Clinical background of rheumatoid vascular disease.

Whether or not these are simply different stages of the same disease process is unknown, but certainly rheumatoid subjects not uncommonly show more than one type of lesion during the later stages of the disease. The most readily recognized clinical manifestations of rheumatoid vascular disease are those involving the skin. Crops of nail-edge lesions and petechia-like lesions of the finger pulps and bony prominences are not uncommon if sought repeatedly and diligently (Golding, Hamilton, and Gill, 1965). Less common are Raynaud's phenomenon, cutaneous nodules over bony prominences, chronic leg ulcers, erythematous macular and papular rashes, and livedo reticularis. Peripheral neuropathy from involvement of vasa nervorum may occur with or without skin lesions, but other features such as episcleritis, renal hypertension, and gangrene usually imply a more widespread necrotizing arteritis with a much poorer prognosis. In this study a group of 260 hospital patients with rheumatoid arthritis have been analysed according to the presence or absence of vascular lesions in the hope of uncovering those features associated with, and perhaps predisposing to, vasculitis. Material and Methods Case notes of patients seen repeatedly during the 2-year period ending July, 1966, were reviewed, and only those containing all required information were included in the study. Since in-patient records were usually more complete, the cases included contained an excess of patients with disease of sufficient severity or chronicity to require admission to hospital. The information sought included a full history with details of past treatment. Any patient receiving corticosteroids for 3 months or more was accepted into the corticosteroid-treated category. The family history included positive information about all first-degree relatives and the results of inquiry for more distant relatives with rheumatoid arthritis and other related and possible auto-immune diseases, including psoriasis, ulcerative colitis, diabetes mellitus, pernicious anaemia, thyroid disease, and asthma. Positive responses were checked by interrogation of the patient and only a clear description of a disease in a relative was accepted. Only occasionally were affected relatives contacted. All patients were examined repeatedly for extra-articular lesions and for possible vascular lesions. Only those with cutaneous vascular lesions or with histologicallyproved rheumatoid vascular disease were included in the arteritic group. The occurrence of myocardial and cerebral infarction was not allowed to support the diagnosis of rheumatoid arteritis, since so many patients belonged to an age group where such lesions might be expected on an atherosclerotic basis. Tests for rheumatoid factor, using either sheep cells or latex particles, were performed only once if positive but were repeated at least once during the study if negative. All patients fulfilled the clinical criteria for "definite" or "classical" rheumatoid arthritis laid down by the American Rheumatism Association (Ropes, Bennett, Cobb, Jacox, and Jessar, 1959), but three patients included in the rheumatoid arteritic group would have been excluded from the American Rheumatism Association classification because they showed histological evidence of polyarteritis. The patients were grouped according to the presence or absence of vascular lesions. None of those with vascular disease had active psoriasis although one gave a history