Pasteurella septica meningitis with survival.

bacilli from the joint aspirates rule out a tuberculous arthritis. The clinical picture is consistent with rheumatoid arthritis, although the Rose-Waaler test is only weakly positive. The continued pain and elevated ESR suggest that there is persistent inflammatory or destructive activity in the joints. Radiological deterioration in the joints has been associated with an increase in the number of subarticular cysts. Another unusual radiological feature is the occurrence of areas of circumscribed opacities in the soft tissues of the fingers. These lesions consisted merely of amorphous debris but no urate deposits were detected. These findings are in many ways similar to those described in Bywaters' patients. As in our patient, staphylococci were occasionally isolated from the sinuses. He postulated that bone cysts were formed by the propulsion of synovial fluid into the cancellous bone under the inflamed joint surfaces which were denuded of cartilage. Necrotic fragments of bone resulting from stress microfractures were extruded from the cysts and were eventually discharged through the skin, forming sinuses. The track, at first sterile, might become secondarily infected with staphylococci. In the case described above, bone cysts are associated at some sites with thin-walled sacs beside the shafts of the bone. It is possible that debris from the joint or from destroyed subarticular bone has remained in the subcutaneous tissue and has become surrounded by a fibrous wall. We conclude that these chronic sinuses and multiple bone cysts are manifestations of the destructive features of rheumatoid arthritis. Steroid therapy has not been given to the above patient because of her already immobile state, her age, and the relative lack of severe symptoms, and it is not yet known whether the chronic destructive process could be suppressed by such treatment.