MYLOIDOSIS as a complication of "ar-
A thritis" was first noted more than a century ago1; however, only within the past 15 years has this association with rheumatoid arthritis received careful s t ~d y . l -~ Using postmortem material, Missen and Taylor1 found that 15.9 per cent of patients with rheumatoid arthritis had this complication. In studying the causes of death in 130 cases of rheumatoid arthritis during an average 9.6 year period, Cobb and co-workers6 found only four deaths attributed to amyloidosis.
Amyloidosis may be responsible for a variety of disabling symptoms including those manifested via the gastrointestinal tract. The incidence of gut involvement may range from 30 per cent to 100 per cent.3s7-10 Such involvement may produce dysphagia,ll gastric ulceration, hematemesis, antral narrowing, ileus,12 diarrhea,13 acute abdominal pain,14 and diffuse colonic ~1ceration.l~ Malabsorption due to secondary amyloidosis is uncommon, and we have found but one report of its occurrence in association with rheumatoid arthritis.O The case histories of two patients with long-standing joint disease who came to the Mayo Clinic principally because of "diarrhea" are re-corded here. Peroral biopsy of the small bowel revealed amyloidosis.
REPORT OF CASES
Case 1
A 62-year-old farmer first came to this clinic in 1960 because of persistently active, generalized arthritis of 38 years' duration. Physical findings were within normal limits except for a subcutaneous nodule, joint deformities consistent with rheumatoid arthritis, and atrial fibrillation. Laboratory findings (Table 1) and roentgenograms of involved joints supported the clinical diagnosis of rheumatoid arthritis. The patient was hospitalized for three weeks and improved on a regimen of physical therapy and salicylates.
Six months later he noted the gradual onset of yellow, watery stools occurring three or four times a day, associated with loss of weight and fatigue. When seen at this clinic in August 1962 because of this change in bowel habits, he had lost 40 pounds and looked emaciated. Except for moderate ankle edema, findings on physical examination were unchanged. Results of laboratory examinations are listed in the Table 1. Values for stool fat, serum calcium, total protein, and carotene were all consistent with malabsorption. Roentgenograms of the small bowel showed no abnormality. Barium examination of the colon revealed widespread mncosal changes and a shortened, narrowed bowel. Proctoscopic findings showed a friable, granular mucosa starting 12 cm. above the dentate line. Unfortunately no biopsy was obtained.
A peroral jejunal biopsy specimen stained with hematoxylin and eosin was interpreted as normal;