To learn whether the removal of immune complexes from the circulation by plasma exchange could effect an improvement in disease activity in rheumatoid arthritis (RA) patients, we performed a controlled study of 20 patients with severe progressive disease which had not responded to previous therapy. Ten patients (Group 1) were hospitalized, continued on their regular antiinflammatory medication, and given a graded course of physiotherapy. A further 10 patients (Group 2) received the same treatment as the first group with the addition of a concurrent course of plasmapheresis. Clinical measurement of disease activity after treatment revealed little difference between the two groups with a statistically significant improvement in four measures in Group 1 and in five in Group 2. Laboratory studies suggested that the intensity of plasma exchange was sufficient to remove circulating immune complexes in these patients. Our results confirm that hospitalization in itself is of benefit in the treatment of acute exacerbations of rheumatoid arthritis. The marginal improvement achieved by the addition of plasma exchange in the management of these patients (despite the removal of circulating immune complexes) makes its short‐term use of questionable value in the treatment of severe rheumatoid arthritis.

The assessment of anemia in patients with rheumatoid arthritis may be difficult, especially when iron deficiency and the anemia of chronic disease coexist. The development of a radioimmunoassay for serum ferritin concentration has aided the detection of reduced body iron stores in uncomplicated iron deficiency, but its use is compromised in clinically active rheumatoid arthritis by the tendency of serum ferritin to behave as an acute phase reactant. In this latter role it correlated well with disease activity in the patients we studied. Followed serially, serum ferritin levels fell in patients whose disease activity improved after institution of appropriate therapy. In anemic patients with clinically inactive disease, supplemental iron was associated with a significant rise in hemoglobin when compared to untreated patients. Serum ferritin levels behaved independently of hemoglobin levels. Therefore even in clinically inactive rheumatoid arthritis, serum ferritin does not accurately reflect an iron deficiency.

SUMMARY A patient with angioimmunoblastic lymphadenopathy with dysproteinaemia is described. The patient had a severe clinical illness with a pronounced haemolytic anaemia, which followed well-established polyarthritis and gold therapy. It was accompanied by in-vitro evidence of suppressed cell-mediated immune responses and by development of serum antismooth muscle antibodies. These features are unusual and support theories that this disease has an immunological basis. Improvement occurred with prednisone and azathioprine therapy, suggesting that combined use of these agents is useful in some patients with AILD. The patient subsequently developed a lymphoma.Angioimmunoblastic lymphadenopathy with dysproteinaemia (AILD) is a recently described benign lymphoproliferative disorder characterised by fever, sweats, weight loss, a rash, generalised lymphadenopathy, hepatosplenomegaly, haemolytic anaemia, polyclonal hypergammaglobulinaemia, and diagnostic histological abnormalities.'2 Its aetiology remains uncertain, though immune processes have been implicated. The best treatment is unknown. We describe a patient whose disease followed wellestablished arthritis and sodium aurothiomalate (Myocrysin) therapy and which was accompanied by an unusually severe haemolytic anemia. In-vitro cell-mediated immune responses were suppressed, and serum contained antismooth muscle antibodies.These findings support an immunological aetiology for AILD. Marked clinical improvement followed the use of immunosuppressive therapy, suggesting that this form of treatment has an important role in some patients with this disease. Case reportA 60-year-old woman presented at the University of Alberta Hospital in April 1977 for treatment of an acute seronegative polyarthropathy involving both

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