Eleven patients with intractable
rheumatoid arthritis were treated with fractionated total
lymphoid irradiation at a total dose of 20 Gy. Lasting improvement in clinical symptoms was found in four patients during treatment and the remaining patients experienced a similar benefit within 2 months of irradiation. There was marked reduction in exacerbations and the number of joints involved. Morning stiffness, joint swelling and tenderness decreased. Complications included severe
fatigue during treatment and acute
bacterial arthritis in multiple joints in one patient. Four of the patients have since died, one of
renal failure and another of
cardiogenic shock following surgery 3 and 24 months after total
lymphoid irradiation. Both had generalised
amyloidosis. The third patient developed joint
empyema and died of toxic
cardiac failure. The fourth died 3 months after resection of a
Kaposi's sarcoma complicated by
wound infection which responded to treatment. Immunologically, total
lymphoid irradiation resulted in suppression of the absolute lymphocyte count and a reduction in T-helper cells, while the number of T-suppressor cells remained unchanged. These data provide evidence of T-cell involvement in the pathogenesis of
rheumatoid arthritis. Total
lymphoid irradiation can induce sustained improvement in clinical disease activity, but severe, possibly fatal, side-effects cannot be ignored.