Hepatitis-B antibody in polymyalgia Rheumatica

Polymyalgia rheumatica: 125 years of epidemiological progress?

OBJECTIVES

On the 125th anniversary of the first recognised publication on polymyalgia rheumatica, a review of the literature was undertaken to assess what progress has been made from the point of view of the epidemiology of this disease and whether such studies have advanced our knowledge of its aetiopathogenesis and management.

METHODS

The authors searched Medline and PubMed using the search terms 'polymyalgia rheumatica', 'giant cell arteritis' and 'temporal arteritis'. As much as possible, efforts were made to focus on studies where polymyalgia and giant cell arteritis were treated as separate entities. The selection of articles was influenced by the authors' bias that polymyalgia rheumatica is a separate clinical condition from giant cell arteritis and that, as yet, the diagnosis is a clinical one.

RESULTS

This review has shown that, following the recognition of polymyalgia as a distinct clinical problem of the elderly, the results of a considerable amount of research efforts investigating the populations susceptible, the geographic distribution of these affected populations and the associated sociological and genetic elements that might contribute to its occurrence, polymyalgia rheumatica remains a difficult problem for the public health services of the developed world.

CONCLUSIONS

Polymyalgia rheumatica remains a clinical enigma and its relationship to giant cell arteritis is no clearer now than it has been for the past 125 years. Diagnosing this disease is still almost exclusively dependent on the clinical acumen of a patient's medical attendant. Until an objective method of identifying it clearly in the clinical setting is available, uncovering the aetiology is still unlikely. Until then, clear guidelines on the future incidence and prevalence of polymyalgia rheumatica and the public health problems of the disease and its management, especially in relation to the use of long term corticosteroids, will be difficult to provide.

Conjugal giant cell arteritis

While the pathogenesis of giant cell arteritis (GCA) remains unclear, a number of factors may be contributory, including genetic, environmental, and immune. There have been few reports of GCA occurring in a conjugal pair, all originating from Northern Europe or the Northern United States. We document GCA occurring in a husband and wife from the southern Gulf Coast of the United States and discuss the implications of this, as well as the current understanding of the pathogenesis of GCA.

[Giant cell arteritis (temporal arteritis). Pathophysiology, immunology]

The diagnosis of giant cell arteritis is established by temporal artery biopsy. The findings are those of a panarteritis with mononuclear infiltrates penetrating all layers of the arterial wall. Typically, activated T cells and macrophages are arranged in granulomas. Multinucleated giant cells, when present, are usually close to the fragmented internal elastic lamina. Often, the intimal layer is hyperplastic, leading to concentric occlusion of the lumen. The CD4(+) T cells are the main players in the disease process. T-cell activation in the arterial wall requires the presence of specialized antigen-presenting cells, the dendritic cells. The activation of monocytes and macrophages is responsible for the systemic inflammatory syndrome in giant cell arteritis and polymyalgia rheumatica. The blood vessel wall determines the site specificity of giant cell arteritis and provides the ground for the cell to cell interaction.

Is giant cell arteritis an infectious disease?

The etiology of giant cell arteritis and polymyalgia rheumatica remains unknown, although the HLA-DR4 group and the pre-existence of a degenerative vascular disease are confirmed risk factors. The incidence may vary between countries, but the North-South gradient should be considered with caution because of potential detection and collection bias. Infectious trigger factors have been looked for both at the epidemiological and biological level: annual, cyclic variations of incidence have been shown in Minnesota, seasonal variations in Scotland, France or Israel. The pre-existence of clinical, mainly respiratory, infection has been suggested in one study, but not confirmed afterwards. Simultaneous occurrence of peaks of GCA/PMR and respiratory infections have been observed in Denmark. Several viruses have been suspected as triggers and assessed by serological testing, PCR or immunostaining on temporal artery biopsies, or both techniques: the hepatitis B virus can be ruled out, as well as Herpes simplex 1 and 2, Herpes varicellae, Epstein-Barr virus and cytomegalovirus. Recent studies focused on parainfluenza virus, Parvovirus B19 and Chlamydia pneumoniae. Immunological studies suggest, at the origin of the inflammatory reaction leading to the typical pathological features of giant cell arteritis, the existence of a triggering antigen of unknown nature activating T-cells in the artery wall.

Extrahepatic manifestations of chronic hepatitis B

Several extrahepatic manifestations are associated with chronic HBV infection, many with significant morbidity and mortality. The cause of these extrahepatic manifestations is generally believed to be immune mediated. PAN is a rare, but serious, systemic complication of chronic HBV affecting the small- and medium-sized vessels. PAN is seen more frequently in North American and European patients and rarely in Asian patients. PAN ultimately involves multiple organ systems, some with devastating consequences, though the hepatic manifestations are often more mild. The optimal treatment of HBV-associated PAN is thought to include a combination of antiviral and immunosuppressive therapies. HBV-associated GN occurs mainly in children, predominantly males, in HBV endemic areas of the world, but is only occasionally reported in the United States. In children, GN is usually self-limited with only rare progression to renal failure. In adults, the natural disease course of GN may be more relentless, slowly progressing to renal failure. Immunosuppressive therapy in HBV-related GN is not recommended, but antiviral therapy with alpha-interferon has shown promise. The serum-sickness like "arthritis-dermatitis" prodrome is seen in approximately one third of patients acquiring HBV. The joint and skin manifestations are varied, but the syndrome spontaneously resolves at the onset of clinical hepatitis with few significant sequelae. Occasionally, arthritis following the acute prodromal infection may persist; however, joint destruction is rare. The association between HBV and mixed essential cryoglobulinemia remains controversial; but a triad of purpura, arthralgias, and weakness, which can progress to nephritis, pulmonary disease, and generalized vasculitis, has characterized the syndrome. Finally, skin manifestations of HBV infection typically present as palpable purpura. Though papular acrodermatitis of childhood has been reported to be caused by chronic HBV, this association remains controversial.

The epidemiology of biopsy-positive giant cell arteritis: special reference to cyclic fluctuations

OBJECTIVE

The aim of this work was to study changes in the incidence of biopsy-proven giant cell arteritis (GCA) over a period of 20 yr in Göteborg, Sweden.

METHODS

All cases of biopsy-verified GCA between 1976 and 1995 were included in the study. The annual incidence was calculated for the whole material, for women and men separately, and its fluctuations were tested statistically. In addition, the monthly variation during the last 9 yr could be statistically analysed for the whole material.

RESULTS

In total, 665 patients were diagnosed with biopsy-verified GCA during the 20 yr period. The average annual incidence was 22.2/100000 inhabitants over 50 yr of age (women 29.8, men 12.5). The annual incidence increased significantly with time (P<0.001) for both men and women. Statistical analysis did not reveal any cyclic fluctuation in the annual incidence (P=0.26), while the monthly number of positive biopsies showed significant fluctuation with peaks in late winter and autumn (P=0.041).

CONCLUSIONS

The annual incidence of biopsy-positive GCA increased during the years 1976 through 1995. The significant seasonal variation, as well as considerable variation in annual incidence, might be due to the influence of exogenous triggering factors, such as infections. Further support for an exogenous aetiology, in terms of a statistically significant cyclic fluctuation of the annual incidence, was not found, however.

Temporal arteritis associated with acute Q fever. A case report

The authors describe the case of a sixty-four-year-old man who presented with clinical and histopathologic evidence of temporal arteritis associated with acute Q fever. This association, which has not been previously reported, supports the possible infectious etiology in temporal arteritis.

Rheumatic diseases in African blacks

Contrary to previous belief, there is increasing evidence that a broad spectrum of rheumatic diseases do affect African blacks. Although properly conducted epidemiological studies have yet to be performed, reports of population surveys from a variety of sub-Saharan African countries indicate that diseases such as rheumatoid arthritis (RA), gout, and the connective tissue diseases are observed, although some differences in clinical presentation may occur as a result of cultural, racial, and socioeconomic factors. Rheumatoid arthritis is common in some parts of Africa and less common in others. In particular, a significantly lower prevalence of RA in rural areas compared with urban cohorts has led to the hypothesis that environmental factors associated with urbanization may be involved in disease pathogenesis. A similar hypothesis has been suggested for hyperuricemia and gout. Clinical features of disease may also be different in Africans when compared with other population subgroups such as with systemic lupus erythematosus although this may be artefactual as different accessibility to health care and referral practices may result in only the more severe cases coming to medical attention (eg, lupus nephritis). Immunogenetic factors may reduce the prevalence of some conditions such as the spondyloarthropathies. Although the association between HLA-DR4 and RA holds true in Africans, the same is not so for the association of HLA-B27 with ankylosing spondylitis (AS). The prevalence of HLA-B27 in African blacks is 10 times less than Caucasian populations, in part accounting for the low prevalence of spondyloarthropathies, although its association with AS is low. Other conditions such as human immunodeficiency virus (HIV)-related arthropathies appear to be an increasing medical problem. The panepidemic of acquired immunodeficiency syndrome in Africa has resulted in an increased awareness of the different types of arthritis that may be associated with HIV. These are similar to those reported in other parts of the world, although risk factors are different in Africa where heterosexual transmission is a more common cause than homosexual transmission or i.v. drug usage. Information on other rheumatic diseases such as osteoarthritis and soft tissue rheumatism are slowly emerging. Rheumatic manifestations of the infectious diseases, which are endemic in Africa, remain a uniquely fascinating aspect of rheumatology practice on the African continent. Therefore, African countries will increasingly be a continued valuable source of clinical material for comparative studies to help elucidate factors that influence the development of rheumatic diseases.

Clinical and laboratory findings with giant cell arteritis

Out of 66 patients who were diagnosed as suffering from polymyalgia rheumatica (PMR; n = 40), temporal arteritis (AT; n = 14) or both (n = 12) in a 6.5 year period (incidence 3.4/100,000 per year), 9 died and 49 were followed up for an average period of 28 months. Exacerbations of the illness (n = 24) and complications in the course (n = 32) were more frequent with an initial ESR greater than 90 mm/h. Postural vertigo (n = 11), amaurosis fugax (n = 11) and polyneuropathy (n = 8) were the most frequent neurological complications. Persisting unilateral blindness and aromatic anosmia developed in 2 patients each. Complications were significantly more frequent in patients with initial symptoms of AT (chi 2 P less than 0.001). CRP-levels correlated better with persisting symptoms in the course than did the ESR. Recurrences after treatment were significantly more frequent when the length of corticosteroid-therapy was less than 20 months (chi 2 P less than 0.009). On follow up there were normal values for neopterin, tumour necrosis factor and antibodies against Borrelia burgdorferi.

A seasonal pattern in the onset of polymyalgia rheumatica

The seasonal distribution in the onset of polymyalgia rheumatica (PMR) was determined in 58 patients with the disease and compared with that in 44 patients affected by rheumatoid arthritis of elderly onset (EORA). Thirty six (62%) cases of PMR developed during May to August; by contrast, only 14 (31%) cases of EORA developed in the same months, this latter disease failing to show any seasonal clustering. The monthly distribution of PMR correlated with outside temperature and hours of sunshine. These data suggest that PMR might be triggered by such factors as actinic damage of superficial vessels or infective agents with a seasonal cycle. Finally, the summer clustering of PMR may be helpful in the differential diagnosis from EORA.

Polymyalgia rheumatica and temporal arteritis

Polymyalgia rheumatica and temporal arteritis are a clinical syndrome and clinicopathologic entity, respectively. Polymyalgia rheumatica occurs more commonly than temporal arteritis, with approximately half of all patients with temporal arteritis having the polymyalgia rheumatica syndrome. Both conditions are found in the population over 50 years of age and are associated with an elevated ESR. The etiology of both is unclear, although genetic, and potentially, environmental factors may play significant roles. Both conditions respond to corticosteroid therapy, but patients with temporal arteritis require significantly higher doses to control symptoms and to prevent blindness.

Clinical and pathologic studies of synovitis in polymyalgia rheumatica

Clinically detectable joint swelling was found in 10 of 13 fully evaluated patients considered to have polymyalgia rheumatica. Five patients had some joint findings at disease onset. Knees were most commonly affected. Sternoclavicular involvement was seen in 3 patients. Joint effusions in 8 patients had 300-5,700 leukocytes/mm3 with a mean of 2,900. Six synovial biopsy specimens studied by light microscopy revealed mild to moderate synovial proliferation and chronic inflammation that was generally less severe than in typical rheumatoid arthritis. Electron microscopy identified microvascular changes and large amounts of vesicular and granular debris in lining cells. In 1 patient, a "fingerprint" pattern in the granular material was suggestive of the findings in some immune complexes. This still unexplained synovitis may, as previously suggested, be important in the pathogenesis of the polymyalgia rheumatica syndrome.

B- and T-lymphocytes in ocular disease

Ocular inflammatory diseases and ocular adnexal lymphoid tumors have become less obscure and intimidating by virtue of our ability to study the infiltrates in these various diseases for their B-lymphocyte and T-lymphocyte composition. Comparisons are also possible between lymphocytic profiles in the peripheral blood and the precise composition of the in situ infiltrates within the ocular tissue themselves. The availability of monoclonal antibodies, which can determine T-lymphocytic subsets such as T-helper cells and T-suppressor/cytotoxic cells, natural killer cells, and monocytes-histiocytes, has provided a powerful technology for the delineation of the distinctive immune composition of the inflammatory infiltrates, as well as any possible disturbances in T-cell immunoregulation. B-lymphocytes produce immunoglobulins, which may be misdirected as autoantibodies in local or systemic autoimmune diseases. Immunoglobulin-mediated and therefore B-cell derived conditions include vasculitis, progressive cicatricial ocular pemphigoid, Mooren's corneal ulcer, scleritis, and hay fever and vernal conjunctivitis. Other diseases in which B-lymphocytes, their immunoglobulin products or immune complexes formed with presently unknown antigens are potentially at fault are chronic non-specific uveitis; iridocyclitis in Behcet's syndrome; Fuch's heterochromic syndrome, ankylosing spondylitis, and Reiter's syndrome; Graves' disease; and idiopathic inflammatory orbital pseudotumor and myositis. T-cells do not produce immunoglobins, but rather secrete lymphokines or interact directly with receptors or determinants on viruses or target tissues (eg. immunosurveillance against neoplasia); it is possible that some autoimmune diseases are the result of neo-antigens on the surfaces of host tissues that have been coded for by a cryptic inciting virus. T-cell diseases include phlyctenulosis graft rejections, graft versus host disease, and possibly sympathetic ophthalmia and temporal arteritis. Natural killer cells are involved in many of the same diseases as cytotoxic T-cells, except that the former require no period of sensitization (natural immunity), whereas cytotoxic T-cells must undergo an antigen-specific blast transformation (acquired immunity of the delayed hypersensitivity type). In many diseases in which B-cell derived auto-antibodies are at fault, there may be local tissue or systemic T-cell imbalances, with a reduction in T-suppressor cells and a relative augmentation in T-helper cells, thereby facilitating production of misdirected auto-antibodies.(ABSTRACT TRUNCATED AT 400 WORDS)

Status of hepatitis B virus in the aetiology of uveitis in Great Britain

Viruses have been demonstrated or suspected as the causative agents of various types of uveitis. Hepatitis B virus (HBV), apart from causing hepatitis, has also been implicated in the pathogenesis of systemic vasculitis, for example in glomerulonephritis and polyarteritis nodosa. It is therefore possible to postulate that a similar vasculitic process might occur in the eye leading to intraocular inflammation. A recent report from Switzerland suggests that HBV may be implicated in the aetiology of uveitis, as hepatitis B surface antigen (HBsAg) was found in the serum of 13% of cases of uveitis. Since the status of HBV in the aetiology of uveitis in Great Britain has not been investigated, we have examined serum from 200 cases of uveitis of various clinical types for the presence of circulating HBsAg. Only 4 cases (2%) were found to be HBsAg positive. This study failed, therefore, to confirm HBV as an important cause of uveitis in this country, but one cannot exclude the possibility that it may play a pathogenetic role in a small proportion of such cases.

Serologic and immunopathologic findings in temporal arteritis

In 104 patients undergoing biopsies for temporal arteritis, lymphocyte characterization identified both T4 helper/inducer and T8 cytotoxic/suppressor lymphocytes in approximately equal numbers. B lymphocytes were absent. Deposition of IgM and IgG was observed in three of 16 positive biopsy specimens. Antinuclear antibodies were present in ten of 16 biopsy-proven cases of temporal arteritis compared with 19 of 55 in the control group with negative biopsy specimens. Anti-smooth-muscle, anti-DNA, and antimitochondrial antibodies were not useful in distinguishing between the two groups.

Hepatitis B virus infection in patients with rheumatic diseases

Two hundred and thirty-nine patients with different rheumatic diseases were investigated for serological markers of hepatitis B virus (HBV) infection. An increased prevalence of anti-HBs was found in patients with systemic lupus erythematosus. The total prevalence of HBV markers in patients with polymyalgia rheumatica, temporal arteritis, juvenile and adult rheumatoid arthritis (RA) and systemic sclerosis was not significantly different from age-matched controls. Remarkably, 6 patients were HBsAg-positive of whom 3 had RA (4%). Two patients with RA were "healthy' HBsAg carriers. The third patient had circulating HBeAg as well and had shown progression from acute hepatitis to cirrhosis during the time of observation. Three of 18 patients with polyarteritis nodosa were HBsAg- and HBeAg-positive, and all 3 were young men. Clinical improvement was seen in one of these patients and was associated with seroconversion from HBeAg to anti-HBe. Our data do not support the theory that HBV is an aetiological factor in rheumatic diseases except in some cases of polyarteritis nodosa.

In vitro cytotoxicity of human endothelial cells in polymyalgia rheumatica and giant cell arteritis

We studied sera from 20 patients with polymyalgia rheumatica (PMR)/giant cell arteritis (GCA), 15 patients with systemic lupus erythematosus (SLE), 15 patients with the CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangietasia) and 33 age and sex matched controls for cytotoxicity against human endothelial cells using a 51Cr release assay. We observed increased levels of endothelial cytotoxic activity in the PMR/GCA sera compared with controls (P less than 0.001). This cytotoxicity was predominantly found in the GCA group, where 7 out of 10 patients (70%) demonstrated significant cytotoxicity. Sequential studies showed that the cytotoxic activity returned to normal when the disease was under control. Although 7 SLE and 3 CREST sera had significant cytotoxic activity, as a group they did not differ from controls (P less than 0.05). Pre-incubation with soybean trypsin inhibitor suppressed the cytotoxic activity in the positive sera suggesting the cytotoxicity is mediated via a protease mechanism. Our results demonstrate the presence of a cytotoxic factor in the serum of patients with PMR/GCA which may play an important role in the pathogenesis of the vascular lesions observed in these disorders.

Hepatocellular disease in the giant-cell arteritis/polymyalgia rheumatica syndrome

An elderly man developed temporal arteritis and polymyalgia rheumatica with coexisting biochemical abnormalities of liver function. Biopsy revealed hepatic changes which have not been previously reported. There was hepatocellular necrosis and inflammation together with a prominent hyperplasia of perisinusoidal lipocytes of Ito. Temporal artery biopsy confirmed the presence of granulomatous panarteritis. Corticosteroid therapy produced rapid resolution of symptoms and reversion of liver function tests to normal.

Hepatitis B surface antigen circulating immune complexes (HBsAg-CICs) in patients with bleeding disorders

Approximately 90% of 67 multi-transfused patients with bleeding disorders were positive either for anti-HBs (85%) or HBsAg (45%). Using a polyethylene glycol trypsinization assay, we found anti-HbsAg-containing specific circulating immune complexes (HBsAg-CICs) in 3 of the 57 HBsAg-negative haemophiliacs possessing anti-HBs. The occurrence of HBsAg-CICs may be a regular event in the conversion phase of HBs infection. Circulating immune complexes as detected by the anticomplementary assay were found in 32 of the 67 (48%) patients.

Hepatitis B virus and polymyalgia rheumatica: a search for HBsAg, HBsAb, HBcAb, HBeAg, and HBeAb

Forty-three consecutive patients with polymyalgia rheumatica were studied for serological markers of actual or previous hepatitis B virus infection. Signs of active virus replication, which include HBsAg supported by the presence of HBeAg and anti-HBc in high titres, were not found in any cases. Anti-HBs, a serological sign of previous hepatitis B virus exposure, was present in 16.8%. The prevalence of anti-HBs is strongly age-dependent in the normal population, and its prevalence in polymyalgia rheumatica was not significantly different from the incidence found in other hospital patients. No significantly raised incidence was found in any subgroups, including patients without liver dysfunction. These results do not support the concept that current or previous hepatitis B virus infection plays any role in the pathogenesis of the majority of cases of polymyalgia rheumatica.

Serum immunoconglutinin titers during acute and chronic hepatitis B virus infection

Sera from 99 chronic hepatitis B surface antigen carriers, 12 individuals with acute type B hepatitis, 26 hepatitis B surface antibody-seropositive subjects, and 50 hepatitis B surface antigen, hepatitis B surface antibody-seronegative subjects were evaluated for the presence of serum imunoconglutinis (IKs). The mean serum IK titers of hepatitis B surface antibody-seropositive and hepatitis B virus-seronegative subjects wre 5.3 and 4.9, respectively. The IK titers of subjects with acute and chronic hepatitis B virus infections were 215.4 and 19.1, respectively. These groups also manifested IK titers greater than or equal to > 16 significantly (P < 0.005) more often than controls did. Among chronic hepatitis B surface antigen carriers, high IK titers were associated with low levels of hepatitis B surface antigen. IK titers of individuals chronically infected with hepatitis B virus and having the rheumatoid factor were similar to those of individuals without the rheumatoid factor. Elevated IK titers represent a physiological autoimmune response and may indicate the presence of immune complexes in acute and chronic hepatitis B virus infection.

Polymyalgia rheumatica in a husband and wife

The case histories of an unrelated husband and wife in whom polymyalgia rheumatica developed within one month are described. In the wife, giant-cell arteritis was present. The clinical courses were similar and there was a typical good response to treatment with prednisone. Both patients were HLA-B8. Only the husband had positive hepatitis-Bs antibody. The aetiology of the disease is discussed in relation to tissue antigens and hepatitis-B infection.

Polymyalgia arteritica: a clinical review

In a series of thirty-seven consecutive patients with polymyalgia arteritica, twenty-five had polymyalgia rheumatica and twelve had cranial arteritis. Some failed to respond promptly to low doses of prednisolone and it is recommended that the initial dose should be in the order of 40 mg daily. An ESR above 40 mm in the first hour was present in four patients 3 months after admission; three were found to have rheumatoid disease and one pulmonary tuberculosis. Symptomatic relapses occurred in fourteen patients on twenty-one occasions and all responded to an increase in the daily dose of maintenance prednisolone. Most occurred in the first year and were attributable to an excessively rapid reduction in steroid therapy. Relapses occurring in patients on a stable dose of prednisolone were commonly associated with the development of rheumatoid disease. In elderly patients who have relapsed, or who have had arteritic complications, life-long prednisolone therapy appears justifiable.

Giant cell arteritis (cranial arteritis, polymyalgia rheumatica)

Giant cell arteritis, which is probably due to disturbed immune mechanisms, has a spectrum of clinical symptoms in elderly people. In nearly all cases such general signs as loss of appetite, loss of weight and fever are present. The sedimentation rate is almost without exception about 100 mm in the first hour. The two most frequent and typical clinical syndromes are polymyalgia rheumatica and cranial arteritis. The polymyalgia rheumatica is characterized by periarticular pain which is mostly symmetrical and accentuated in the shoulder girdle. Increasingly severe temporal headache and ocular distrubances are found with cranial arteritis in more than 50% of cases. A combination of both diseases is frequent. Other arterial branches are rarely involved. The course of the disease is over a period of 1 1/2 to 2 years. Treatment with corticosteroids is indicated mainly because of the severe ocular complications with blindness. It should begin immediately, be intensive and last over a long period. Regular followup is necessary over several years in order to avoid relapses.

Neutrophil chemotaxis in ankylosing spondylitis, Reiter's disease, and polymyalgia rheumatica

Neutrophil chemotaxis was found to be normal in 14 patients with ankylosing spondylitis, in 10 patients with Reiter's disease, and in 8 patients with polymyalgia rheumatica.

Giant cell arteritis. Clinical features and involvement of different organs

Sixty-eight patients with giant cell arteritis (GCA) are described. In 42, histological evidence of arteritis was recorded at biopsy of a temporal artery. Twenty-six patients were included according to clinical criteria. In 20 patients the onset of illness was associated with an infection. The first symptom was: in 30 patients, muscle pains; in 14, fever; in 11, headache with temporal localization, and in 13 patients, tiredness and anorexia. In all, 50 patients had muscular symptoms and 30 had symptoms of localized temporal arteritis. In 5 patients neither muscular symptoms nor localized arteritis were found. A high erythrocyte sedimentation rate was seen in all cases and elevated platelet count was found in 24 patients. Abnormal liver function was a common finding, whereas impaired renal function was not observed. In 8 cases reversible eye symptoms were noted and reduced hearing capacity was demonstrated in 5 patients.

Association of polymyalgia rheumatica and giant-cell arteritis with HLA-B8

Histocompatibility antigens were determined in 30 patients with temporal arteritis, 27 patients with polymyalgia rheumatica, and 216 normal blood donors. HLA-B8 was significantly more common in patients with polymyalgia rheumatica (59%) and temporal arteritis (50%) than in the controls (27%). The findings of HLA-A10 in 26% of the patients with polymyalgia rheumatica compared with only 10% of the controls may be associated with the suggested immunological pathogenesis of the condition.

Hepatitis-B: a review

The recent literature on various aspects of hepatitis-B is reviewed with emphasis on the interrelationships of viral structure, antigenic components, and host immune response in acute, chronic, and asymptomatic carrier states of the infection. The mode of replication and mechanisms of transmission are discussed. Special attention is paid to potential non-parenteral routes of spread. The role of hepatitis-B in associated immune complex diseases and in hepatoma is outlined. A guide to the interpretation of serologic tests for hepatitis-B associated antigen and antibody patterns is presented in relation to the clinical stage and prognosis of the infection. Therapy, except in conceptual terms, is not covered but a summary of the current status of active and passive immunization is given. The unresolved question of the infectivity of carrier medical staff for their patient contacts, and the reverse, is discussed.

Circulating immunoblasts in polymyalgia rheumatica

The percentage of immunoblasts circulating in the peripheral blood has been examined in a group of 29 patients with polymyalgia rheumatica (PMR). Less than 0.5% of immunoblasts were found in healthy young controls, but 18 of 29 unselected patients with PMR were positive when first tested, a similar proportion to that found in rheumatoid arthritis. Raised immunoblasts were found in only one of 12 elderly controls. The presence of circulating immunoblasts correlated with the activity of polymyalgia both as assessed by the erythrocyte sedimentation rate (ESR) and as assessed by an independent clinical observer. This was true in the group overall and in those patients where serial studies were made. Patients studied from the time of disease presentation showed a concurrent fall in ESR and in immunoblasts on starting steroid therapy. Detection of circulating immunoblasts can be a useful additional test in the assessment of disease activity in PMR, especially in cases with a low ESR. The presence of circulating immunoblasts supports the concept of an immunological aetiology for PMR. This is strengthened by the finding that raised immunoglobulins were more common in patients with circulating immunoblasts.