Chinese Medical Journal

60 THE CHINESE MEDICAL JOURNAL

DISCUSSION

The patient was a young man who had a history of migrating joint pain for two years. The symptoms and signs all spoke for the diagnosis of rheumatic heart disease with aortic and mitral stenosis and insufficiency in cardiac decompensation. The diagnosis was obvious and no discussion is needed here. As the patient had petechiae, pain in the finger tips and toes, enlarged and tender spleen, positive urine findings and positive bone marrow culture, the diagnosis of subacute bacterial endocarditis could be established without doubt.

Rheumatic heart disease is the most common heart disease seen in _ southwest China and is often complicated with subacute bacterial endocarditis. But cases complicated with cutaneous endotheliosis, such as ours, are probably very rare. .

Opinions differ as to the origin of macrophages. Some authors consider that they are derived from monocytes and others from reticulum cells(2). Soviet authors(3) have shown that in rheumatic or bacterial endocarditis the presence of macrophages results from the proliferation of. endothelial cells of the blood vessels during the hypersensitive state. In rheumatic disease, this kind of endotheliosis may not be apparent as in bacterial endocarditis during routine blood examination but can be demonstrated by the ‘cupping-glass’ test. In Yen’s case the biopsy from the skin of the ear lobe showed cutaneous endotheliosis of the blood vessel. Unfortunately this examination was not done in our patient during the early period of his hospitalization because his ear lobes were purplish red and swollen from too frequent punctures for blood examination. Valedman(3) is of the opinion that endotheliosis is a generalized reaction in rheumatic heart disease and bacterial endocarditis, and the hyperplastic change of the endothelium of the blood vessels may vary in degree depending upon the location, the kind and the size as well as the degree of allergic reaction of the blood vessels. In this case, the variation of the white count from the blood of the ear lobe might be explained on the difference of the hyperplastic state of the blood vessels. However, the squeezing in the process of taking blood might also be an important factor. Its mechanism is similar to that which causes the appearance of macrophages in the blood smear when the cupping glass is applied.

In our patient, the white count and the percentage of the macrophages at first fluctuated a great deal, but soon after the middle of January they began to show a general tendency to decline and finally at the end of February they came down to the normal limits. It is believed that the improvement of the blood picture was not directly related to the subacute bacterial endocarditis, because when penicillin treatment was