Prevalence of STAT3 mutations in patients with rheumatoid arthritis-associated T-cell large granular lymphocytic leukaemia and Felty syndrome

OBJECTIVES

Neutropenia is a key presentation of Felty syndrome (FS) and rheumatoid arthritis (RA)-associated T-cell large granular lymphocytic (T-LGL) leukaemia. Clonal rearrangement of T-cell receptor (TCR) gene supports the diagnosis of T-LGL leukaemia but not FS. Mutations in the signal transducer and activator of transcription 3 (STAT3) gene are highly specific for T-LGL leukaemia, but their prevalence in FS remains poorly clarified.

METHODS

The study included 100 patients with RA and unexplained neutropenia. TCR rearrangements were examined in blood (100 cases), bone marrow (47 cases), and spleen (12 cases) using the BIOMED-2 protocol. Patients were stratified into RA-associated T-LGL leukaemia cohort if a clonal TCR rearrangement was identified in any of the tested patient samples, and into FS cohort in other cases. Mutations in the STAT3 were examined using next-generation sequencing (NGS) technology in blood (100 cases), bone marrow (37 cases), and spleen (7 cases).

RESULTS

STAT3 mutations were identified in 71% (49/69) patients with RA-associated T-LGL leukaemia and in 10% (3/31) patients with FS (p=4.7×10-8). Three samples from the RA-associated T-LGL leukaemia cohort and 5 samples from the FS cohort had STAT3 mutations in the absence of clonal TCR rearrangement.

CONCLUSIONS

The results suggest that STAT3 mutations are significantly less common in FS than in RA-associated T-LGL leukaemia. Moreover, NGS can detect clones undetectable by fragment analysis. We speculate that in patients with RA and neutropenia, the detection of STAT3 mutations can point to T-LGL leukaemia even in the absence of clonal TCR rearrangement.

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSES

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

INTERVENTIONS

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

OUTCOMES

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

LESSONS

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

Analysis of a single-institution cohort of patients with Felty's syndrome and T-cell large granular lymphocytic leukemia in the setting of rheumatoid arthritis

T-cell large granular lymphocytic leukemia (T-LGLL) is a lymphoproliferative disorder characterized by a persistent increase in the number of large granular lymphocytes (LGLs), neutropenia, and splenomegaly. Clinical manifestations of T-LGLL in the setting of rheumatoid arthritis (RA) are often identical to those in which one would suspect Felty's syndrome (FS). These disorders are distinguished by the presence of T-cell clonality, which is present in T-LGLL but not in FS. Mutations in the signal transducer and activator of transcription 3 (STAT3) and 5b (STAT5b) genes can be used as molecular markers of T-LGLL, but their prevalence in FS is unknown.Eighty-one patients with RA and unexplained neutropenia or/and an increase in the number of LGLs above 2 × 10⁹/L were stratified into RA-associated T-LGLL (N = 56) or FS (N = 25) groups based on the presence or absence of T-cell clonality. STAT3 and STAT5b gene mutations were assessed in each group by means of allele-specific polymerase chain reaction assays. Clinical, immunological, laboratory data and the results of immunophenotyping of blood and bone marrow lymphocytes were also evaluated.Mutations of the STAT3 gene and an increase in the number of LGLs above 2 × 10⁹/L were detected in RA-associated T-LGLL, but not in FS (39% vs 0% and 21% vs 0%, respectively). Mutations in the STAT5b gene were not observed in either group. Expression of CD57, CD16, and CD5^-/dim on CD3⁺CD8⁺ T-lymphocytes was observed in both RA-associated T-LGLL and FS.STAT3 gene mutations or LGL counts over 2 × 10⁹/L in RA patients are indicative of T-LGLL.

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

Felty's Syndrome: A Qualitative Case Study

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

Non-articular Felty's syndrome: An uncommon diagnosis

Felty's syndrome is a triad of rheumatoid arthritis, neutropenia, and splenomegaly. We hereby report an unusual case of non-articular Felty's syndrome and its management along with discussing the importance of appropriately ruling out alternate causes of neutropenia with splenomegaly.

Felty's syndrome and Kala-azar: a challenge for the rheumatologist

Case report of a patient with rheumatoid arthritis who developed severe neutropenia, splenomegaly and was diagnosed with Felty's syndrome. The patient later developed Kala-azar. Both diseases have similar clinical and laboratory presentation, making the differential diagnosis difficult. The present case report aims at drawing attention to the identification of visceral Leishmaniasis infection in patients with rheumatic diseases, as well as possibility of a patient with Kala-azar mimicking a set of symptoms of systemic rheumatic disease.

[T-large granular lymphocyte leukaemia. An important differential diagnosis to Felty's syndrome]

T-Large Granular Lymphocyte (T-LGL) leukaemia is a rare clonal disease characterized by neutropenia and/or anaemia. Because of its strong association with rheumatoid arthritis (RA), T-LGL leukaemia is an important differential diagnosis to Felty's syndrome. This differentiation might be especially difficult since, in severe RA with extraarticular manifestations, there is often an expanded memory effector T-cell population which can hardly be separated from T-LGL leukaemia cells by means of immunophenotyping. The main criterion for T-LGL leukaemia is the detection of a clonal T-cell-receptor rearrangement by PCR. First-line therapy consists of weekly low-dose methotrexate. Alternatively, other immunosuppressives or cytotoxic agents can be useful. There are very limited data from therapy studies. The German CLL study group has initiated a protocol using parenteral low-dose methotrexate as first-line therapy and fludarabine as second-line medication.

Felty's syndrome with chronic hepatitis and compatible autoimmune hepatitis: a case presentation

A 68-year-old woman with Felty's syndrome was admitted to our hospital due to breathlessness. She was diagnosed as having rheumatoid arthritis at age 59 years. Abdominal computed tomography indicated ascites, splenomegaly and liver atrophy. She had no antigens or antibodies for hepatitis virus, or antibodies for mitochondria with the exception of antinuclear antibody. According to the International Autoimmune Hepatitis (AIH) scoring system, she was diagnosed as having chronic hepatitis, compatible with AIH. The association of Felty's syndrome with AIH is very rare and the most difficult problem to overcome is whether or not steroid therapy is necessary in patients with Felty's syndrome complicated by AIH.

Hematological manifestations of rheumatoid arthritis

OBJECTIVE

To inform clinical rheumatologists about the common and rarer hematological manifestations of rheumatoid arthritis with an emphasis on diagnosis and therapy and a particular reference to Felty's syndrome.

METHODS

Literature review.

RESULTS

The hematological manifestations can be conveniently categorized into the broad areas of; anemia, particularly NSAID induced iron deficiency anemia and the anemia of chronic disease, neutropenia, particularly Felty's syndrome and the large granular lymphocyte syndrome and drug induced neutropenia; thrombocytopenia, particularly autoimmune and drug induced thrombocytopenia; and hematological malignancy. Rarer conditions, their diagnosis and therapy are also described in this review.

CONCLUSION

Hematological manifestations of rheumatoid arthritis are very common. A logical approach using easily available tests should allow straightforward decisions about diagnosis and therapy to be made, even in patients with some of the rarer manifestations.

[Felty's syndrome]

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

INTERPRETATION

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

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

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

[A case of recurrent bilateral shoulder dislocation in a patient with Felty's syndrome]

A case of recurrent bilateral shoulder dislocation in patient with Felty disease is presented. Good clinical result has been achieved after surgical treatment inclusive of synovectomy and bone bar implantation into the anterior edge of the scapula followed by appropriate rehabilitation.

[The ocular manifestations in Felty's syndrome]

The Felty syndromme is a rare clinical form of the rheumatoid poliarthritis, which involves, besides the articular manifestations specific to the latter, other manifestations such as: splenomegalia with hypersplenism, poliadenopathy, ulcerations at the low leg level and skin pigmentation. In some cases, the Felty syndromme may be associated with ocular modifications: episcleritis, nodular scleritis, corneal ulcer, Sicca syndromme, iridocyclitis, retineal vasculite. A clinical observation of Felty syndromme associated with ocular modifications is presented. Some aspects regarding the nosologic classification of Felty syndromme, its clinical and ethiopathogenical particularities are discussed; the accent is put on the immunopathological component. The ocular modifications particularities, their diagnosis and the therapeutical aspects are presented.

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

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

[Rheumatoid arthritis, neutropenia and splenomegaly: the Felty syndrome]

HISTORY AND FINDINGS

A 59-year-old asymptomatic man, first diagnosed to have rheumatoid arthritis 27 years ago, was admitted to hospital because of splenomegaly and neutropenia, first noted 2 years ago. Physical examination confirmed splenomegaly and also revealed pretibial hyperpigmentation, but no evidence of active rheumatoid arthritis.

EXAMINATIONS

Biochemical tests showed relative and absolute neutropenia (white blood cell count 2200/microliters; 1% neutrophils), thrombocytopenia and polyclonal hypergammaglobulinaemia. He also had increased erythrocyte sedimentation rate (38/92), a high titre of rheumatic factor (2128 IU/ml) and increased circulating immune-complexes (74%). Thoracic and abdominal computed tomography provided no evidence of malignant tumor. The spleen measured 15 x 7 x 10 cm. Bone-marrow biopsy from the iliac crest revealed abnormal maturation of granulopoiesis and marked lymphoid infiltration. The clinical triad of rheumatoid arthritis, splenomegaly and neutropenia are diagnostic of Felty's syndrome. As the patient was asymptomatic there was no indication for treatment.

CONCLUSION

Felty's syndrome is a rare condition demanding considerable effort in differential diagnosis.

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

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

Primary T cell lymphoma of the liver in a patient with Felty's syndrome

We describe a case of primary T cell lymphoma of the liver developing in a patient with Felty's syndrome (FS). We discuss the possible relationship of the two conditions with particular reference to liver disease in FS, and the role of the T cell in RA.

Pseudo Felty's syndrome. A polyclonal disease with a favorable prognosis. Report of two cases with Southern blot analysis of TCR

The authors report two patients with large granular lymphocyte (LGL) expansion associated with rheumatoid arthritis corresponding to pseudo Felty's syndrome. These cells have natural killer and T cell surface antigen markers. LGL are a heterogeneous population and expansion of these cells is responsible for leukemia, which is generally a monoclonal proliferation. It has been suggested that Epstein-Barr virus (EBV) is a putative agent in this leukemia. No EBV DNA was found with a polymerase chain reaction analysis in the lymphocyte DNA of our two patients. Some cases of pseudo Felty's syndrome have exhibited a monoclonal pattern on Southern blot analysis of the T cell receptor. On the contrary, our two cases showed a polyclonal pattern with TCR beta chain Southern blot analysis. This fact, associated with the mild course seen in both over more than twenty years, suggest that pseudo Felty's syndrome is a disease with a good prognosis.

[Polyarthritis revealing hairy cell leukemia]

A female patient simultaneously developed hematologic evidence of hairy cell leukemia and marked but short-lived inflammatory involvement of a number of joints. Both these groups of symptoms resolved simultaneously and rapidly under alpha-2 interferon therapy. This course suggests that the arthritis was a rheumatologic manifestation of the hematologic disease. The concomitant occurrence in this patient of arthritis, splenomegaly and leukopenia was suggestive of Felty syndrome: these two conditions need to be differentiated.

Coexistent Felty's syndrome and palindromic rheumatism

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

[Felty's syndrome]

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

[Rheumatoid arthritis and chronic granular T-cell lymphocytosis with neutropenia. A clinical condition distinct from Felty's syndrome]

103 cases of rheumatoid arthritis who had been diagnosed between 1984 and 1985 have retrospectively been analyzed, in order to identify those patients who had presented with associated neutropenia and in whom it was thus possible to suggest a presumptive diagnosis of either Felty's syndrome or chronic granulated lymphocytosis with neutropenia. Four patients (3.8%) satisfied the clinical criteria for the latter diagnosis while only one had typical Felty's syndrome. They were again studied using blood counts, microscopy of bone marrow and surface antigen analysis of mononuclear cells and the above mentioned diagnoses were confirmed. Though clinically indistinguishable, these two conditions are clearly distinct on both hematologic and immunological grounds. The four patients with rheumatoid arthritis and chronic granulated T cell lymphocytosis with neutropenia represent 36.3 per cent of our institution's patients with chronic granulated T cell lymphocytosis of undetermined significance. Caution should be used in the treatment of rheumatoid arthritis of the patients with associated granular lymphocyte proliferation, considering the possible adverse effects that drugs such as gold salts, penicillamine, cyclosporine and methotrexate may exert not only on the immunological system but also on granulocytopoiesis.

Felty's syndrome in a Nigerian

The first case of Felty's syndrome to be reported in a Nigerian, a fifty five-year-old woman who developed splenomegaly and leukopenia during the course of strongly seropositive rheumatoid arthritis of ten years duration is presented. her arthritis had lasted for about ten years, but she did not have the severe deforming disease known to be associated with Felty's syndrome. Radiologically there were no erosions and subcutaneous nodules were absent. She had a positive granulocyte specific anti-nuclear factor, cryoglobulins containing IgA and IgM and her polymorph-nuclear granulocytes showed evidence of impaired killing of staphylococci.

[Agranulocytosis and connectivitis different from Felty's syndrome: 4 cases. Success of cyclosporin in a case]

Four cases of chronic agranulocytosis in patients with systemic diseases different from Felty's syndrome are reported. Two patients had primary Sjögren's syndrome (confirmed in one, suspected in the other), one had systemic lupus erythematosus and the last patient had an unclassifiable connective tissue disease. Only one severe infection was recorded. The pathophysiological mechanisms involved are discussed. There is a strong suspicion that the cytopenia is of immune origin. Corticosteroid therapy was effective in all four patients. One patient who could not tolerate corticosteroids was successfully treated with cyclosporin A.

[A case of progressive systemic sclerosis associated with mutilans-type arthropathy and suspected Felty's syndrome]

A patient who developed mutilans-type arthropathy, splenomegaly, leukopenia, leg ulcer and massive hydroxyapatite accumulation during the course of progressive systemic sclerosis (PSS) was reported. A 56-years-old female had suffered Raynaud's phenomenon since the beginning of her third decade. She developed multiple symmetrical arthritis and morning stiffness at the age of 29, and was treated with NSAIDs and low dose corticosteroids under the diagnosis of rheumatoid arthritis (RA) Because of dysphagia and diarrhea, she was admitted in Niigata-Kenritsu Senami Hospital in September, 1987. Physical and roentgenographic examinations revealed diffuse scleroderma, mutilans-type arthropathy, lung fibrosis, splenomegaly and right leg ulcer. Laboratory examinations showed leukopenia, high titer of anti-DNA antibody, positive anti-Scl-70 antibody and mild hypocomplementemia. These findings suggested that she had PSS and Felty's syndrome. Furthermore, massive subcutaneous and intraarticular hydroxyapatite accumulation were noticed. The leg ulcer and laboratory data gradually improved with the combination therapy of corticosteroids, D-penicillamine and plasmapheresis. Although it has been well recognized that PSS patients reveal frequently the articular lesions similar to these of RA, severe mutilans-type arthropathy seen in this case is extremely rare. The joint contracture might be induced by hydroxyapatite accumulation, of which the early diagnosis seems to be very important in long-standing PSS patients.

Felty's syndrome in black Americans: a case report

This is a case report of a black woman with Felty's syndrome, who had recurrent, severe leg ulcers refractive to the usual treatment. The leg ulcers healed promptly after splenectomy and there has not been a recurrence of these lesions after three years' follow-up. The rarity of Felty's syndrome in blacks is highlighted and the literature on this aspect is reviewed. Information on seven patients with Felty's syndrome seen at the University of Cincinnati Medical Center is provided and the relationship of skin ulcers to splenectomy reviewed.

Plasma lactoferrin in patients with neutropenia

This study examines the role of plasma lactoferrin in the assessment of neutropenia. In particular, we have studied lactoferrin as an inhibitor of granulopoiesis and as an indicator of the size of the total blood granulocyte pool (TBGP). Plasma lactoferrin concentration was determined in a heterogeneous group of 30 patients with neutropenia. Serial plasma lactoferrin levels in a patient with cyclic neutropenia correlated with the cycles of the neutrophil count. Patients with splenomegaly had a grossly elevated lactoferrin:neutrophil ratio. Most chronic idiopathic neutropenia patients had no real clinical problems and a normal plasma lactoferrin level. The results provide further evidence to support the concept that plasma lactoferrin indicates the size of the TBGP and the lactoferrin: neutrophil ratio indicates the degree of granulocyte margination. There was no evidence to suggest that lactoferrin acting as a feedback inhibitor of granulopoiesis caused neutropenia in these patients.

Felty's syndrome in a child

The occurrence of the triad of leukopenia, splenomegaly and rheumatoid arthritis (RA) (Felty's syndrome) during childhood has not been reported previously. We describe an adolescent with onset during childhood of seropositive, nodular, erosive, polyarticular RA in whom both leukopenia and splenomegaly were accompanying features. Neither nonsteroidal antiinflammatory agents nor plasmapheresis were therapeutically beneficial, but low dose oral prednisone therapy resulted in both clinical and hematological improvement.