Synovial Biopsy, Synovium, Synovial Fluid & Arthrocentesis
Rheumatic Fever (synovium) Photo/Slide Viewer
(Jaccoud's) ArthropathyA small percentage of patients with rheumatic heart disease develop chronic hand deformities (1,2). Fingers may show ulnar deviation, swan-neck deformities, and subluxations that are generally correctable. Soft tissue swelling is minimal and there is little or no clinical or laboratory evidence of active inflammation. X-rays do not show joint destruction but there may be hook-like bone lesions on the radial and palmar aspects of the metacarpal heads. Feet may also be involved. Patients often recall unusually severe recurrent earlier attacks of rheumatic fever.
Rheumatoid factor is negative in typical cases.
Most authors have felt that the pathologic alteration is in periarticular tissues rather than synovium.
Light MicroscopySynovial membrane has been described as normal but associated with fibrous thickening of capsular tissue (1,3,4).
Synovial FluidJoint effusions are generally not seen and reports of synovial fluid analyses were not found.
Electron microscopyWe have studied a surgical biopsy of MCP capsule and synovium from one typical patient whose tissues appeared normal by light microscopy.
A fibrous capsule with normal appearing fibrocytes was seen. A single dilated lymphatic of still unknown significance was found. Venules had thick endothelial cells.
Synovial lining cells included mostly type B and C cells with some mild dilatation of rough endoplasmic reticulum and lipid droplets. Most striking were the large number of thin extracellular fibrils surrounding the lining cells. Scattered among these thin fibrils and deep to the lining cells were normal appearing mature collagen fibers. There were occasional dark appearing possibly degenerated lining cells. Small patches of fibrin-like or dark finely granular material were also seen on the surface and between the fibrils.
Vessels had large endothelial cells, some of which had unusually pale cytoplasm. Vascular basement membrane was multilaminated.
ImplicationsPathologic changes at the time of diagnosis of the arthropathy have not shown inflammation although earlier inflammation at these sites is possible. The still limited electron microscopy suggests deposition of collagen with large amounts of thin filaments that appear to be immature collagen. The finely granular dense material among the fibrils might include antigen, antibody or other materials contributing to the fibrous process. The nonspecific findings in the vessels are seen also in many other synovia and might for example suggest some decreases perfusion as a contributing factor or could be purely secondary.
Secondary osteoarthritis has been seen and attributed to the excessive joint motion seen in some cases (3).
Very similar initially correctible hand deformities occur in some patients with systemic lupus erythematosus.
References1. Bywaters EGL. Relation between heart and joint disease including "rheumatoid heart disease" and chronic post-rheumatic arthritis (type Jaccoud). Brit Heart J. 12:101-131, 1950.
2. Zvaifler NJ. Chronic post rheumatic fever (Jaccoud's) arthritis. NEJM 267:10-14, 1962.
3. Girgis FL et al. Jaccoud's arthropathy. A case report and necropsy study. Ann Rheum Dis 37:561-565, 1978.
4. Bywaters EGL. Anatomical changes in Jaccoud's syndrome. Arth Rheum 14:153, 1971 (Abst).
References Related to Rheumatic Fever
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