muscle biopsy sections.There were no clinical differences noted betweenthese cases with " positive " biopsies and thosecases with " negative " biopsies.The conclusion therefore appears to be that one

nodule or multiple nodules are commonly found insections of muscle removed by biopsy in cases ofrheumatoid arthritis. The results are all the morestriking as only small portions of muscle wereremoved at biopsy and yet the lesions were readilydetected in fourteen of the thirty-four casesexamined (40 per cent.). The histological findingsin this series of fourteen " positive " biopsiesconform to the descriptions of " nodular poly-myositis" given by Steiner and others (1946).

However, it must be realized that the resultsof the reported investigations and of the presentinvestigation have confirmed only one point, that is,the high incidence of " nodular myositis " in casesof rheumatoid arthritis. The other problem, whichwas immediately presented to Steiner and others(1946) and to other workers, was whether thesefindings are specific to rheumatoid arthritis orwhether they also occur in a variety of conditions.Neurologists, for example, have often described theoccurrence of " lymphorrhages " in the muscles ofcases of myasthenia gravis (Kinnear Wilson, 1940;Russell Brain, 1947), yet this fact appears to havebeen largely overlooked by various investigators.

Review of the Literature on Control Cases

Steiner and others (1946) examined muscles in aseries of controls from 196 routine autopsies. Withthe exception of one case of dermatomyositis andone case of trichiniasis, they were unable to demon-strate " nodular myositis " in any of these muscles.Morrison and others (1947) examined a control

series of muscles in fifty autopsies ; in a " fewcases" of dermatomyositis, disseminated lupuserythematosis, and scleroderma, they found musclelesions which closely resembled the inflammatorynodules in rheumatoid arthritis, but the rest of thecontrols were " negative ".De Forest and others (1947) performed muscle

biopsies on ten control cases (excluding the fourcases of " non-specific infectious arthritis ", andtheir one case of osteo-arthritis which " had ahistory suggestive of rheumatoid arthritis ") andwere unable to find any instances of " nodularmyositis" in these ten cases.Desmarais and others (1948), in their series of

control muscle biopsies, found characteristic foci of

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MUSCLE LESIONS IN RHEUMATOID ARTHRITIS

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FIG. 5.

FIG. 6.

FIGS. 5 and 6.-Gout. Inflammatory foci, consisting chiefly of lymphocytes, werenoted in the sections from a deltoid muscle biopsy in a case of gout. The fociresembled those seen in rheumatoid arthritis, but differed in being accompanied byseveral " foreign-body " giant cells (as in tophi). and by being situated mainlyin the subcutaneous tissue, extending into the epimysium. (Haematoxylin and

eosin, x 130.)

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ANNALS OF THE RHEUMATIC DISEASES

"nodular myositis " in one case of Still's disease,but the remainder of their controls were " negative "

(including four cases of subacute rheumatic infectionwith cardiac involvement; one case of rheumaticfever with rheumatic heart disease ; seventeen casesof ankylosing spondylitis; six cases of gout;six cases of osteo-arthritis; three cases of polio-myelitis ; three cases of specific infective arthritis;one case of Paget's disease ; one case of prolapseddisc ; and one case of amyotonia congenita). Onecase of Volkmann's ischaemic contracture showeddiffuse round-cell infiltration in the fibrous tissueamong the muscle fibres, but the cells were notrelated to blood vessels as in rheumatoid arthritis.Two cases of reaction to muscle trauma had lesionssimilar to " nodular myositis ". One case oftuberculous spondylitis had a tiny paravascularfocus consisting of about twenty lymphocytes.Thus, with rare exceptions (chiefly in post-traumaticcases) their control series did not reveal lesions of" nodular myositis ", and this finding, in theiropinion, emphasized the importance of its highincidence in rheumatoid arthritis.The finding of muscle lesions in such conditions

as dermatomyositis, disseminated lupus erythe-matosus, and scleroderma, indicated that nodulesof inflammatory cells in muscles could not beregarded as quite specific to rheumatoid arthritis.These observations do not greatly detract from thevalue of muscle biopsy in rheumatoid arthritis, asthe diseases mentioned above are comparativelyrare, and as there might be some as yet undeterminedrelationship between them and rheumatoidarthritis.

However, Clawson and others (1947) havereported results which, if correct, are irreconcilablewith the findings of all the previous investigators.They collected seven muscles from each of 450autopsies, and in 118 cases (that is 26 per cent.)inflammatory lesions were observed in one or moremuscles and of one or more grades ! They dividedtheir inflammatory lesions into four grades: theirgrade 4 corresponds with one of the large nodulesillustrated by Steiner and others, and their grade 1resembles a small nodule as illustrated by Steinerand others (1946). They noted these " positive "biopsy results in a wide variety of diseases: acuterheumatic fever, bacterial endocarditis, hyper-tension, coronary sclerosis, accidents and trauma,"tumors ", cerebral haemorrhage, cirrhosis," gastro-intestinal conditions ", tuberculosis, polio-myelitis, pneumonia, infections of the bladder andkidneys, etc.

These results, if correct, challenge the validityof the results reported by Steiner and others (1946),

Desmarais and others (1948), de Forest and others(1947), and Morrison and others (1947) in theirseries of control cases.

It is difficult to find a possible source of error inClawson and others' investigations (1947). Theyadmitted that " rheumatoid arthritis may havebeen present to some extent without being mentionedin the histories " in some of their cases, but statis-tically it is very improbable that coincidentalrheumatoid arthritis was present in more than afraction of the cases.Nor can it be said that the criteria employed by

Clawson and others (1947) in their diagnosis of" positives " were very different from thoseemployed by former workers. They specificallystated that they did not regard " the presence of buta few lymphocytes " as indicating a " positiveresult ". Their illustrations of " positive results 'appear similar to those shown by previous investi-gators. Most of their " positive " results weregrouped in grades 1 and 2, but many were groupedin grades 3 and 4, and were thus examples of largenodules. Clawson and others commented that thelesions were found more frequently in cases in whichdeath occurred in the upper decades of life.Yet in an extensive examination of muscles in

" control " cases (including approximately sixtymuscle biopsies, and the examination of muscles ofapproximately 250 cases at autopsy), Steiner andothers (1946), de Forest and others (1947), Morrisonand others (1947), and Desmarais and others (1948)noted no " positive " results with the exceptionof the few cases of dermatomyositis, etc., mentionedabove.Bunim and others (1948) also stated that the

characteristic muscular nodules were present inmany diseases in their control group. The histo-logical appearances and anatomic locations of thesenodules were strikingly similar to, and in somecases indistinguishable from, those seen in rheuma-toid arthritis. Their control series included notonly cases of rheumatic fever, Still's disease,ankylosing spondylitis, lupus erythematosis, anddermatomyositis, but also cases of gout, osteo-arthritis, gonococcal arthritis, tuberculous arthritis,and Pott's disease. Bunim and others thereforeconcluded that if the nodules occurred in a numberof unrelated diseases then they could hardly beconsidered to be specific for rheumatoid arthritis.Bennett (1948) agreed with these conclusions,although his " observations were limited ".On the other hand, Freund (1948) has repeated

his belief that the nodules of " nodular myositis "are specific for rheumatoid arthritis. He agreedthat similar nodules may occur in disseminated

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MUSCLE LESIONS IN RHEUMATOID ARTHRITISlupus erythematosus, in dermatomyositis, in trichini-asis, and in Still's disease, but denied that the nodulesoccurred in other conditions such as ankylosingspondylitis, gout, osteo-arthritis, and gonococcalarthritis.How are these diverse results to be reconciled ?

It is possible that Clawson and others (1947)detected the high incidence of muscle lesions innumerous diseases on account of their extensiveexaminations on seven muscles at each of the 450autopsies, whereas the other observers haveexamined only smaller pieces of muscle removedby biopsy or at autopsy. Nevertheless, if Clawsonand others (1947) and Bunim and others (1948)are correct in their observations, then theseobservations constitute a very serious obstacle tothe claims that these inflammatory nodular focifound in muscle in cases of rheumatoid arthritis arein any way diagnostic of the disease.

Results of Muscle Examination in TwentyControl Cases

Muscle biopsies were performed in twelve controlcases. The muscle was obtained from the deltoidin nine cases (consisting of two cases of acuterheumatic fever, one case of osteo-arthritis, onecase of " fibrositis ", one case of generalizedscleroderma, one case of acute diffuse glomerulo-nephritis, two cases of gout, and one case of acutepoly-arthritis of unknown aetiology); from thepectoral muscle of a case of hypertension; andfrom the sacrospinalis and gastrocnemius musclesrespectively in two cases of polyarteritis nodosa.

In addition, muscle was examined at autopsyin eight cases. The gastrocnemius was examinedin a case of acute porphyria, and the deltoid wasexamined in the other seven cases (consisting of twocases of miliary tuberculosis; one case of general-ized peritonitis; one case of myocardial infarctionand three cases of death due to violence).Although the series of control cases is

admittedly small, it is interesting that (with threeexceptions) no muscle lesions were encounteredin the twelve muscles examined by biopsy and in theeight muscles examined at autopsy.Of the three cases with muscular lesions, two were

cases of polyarteritis nodosa in which the expectedcharacteristic vascular lesions were found (Selzerand Horwitz, 1949). They were distinguishablefrom the lesions of " nodular myositis " in therheumatoid arthritis series.The third case with muscular lesions had gout

(the diagnosis had been proved by demonstratingthe presence of sodium biurate crystals in a tophusremoved from the elbow (Horwitz, 1949)). The

deltoid muscle biopsy was performed while thepatient was suffering from an attack of gout in theknees and ankles. The histological appearanceswere interesting (Figs. 5 and 6), and have not beennoted hitherto in examinations of muscle biopsies.Inflammatory foci were present which closelyresembled those seen in rheumatoid arthritis, but itwas at once possible to differentiate sections fromthose of the rheumatoid arthritis series by means oftwo features: (1) Numerous foreign-body giant cellswere present in, or at the edge of, several of theinflammatory foci (Fig. 5). The lesions thus seemedto resemble those seen in tophi and were presumablya tissue reaction to the local deposition of biuratecrystals. (2) The majority of the inflammatory fociwere situated in the connective tissue on the surfaceof the deltoid muscle (Fig. 6), extending into theepimysium and sometimes into the perimysium.The situation of the inflammatory foci was thusprimarily in the subcutaneous tissue, and the exten-sion into the muscle appeared to be secondary. Adeltoid muscle biopsy was performed on a secondcase of gout, but no lesions were found in theconnective tissue or in the muscle. The " positive "result in the first case of gout is interesting as itprobably indicates a deposition (in the past attacksor in the present attack of gout) of sodium biuratein the deep subcutaneous tissue, and in the intra-muscular connective tissue. It is well known thattophi may occur, not only in joints, cartilage,bursae, and tendons, but also in subcutaneoustissue, and the histological appearances in thiscase probably represent " a microscopic tophus ".(No tophi were present over the shoulders onclinical examination before the muscle biopsy wasperformed).

Summary1. In a series of muscle biopsies performed in

thirty-four cases of rheumatoid arthritis, noduleswere found in the endomysium or in the perimysiumin fourteen cases. The histological appearancesclosely resembled the descriptions of " nodularmyositis" in the literature. The findings con-firmed the fairly high incidence of these musclelesions in rheumatoid arthritis.

2. The lesions were noted in " active " and in"burnt-out " cases.

3. The nodules were detected with great facilityon histological examination. In some cases theywere sufficiently large to be visible to the naked eye.

4. In an examination of the muscles of a smallcontrol series of twenty cases, by biopsy or atautopsy, similar inflammatory nodules were foundin only one case-a case of gout. Certain additionalfeatures rendered the differentiation possible from

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ANNALS OF THE RHEUMATIC DISEASESthe " nodular myositis " seen in rheumatoidarthritis. Two cases of polyarteritis nodosashowed the characteristic vascular lesions of thatdisease.

Muscle examinations in two cases of polyarteritisnodosa showed the characteristic vascular lesionsencountered in the disease.

5. In reviewing the literature it was noted thatsome investigators have reported the occurrence of" nodular myositis " in a miscellaneous collectionof diseases. If their findings are confirmed, itwould indicate that " nodular myositis " is acomparatively common condition in a wide varietyof diseases and that it is of no diagnostic value incases of rheumatoid arthritis.The number of control cases in this series was

too small to enable final conclusions to be drawn,but the results were more in conformity with the" negative " findings noted by most investigatorsin the examination of muscle in control cases.

I am greatly indebted to Prof. F. Forman, Dr. P. W. J.Keet, and the Hon. Physicians of the Groote SchuurHospital, Cape Town, for permission to investigate thecases under their care ; to Prof. B. J. Ryrie and Prof.M. van den Ende for assistance and facilities affordedin the Department of Pathology, University of CapeTown ; to Dr. G. Selzer for valuable assistance in thehistological examinations; to Mr. W. Taylor for thehistological preparations; and to Mr. G. C. McManusfor the microphotography. A grant from the StaffResearch Fund, University of Cape Town, is gratefullyacknowledged.

REFERENCESBennett, G. A. (1948). Annals ofthe Rheumatic Diseases,

7, 251 (discussion).Brain, W. R. (1947). " Diseases of the Nervous

System ". Third Edition. London: OxfordUniversity Press.

Bunim, J. J., and others (1948). Annals of the RheumaticDiseases, 7, 251.

Clawson, B. J., and others (1947). Arch. Path., 43, 579.Curtis, A. C., and Pollard, H. M. (1940). Ann. int. med.

13, 2265.de Forest, G. K., and others (1947). Annals of the

Rheumatic Diseases, 6, 86.Desmarais, M. H. L., and others (1948). Ibid., 7, 132.Freund, H. A. (1948). Ibid., 7, 251 (discussion).Gibson, H. J., and others (1946). Ibid., 5, 131.Horwitz, M. (1949). Clin. Proc., 8, 73.Morrison, L. R., Short, C. L., Ludwig, A. O., and

Schwab, R. S. (1947). Amer. J. med. Sci.,214, 33.

Selzer, G., and Horwitz, M. (1949). S. Afr. med. J.,23, 8.

Steiner, G., and others (1946). Amer. J. Path., 22, 103.Wilson, S. A. K. (1940). " Neurology ". First Edition.

2 Vols. London: Arnold.

Lesions Musculaires dans la PolyarthriteChronique Inflammatoire

REsuME

1. Une serie de biopsies musculaires pratiquees danstrente-quatre cas de polyarthrite chronique inflammatoire,a montre, dans quatorze cas, des nodules dans l'endo-mysium et le perimysium. L'aspect histologiqueressemblait beaucoup a ce qu'on decrit sous le nom de" myosite nodulaire " dans la litterature. Lesconstatations confirmerent l'assez grande frequence deces lesions musculaires dans la polyarthrite chroniqueinflammatoire.

2. On remarqua ces lesions dans des cas qui etaienten phase evolutive ou en phase de "calme ".

3. Les nodules furent decouverts tres facilement Al'examen histologique. Dans certains cas, ils etaientassez importants pour etre vus a l'oeil nu.

4. Pour une serie de vingt "cas temoins " (2 rhuma-tismes articulaires aigus, I osteoarthrite, 1 cellulite,I sclerodermie, 1 glomerulo-nephrite aigiue, 2 gouttes,1 polyarthrite d'etiologie inconnue, I hypertension,2 periarterites noueuses, I porphyrinurie aigiue, 2 tuber-culoses miliaires, 1 peritonite generalisee, 1 infarctus dumyocarde, 3 cas de mort violente), l'examen des muscles,par biopsie ou A l'autopsie, ne revela la presence desemblables nodules inflammatoires que dans un seul cas,un cas de goutte. Certaines differences d'aspect per-mirent le diagnostic avec la " myosite nodulaire"caracteristique de la polyarthrite chronique inflam-matoire.L'examen musculaire de deux cas de periarterite

noueuse mirent en evidence les lesions vasculairescaracteristiques rencontrees dans cette maladie.

5. On remarque dans la litterature que certainsauteurs ont signale la presence de " myosite nodulaire "dans une serie de maladies diverses. Si leurs con-statations sont confirmees, cela semblerait prouver que la" myosite nodulaire " est rencontree assez communementdans une grande variete de maladies et qu'elle n'a pas devaleur diagnostique dans les cas de polyarthrite chroniqueinflammatoire.Dans cette serie le nombre des " cas temoins " fut

trop faible pour permettre d'en tirer des conclusionsdefinitives, mais les resultats semblent plut6t confirmerl'opinion de la plupart des auteurs A savoir l'absencehabituelle des nodules typiques de la polyarthritechronique inflammatoire en dehors de cette maladie.

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