Chronic polyarthritis and graft-versus-host disease.

SIR—In previous studies, the presence of arthralgias and transitory arthritis in graft-versus-host disease (GVHD) has been reported, but not chronic arthritis. We will consider a case of non-erosive polyarthritis after a bone marrow transplantation in the context of chronic GVHD. A 32-yr-old male was diagnosed at the age of 27 as having acute myeloblastic leukosis. One year after the diagnosis, he received an allogenic bone marrow transplant and prophylaxis against GVHD with cyclosporin A. Seven months after the transplant, the patient was admitted for cough and greenish expectoration, with radiological pulmonary infiltration, diagnosed as interstitial bilateral pneumonitis. During the time he was in hospital, acute renal insufficiency developed, brought on by nephrotoxic drugs. The cyclosporin A was then stopped. An increased level of bilirubin and alkaline phosphatase was detected, with negative markers of hapatitis B and C, and the hepatic biopsy showed changes compatible with GVHD and moderate siderosis. A generalized pruritus began without evidence of skin lesions. The patient reported slight xerophthalmia. Schirmer's test indicated a lacrimal secretion of 9 and 12 mm. Chronic GVHD was diagnosed with hepatic, pulmonary and ocular involvement, and treatment with prednisone 30 mg and thalidomide 300 mg was prescribed, with good response. Seven months later, generalized oedema began, with nephrotic type proteinuria becoming evident with conservative renal function. ANA and anti-DNA antibodies were negative. The renal biopsy showed membranous glomerulonephritis, leading to treatment with prednisone 60 mg, by which nephrotic syndrome was resolved. Two years after the transplant, through treatment with prednisone 20 mg, pain in the right elbow and left ankle began, at first subacute. General examination was normal; no skin lesions were observed. Synovitis was detected in the right elbow. Laboratory studies revealed a haemoglobin of 149 g/1, white blood count 7700/mm 3 , platelet count 210 000/mm 3 , ESR 60 mm/h, alkaline phosphatase 1201 IU/1, GGT 670IU/1, ALT 71 IU/1, total bilirubin 11 fimolfl, creatinine 69 pimolfl and a proteinuria of 0.15mg/dl. Rheumatoid factor, smooth muscle and antimitochondrial antibodies were negative. The serology and antigenaemia for cyto-megalovirus (CMV) were negative. The synovial fluid of the elbow revealed 30 000 leucocytes/mm 3 and a neutrophil tendency. The crystals study, cytology and the synovial fluid cultures in habitual media and in Lowenstein-Jensen medium, and for CMV, were negative. In the simple X-rays, signs of avascular necrosis of the right external humeral epicondyle were observed and minimal compact periostic reaction in tibia! …