Lactic Dehydrogenase (LDH) and Transaminase (GOT)

Activity of Synovial Fluid and Serum in Rheumatic

Disease States, with a Note on Synovial
Fluid LDH Isozymes
By ALAN S. COHEN
Lactic acid dehydrogenase (LDH) and
glutamic-oxalacetic transaminase deter-
minations were carried out on the se-
rums and synovial fluids of patients
with a variety of rheumatic diseases. The
LDH activity of the synovial fluid was
elevated in patients with rheumatoid
arthritis, infectious arthritis and gout,
but normal in the fluids of patients with
degenerative joint disease. Transaminase
activity was normal in both serum and
synovial fluid in all cases. Starch gel
zymograms of LDH showed qualita-
tively increased amounts of the isozyme
LDH 5 in the pathological synovial
fluids.
Determinationes del dehydrogenase de
acido lactic e de transaminase glutamic-
oxaloacetic esseva executate in le seros
e le liquidos synovial de patientes con
un varietate de morbos rheumatic. Le
activate de dehydrogenase lactic del
liquido synovial esseva elevate in pa-
tientes con arthritis rheumatoidee, con
arthritis infectiose, e con gutta, sed ill0
esseva normal in le liquido synovial de
patientes con morbo degenerative del
articulationes. Le activitate de trans-
aminase glutamic-oxaloacetic esseva nor-
mal in omne casos tanto in le liquido
synovial como etiam in le sero del san-
guine. Zymogrammas a gel de amylo
pro dehydrogenase de acido lactic
monstrava augmentos qualitative del
quantitates del isozyma 5 de hydrogen-
ase de acido lactic.

T HE VALUE of synovial fluid analysis in the differential diagnosis of

various rheumatic diseases has become increasingly apparent in the
past 10 years since the publication of the definitive monograph of Ropes
and Bauer in 1952.132Cultures, white blood cell and differential counts, sugar
and mucin determinations have become accepted as the most useful labora-
tory studies of synovial fluid. In recent years, as our knowledge of the
specific physiologic activity of the syriovial membrane has i n ~ r e a s e d data
~,~
have appeared in the medicaI literature that suggest that an evaluation of
the synovial 0uid enzyme content might also prove to be of significance. A
number of these enzymes have been studied including amylase, lipase, alkaline
phosphatase,l aminotripeptidase? beta glucuronidase,e and others.7 Until
recently, only limited data, however, have been available on two enzymes,
glutamic-oxalacetic transaminase (GOT) and lactic acid dehydrogenase

From the Robert Dawsolb Evans Department of Clinical Research, Massachusetts

Mmorial Hospitals, and the Department of Medicine, Boston University School of Med-
icine, Boston University Medical Center.
Support of parts of these investigations has been receiocd jrom the National Institute
of Arthritis and Metabolic Diseases, Grant Nos. T1 AM-5285 and AM-04599 and from
The New England Chapter of the Arthritis and Rheumatism Foiindation.
490

ARTHRITISAND RHEUMATISM,VOL. 7, NO. 5 (OCTOBER),

1964
LDH AND GOT ACTIVITY OF SYNOVIAL FLUID 491

(LDH), that have been of proven clinicaI significance in serum and in

effusions in areas other than the synovial space.* The importaat observation
has also been made in the last 10 years that a number of enzymes exist in
more than one molecular variety in a single organi~m.~ Extensive studies
have been carried out in a number of laboratories on the isozymes of LDH
in’ particular and have indicated to a remarkabIe extent that tissues contain
these substances in precise relative patterns.l0S1l
This report contains observations on the synovial fluid levels of LDH
and GOT in various rheumatic diseases characterized by effusions into the
synovial space. Preliminary observations on LDH isozymes in synovial fluid
of patients with rheumatoid arthritis and degenerative joint disease will also
be presented.
AND METHODS
MATERIAL
Methods
Synovial fluids were aspirated with sterile precautions primarily from the knee joints of
hospitalized patients. All fluids were cultured, had red blood cell, white blood ceU and
differential counts, and mucin analyses carried out according to the techniques of Ropes
and Bauer.1 The fasting synovial fluid sugar and a parallel fasting blood sugar analysis was
also performed in most instances.
The LDH activity was determined by the method of Snodgrass and co-workers8 using
a reaction mixture of 1.5 milliliters of sodium pyrophosphate buffer (O.lM, p H 8.8), 1.0
milliliters of sodium lactate (0.16M, p H 7.0) and 0.3 milliliters of dipliosphopyridine
nucleotide ( D P N ) (0.05M,p H 7.5) in a 3 milliliter Beckman pyrex cuvette. The rate
of appearance of reduced DPN at 340 millimicrons was followed and the unit of activity
defined as an increase in optical density units of 0.001 per minute per milliliter of synovial
fluid or serum. Any specimen with visible hemolysis was discarded due to the known high
activity of LDH in red blood cells. Synovial fluids with obvious turbidity were centrifuged
before analysis although a number of fluids were studied before and after centrifugation.
The upper limit of normal in serum for this LDH method is 180 units. Serum and
synovial fluid glutamic and oxalacetic transaminase were measured colorirnetrically by
the method of Reitman and Frankell2 in which the upper limit of normal for serum is
40 units.
The LDH isoenzymes of synovial fluid and serum were separated by the starch gel
electrophoresis method of Smithies13 and identified by the method of Latner and Skillen14
in which lactate is the substrate; DPN, the coenzyme; phenazine methosulfate, the electron
transporter; and nitro blue tetrazolium, the salt that is reduced to an insoluble colored
formazan. A buffer of increased ionic strength15 was utilized since there is evidence that
the dilution effect (relative loss of LDH isozyme 5 on starch gel electrophoresis16) can
be eliminated by appropriate increase in buffer concentration. All gels wele photographed
on the day that the reaction was carried out. Isozyme levels were estimated by visual in-
spection and comparisons are qualitative only.

Clinical Material
The patients with degenerative joint disease had normal sedimentation rates, negative
tests for rheumatoid factor (latex fixation test), radiological evidence of hypertrophic
changes only and no evidence of systemic inflammatory disease. All patients diagnosed
as having rheumatoid arthritis had either classical or definite disease as defined by the
American Rheumatism Association criteria.17 The individuals with gout had acute arthritis
with hypernricemia and a demonstrated response to colchicine. Not all of the gouty
492 ALAN S. COHEN

individuals had joint aspirations during acute phases of their disease. Patients 7, 8, 9 and
10 had noninflammatory effusions ( containing urate crystals) that persisted approximately
1-2 weeks after the acute a t t z k of gout.

RESULTS
1. Degenerative Joint Disease
The synovial fluids of 10 patients with noninflammatory degenerative
or traumatic joint disease (table 1) demonstrated low white counts (mean
592 cells/cu. mm.), few polymorphon~clearcells (mean 6 per cent), good
mucin, no significant synovial fluid-fasting blood sugar differences. The serum
and synovial fluid LDH and GOT activities were normal in all cases. The
mean of the fluid LDH (613 units) was almost identical with that of the serum
LDH activity (67 units).
2. Rheumatoid Arthritis
Twenty-nine synbvial ef'fusions from 25 patients with classical or definite
rheumatoid arthritis were examined (table 2). With the exception of three
specimens from one patient (27b, 28b, 29b in table 2 ) all had elevated
fluid total white counts, increased numbers of polymorphonuclear cells,
small decreases in synovial fluid sugar and fair to poor mucin tests. Cultures
were uniformly negative. The synbvial fluid LDH activity was almost in-
variably increased, while the GOT was not. Serum activity Qf both enzymes
was within normal limits. The lowest synovial fluid activity (83 units) was
obtained from a specimen preser\,ed in oxalate, a substance that Nielands has
reported to inhibit the enzymatic reaction.l* In one individual there was a
striking difference between the synovial fluid analysis (which was normal)
and the enzyme activity (which was elevated) (27b, 28b, 29b). This patient
had early rheumatoid arthritis with recurrent effusions in his left elbow.
3. Specific Infectious Arthritis
Nine fluids were obtainkd from six patients with culturally proven septic
arthritis (table 3 ) . Elevated total white counts, increased numbers of poly-
morphonuclear cells, poor mucin and marked synovial fluid blood sugar
differences (mean glucose difference 4.5 mgm./100 ml.) were found in all.
These samples demonstrated striking elevations in synovial fluid LDH (mean'
1279 units) and modest incIeases in GOT (mean 63 units) but normal serum
enzyme activities.
Figure 1 depicts the changes in synovial fluid LDH activity and WBC
during the treatment of one patient. In the first few days, while the organism
was not responding to antibiotic treatment the white blood cell count de-
creased slightly while the enzyme activity was doubled. Both fell subsequently
as the effusionwas receding and negative cultures were obtainkd.
4. Acute Gouty Arthritis
Synovial fluid aspirated from the joints of six patients ( 7 fluids) with
acute gouty arthritis was characterized by elevated white blood cell and
L D n AND GOT ACTIVITY OF SYNOVUL FLUID 493

Table l.--Synovial Fluid and Serum Findings in Traumatic or

Degenerative Joint Disease
Synovial Fluid
Per Cent Serum
Specimen WBC Polymorphonuclear
Number LDH GOT (cells/eu. mm.) Cells LDH GOT
1 110 9 - -
2 103 - 1,250 9 -
3 83 - 900 13 - -
4 83 9 400 4 50 13
5 81 10 100 10 90 8
6 60 8 75 5 52 7
7 50 4 1,600 7 68 5
8 43 13 450 2 63 5
9 29 9 100 2 91 23
10 16 3 450 2 53 15
Mean 65.8 8.1 591.7 6.0 66.6 10.9
Range 16110 3-13 75-1,600 2-13 50-91 5-23

polymorphonuclear counts and fair to good mucin (table 4 ). The LDH

activity was increased in all during the height of the attack, but fell rapidly
after treatment, as seen in fluids 5a and 8a drawn’ only one week apart from
the same joint of one individual. Fluids from patients 7, 9 and 10 were also
aspirated approximately two weeks after an acute attack was treated. The
synovial fluid GOT activity was somewhat elevated during the most acute
phase of the disease. Serum LDH and SGOT activities occasionally showed
borderline elevation.

5. Miscellaneous Articular Disorders

Synovial fluid from one patient with intermittent hydroarthrosis and one
with hypertrophic pulmonary osteoarthropathy (secondary to a pulmonary
neoplasm) were essentially normal by routine analysis and enzyme content.
One patient acutely ill with Reiter’s syndrome and two with acute rheumatic
fever had inflammatory changes in their fluids, elevated LDH and normal
GOT activity ( table 5).
Although most fluids were centrifuged prior to enzyme determination sev-
eral were analyzed before and after centrifugation for separation of white
blood cells with little difference in the results of enzyme analysis (table 6).
6. Electrophoretic Separation of LDH Isozymes
Synovial fluids from nine patients with rheumatoid arthritis, three with in-
fectious arthritis, three with degenerative joint disease and one with gout
were subjected to starch gel electrophoresis and stained for LDH isozymes.
In addition, the sera of six normal individuals and six patients with definite
(and active) rheumatoid arthritis were studied in a similar fashiod.
None of the normal nor rheumatoid sera had elevated total LDH activities.
The starch gel patterns of the normal sera revealed 5 bands of varying in-
tensity. The fastest moving band (anodal) was very faint, the subsequent
494 ALAN S. COHEN

-
Table 2.-Synovial Fluid and
.~
Serum Findings in Rheumatoid Arthritis
Synovial Fluid
Per Cent Serum
Specimen WBC Polymorphonuclear
Number LDH GOT (eeUs/cu. mm.) Cells LDH GOT
1 2,413 - 15,050 79 280
2 2,200 100 69,300 85 -
3 1,553 - 74,800 89 122
4 1,006 9 58,350 94 38
5 838 41 17,600 74 95
6 790 - 12,650 92 120
7 660 24 14,100 67 60
8 618 30 9,650 72 44
9 550 32 25,750 88 39
10 495 16 11,900 89 73
11 488 17 14,800 76 60
12 470 - 6,450 62 137
13 413 - 17,750 7.3 137
14 400 - 5,600 27 77
15 353 - 15,400 80 172
16 353 - 4,300 67 47
17 328 21 19,000 14 108
18 280 13 9,050 69 129
19 263 12 15,650 76 64
20 231 17 4,950 88 98
21 186 20 3,700 56 55
22 176 20 6,350 66 -
23 83 11 2,400 30 -
241 1,493 - 11,300 60 20'8
25a 940 28 10,000 64 122
26a 234 - 3,550 38 -
27b 526 20 600 (1)" 51
28b 397 20 900 (1)" -
29b 241 30 250 (1)" -
-
Mean 654.4 25.3 15,902 68.3 101.6 11.2
Range 83-2,413 9-100 250-74,800 14-94 38-208 3-26
-- _____
"Poor smear, accurate differential not possible. These figures were not used in deter-
mining the mean for this column.

two the heaviest, the fourth faint and the cathodal band faint.* The rheuma-
toid sera had similar patterns with one variation, namely a relative elevation
in LDH-5.
The patterns obtained from the synovial fluids of patients with acute ia-
flammatory joint disease (rheumatoid arthritis, infectious arthritis, acute
gout) were strikingly different. In these LDH-5 was very intense, LDH-2
usually of next intensity (LDH-3 was of second greatest magnitude in sev-

"Terminology for LDH isozymes is currently in a state of confusion since some authors
have numbered the bands 1 through 5 starting with the cathodal band while others have
done the opposite. Pending the report of an International Committee on Enzymes19 the
nomenclature used by Vesell et ;11.20 (wherein the most rapidly migrating anode isozyme
is designated LDH-1 and the slowest LDH-5) has been adopted in this paper.
LDH AND GOT ACTIVITY OF SYNOVIAL FLUID 495

Table 3.-Synouial Fluid and Serum Findings in Infectious Arthritis

Synovial Fluid
Per Cent Serum
WBC Polymorpho-
Specimen (cells/ nuclear Organism Isolated
Number LDH GOT cu. mm.) Cells LDH GOT on Culture
-
1 2,020 56 71,750 83 Escherichia coli
2 1,954 90 44,050 93 Hem. Staph aureus
3 1,870 44 59.050 91 Hem. Staph aureus
4 1,520 45 15,650 92 Proteus vulgaris
5a 754 72 39,000 68 Neisseria gonorrhoeae
68 1,540 102 34,200 93 Neisseria gonorrhoeae
7a 470 55 8,350 59
8b 912 58 24,900 95 Neisseria gonorrhoeae
9b 470 49 18,150 93 Neisseria gonorrhoeae
Mean 1,279 63 35,011 85.3 63.7 20.3
Range 470-2.020 44-102 8,350-71,750 6&95 51-71 12-28
a = 3 fluids from one patient, N.B.
b = 2 fluids from one patient, X.Y.

era1 cases) followed by LDH-3, LDH-4 and LDH-1 in sequence (fig. 2).
The synovial fluids of the patients with degenerative joint disease had very
faint patterns, in which only a slight elevation of LDH-5 was discernible.
DISCUSSION
It is only in the past decade that synovial membrane, a specialized part
of the connective tissue, has been subjected to vigorous an'alysis of its bio-
chemical activity. Evidence has been obtained of oxidative and hydrolytic
enzyme activity both in normal and diseased membranes, and a number of
studies of the significance of these findings are in progress.21 Although the
medical literature is replete with studies of the diagnostic and pathogenetic
significance of various enzyme activities in serum, few of these have been
pertinent to connective tissue diseases and even fewer have been' concerned
with the study of enzyme activity in body effusions. Interest in the significaxice
of lactic dehydrogenase activity of serous effusions and especially the pos-
sible significance of such levels in the diagnosis of tumors was aroused by
WroblewskiZ2and has received considerable attention since then.23924Much
of this material was reviewed in' 1961.25
The data obtained from the first part of the present study indicate that
the level of transaminase in serum and synovial fluid is not elevated in
various rheumatic diseases and would appear to be of little diagnostic sig-
nificance.
Lactic acid dehydrogenase, however, is a ubiquitous enzyme in vertebrate
tissues. It catalyzes the interconversion of lactate and pyruvate, and simul-
taneously diphosphopyridine nucleotide ( DPN ) and reduced diphospho-
pyridine nucleotide (DPNH). The data in the present study indicate qualita-
tively that synovial fluid activity is greatly increased in infected fluids and
in rheumatoid fluids as well as in those of acute gout, while the activity in
degenerative joint disease is not elevated. Vesell and co-workerz0in a detailed
study of LDH isozymes demonstrated an increase in synovial fluid LDH ac-
tivity in 7 of 8 rheumatoid fluids, while one patient with osteoarthritis had
496 ALAN S . WHEN

I 10 15

TIME I N DAYS
Fig. 1.-Patient with acute infectious arthritis (Neisseria gonorrhoeae isolated
from knee joint). During first few days of therapy while the organism was not
responding to treatment, the synovial fluid white cell count fell slightly (39,000 to
34,000 cells per cu. mm.) while the LDH level doubled.

a normal level and one with chronic traumatic arthritis had an elevated level.
No clinical data were given, but since the synovial fluid WBC was 18,000
in their latter patient, this individual would not fit the usual definition of
traumatic effusi0n.l West and co-workers26recently reported on the levels of
a large number of glycolytic and oxidative enzymes in the synovial fluid in
various articular diseases. The patients with osteoarthritis generally had
normal activity ( except for aldolase), while individuals with rheumatoid
arthritis, pyogenic arthritis and gout had varying degrees of in'creased
activity.
The source of the elevated LDH activity in the inflammatory articular
diseases is not certain. The enzyme could be derived from synovial membrane
(and has been extracted from it),2* from leukocytes or possibly from the
serum. The last possibility is unlikely due to the marked variation' in enzyme
activity and isozyme content of each. West26 found a positive correlation
between the number of leukocytes in the synovial fluid and the enzyme
activity, and considered this as indirect evidence for release of enzymes
from the white cells. In the present study, analysis of the fluids (table 6 )
with and without separation of the white blood cells seemed to make sur-
prisingly little difference, but WBC enzymes could already have been re-
leased into the fluid. A scattergram was drawn and a correlation coefficient
was determined for the various synovial white blood cell levels and enkyme
+
activity. The result ( r = 0.62) indicated that a significant (P = <0.005)
positive correlation exists between the two. It is important to note that this
LDH AND GOT ACTIVITY OF SYNOVIAL FLUID 497

Table 4.-Synovial Fluid and Serum Findings in..Gout

_
Synovial Fluid
- Serum
Per Cent
WBC Polymorpho- Uric Acid
Specimen (cells/ nuclear (mgm./
liumber LDK GOT en. mm.) Cells LDH GOT 100rnl.)
________------~
1 2,225 82 11,800 92 77 38 -
2 1,610 - 32,200 77 132 - 6.6
3 1,237 - 20,500 77 102 - 7.2
4 1,140 64 15,350 96 129 48 11.8
5a 873 76 21,550 65 145 29 9.3
6 854 30 14,050 - 108 27 9.8
7' 196 39 1,850 30 81 72 -
8a* 178 18 2,100 73 64 32 12.3
9' 150 23 2,000 59 78 45 8.5
~-
10' 57
____
- ~-
750 34
- _.___
202 -
__
8.5
.__

Mean 852.0 47.4 12,215.0 67.0 111.8 41.6 -

Range 57-2,225 18-82 750-32,200 30-96 64-202 27-72 7.2-12.3
_ _ ~ ~

'Joint effusion aspirated about two weeks after acute attack of gout.
a = fluids aspirated from same patient 10 days apart.

Table 5.-Synovial Fluid and Serum Findings in Miscellaneous Articular Disorders

__
Synovial Fluid
Per Cent
WBC Polymorpho- Serum
(cells/ nuclear -
Diagnosis LDH GOT cu. mm.) Cells LDH GOT
_- .- ___- _ _ ~ __
Intermittent hy-
drathrosis 21 7 1,600 10 47 7
Reiter's syn-
drome 317 35 18,400 96 144 63
Hypertrophic
pulmonary os-
teoarthropathy 56 6 750 39 - -
Acute rheumatic
fever 330 18 4,950 79 80 33
Acute rheumatic
fever 350 15 12,000 40 - -
- _ _ ~ _ _ _ _ _ _____

Table d.--Efiect of WBC Separation on Synovial

--
Fluid Level of LDH and-~
~
GOT
LDH GOT
-~
Specimen WBC Present WBC Removed WBC Present WBC Removed

1 470 463 49 46
2 2,570 2,232 128 140
3 2,700 2,550 67 73
4 1,510 1,133 23 20
5 1,025 1,049 - -

does not indicate in any way that a cause and effect relationship exists
between the white blood cell count and enlzyme level. The' cause of the
elevated levels may well be due to another factor or factors. Indeed, Vesell
noted that the elevation in LDH activity was not proportional to the number
of white blood cells observed.20
The finding of a normal serum level of enzyme and elevated synovial fluid
498 ALAN S. COHEN

Fig. 2.-Starch gel zymograms of serum and synovial fluid. There is an increase
in isozyme 5 in the synovial fluid from the patient with rheumatoid arthritis and the
patient with gout.

level points up again the complexity of transport of various proteins and

cells across the synovial “membrane.” The molecular weight of beef LDH
is approximately 135,000.27Substances of this size and larger have been
shown to pass freely through the synoviumZswhile the transport of other small
moIecuIes may be far more cornple~.~9 The Iocal increase of enzyme in in-
flammatory diseases is also comparable to the strictly local synovial fluid
leukocytosis in rheumatoid arthritis and in many infected joints where a
peripheral leukocytosis may be lacking.30
Of much greater significance are the changes in the LDH isozymes found
in synovial fluid in the present study and in that of Vesell.20 Enzyme
heterogeniety has been demonstrated to be a common phenomenon and over
30 enzymes have been shown to exist in multiple forms. The existence of this
phenomenon poses a numher of basic questions which are being investigated
from many points of view; i.e., phylogeny and ontogeny, biochemistry and
diagnostic applications. The heterogeniety of LDH has been extensively
studied by Markert,27V e ~ e l lKaplanll
,~~ and others.
There is the possibility that species specific isozyme patterns may exist as
well as organ specific ones. Thus the pattern obtained from synovial tissue
(and perhaps reflected in’ synovial fluid isozymes) might and, indeed, does
differ from that obtained from skeletal muscle. As work has progressed, how-
LDH AND GOT ACTIVITY OF SYNOVIAL FLUID 499

ever, it has become apparent that many technical problems exist (buffer
concentration,16 dilution16) which are particularly important in a considera-
tion of synovial fluid isozymes, where LDH-5 is elevated. In the present
study, the patients with rheumatoid arthritis and normal total serum LDH
activity were seen to have serum isozyme patterns with a relative increase
in LDH-5. Thus, the isozyme once thought to be fairly specific for liver is
not SO. The alterations in the synovial fluid isozymes were far more striking
(fig. 2 ) and it appeared qualitatively that LDH4 was the major isozyme
in rheumatoid and other inflammatory synovial fluids on starch gel zymo-
grams. Utilizing starch block electrophoresis arid chromatographic techniques,
Vesell and co-workers20found that although LDH-5 was significantly elevated
it was not always the major isozyme quantitatively. It is of interest that in
one individual ( G ) with rheumatoid arthritis where LDH-3 (instead of
LDH-2) was the second most prominent synovial fluid isozyme, a similar
pattern prevailed in the patient's serum.
Although it is possible that the further quantitation of LDH isozymes of
synovial fluid and serum may yield information that is of diagnostic signi-
ficance in various articular diseases, it would appear that this is an unlikely
possibility. Recently chemical and immunochemical observation's have sug-
gested that 5 isozymes are made up of subunits ( H and M ) regulated by
two genes and that LDH-1 and LDH-5 are immunologically distinct but
both related to LDH-2, LDH-3 and LDH-4.32*33 Studies along these lines
in different species and tissues undoubtedly will lead to further elucidation
of their biochemical significance and their importance under pathological
conditions.
SUMMARY
1. Analyses of total synovial fluid and serum lactic acid dehydrogenase
and glutamic-oxalacetic trarisaminase activity were made in 10 specimens
from patients with degenerative joint disease, 29 from patients with rheu-
matoid arthritis, 9 from patients with infectious arthritis, 10 from individuals
with gout and on several specimens from patients with miscellaneous articular
diseases.
2. Synovial fluid (but not serum) LDH was elevated in patients with
idammatory articular disease. Transaminase was normal in both serum and
synovial fluid.
3. Starch gel electrophoresis of the specimens demonstrated marked eleva-
tions in LDH-5 in synovial fluids of rheumatoid, gouty and infected joints;
minimal increases in fluid from degenerative joint disease.
4. Serums from patients with rheumatoid arthritis (and riormal total LDH
levels ) also showed alterations in the zymogram, characterized by increased
amounts of LDH-5.
ACKNOWLEDGMENTS
The writer gratefully acknowledges the assistance of the nwml)c r\ of the 2*irtliriti\ and
Connective Tissue Disease Group of the Boston Univrrsitv \icdlcd G n t t r In thr ( o k t t o n
of synovial fluids and the expert technical assistance of Rtth.\rtl \ l < i ) o

REFERENCES
1. Ropes, M. W. and Bauer, W.: Synovial
Fluid Changes in Joint Disease. C a n -
bridge, Mass., Harvard U. Pre;s,
1953.
2. Furey, J. G., Clark, W. S. and Brine,
K. L.: The practical importance of
synovial fluid analysis. J , Bone and
Joint Surg. 41-A:167-174, 1959.
3 . Cook, E. R., Thomas, D. P. P. and
Dingle, J. T.: Studies on synovial
tissue. 7. Concentrations of creatine
and phosphocreatine in synovial tis-
sue. Biochem. J. 76:120-124, 1960.
4. Thomas, D. P. P. and Dingle, J. T.:
Studies on human synovial niem-
brane in vitro. The nwtabolism of
normal and rheumatoid synovia and
the effect of hydrocortisone. Biochem.
J. 68:231-238, 1958.
5. Ziff, M., Simson, J., Scull, E., Smith,
A , , Shatton, J. and Mainland, D.:
Aminotripeptidase content of synov-
ial fluid in arthritic diseases. J. Clin.
Investig. 34:27-34, 1955..
6. Jacox, R. F. and Feldmahn, A.: Varia-
tions of beta glucuronidase concen-
tration in abnormal human synovial
fluid. J. Clin. Investig. 34:263-267,
1955.
7. Zelnicek, E. and Tovarek, J.: Alpha-
ketoglutamic and pyruvic acids en-
zymes in effusions in man. Clin. Chim.
Acta 6:464-466, 1960.
8. Snodgrass, P. J., Wacker, W. E. C.,
Eppinger, E. C. and 'I'allee, B. L.:
Metallo-enzymes and niyocardial in-
farction. 111. Lactic dehydrogenase
activity of serum-a determinate diag-
nostic measure. New Ehgl. J. Med.
261: 125.94266, 1959.
9. Meister, A,: Reduction of alpha, gam-
ma-diketo and alpha-keto acids cat-
alyzed by muscle preparations and by
. crystalline lactic dehydrogenase. J.
Biol. Chem. 184:117-ll29, 1950,.
10. Markert, C. L. and Moller, F.: Multiple
forms of enzymes: Tissue, ontogenetic
and species specific patterns. Proc.
Nat. Acad. Sci. 45:753--763, 1959.
11. Kaplan, N. 0.and Ciotti, M. M.: Evolu-
tion and differentiation of dehydro-
genases. Ann. N. Y. h a d . Sci. 94:
701-722, 1961.
ALAN S. COHEN
12. Rcitman, S. and Frankel, S.: A color-
imetric method for the determination
of serum glutamic oxalacetic and
glutamic pyruvic transaniinases. Am.
J. Clin. Path. 28:56-63, 1957.
13. Smithies, 0.:Zone electrophoresis in
starch gels and its application to
studies of serum proteins. Adv. Pro-
tein Chem. 14:6,5113, 1959.
14. Latner, A. L. and Skillen, A. W.: Clini-
cal applications of dehydrogenase iso-
enzymes. A simple method for their
detection. Lancet 2: 12861288, 1961.
15. Vesell, E. S.: Effect of dilution on the
lactic dehydrogenase isozyme pattern
obtained in the starch gel. Nature
195:497-498, 1962.
16. Res:iler, N., Schultz, J. and Joseph, R.
R.: Factors influencing the electro-
phoretic migration of lactic dehydro-
genase isozymes. J. Lab. and Clin.
Med. 62:571-578, 1963.
17. Ropes, M. W., Bennett, G. A., Cobb,
S., Jacox, R. and Jessar, R. A.: 1958
Revision of Diagnostic Criteria for
rheumatoid arthritis. Bull. on Rheum.
Dis. 9: 175-176, 1958.
1.8. Nielands, J. B.: Studies in lactic dehy-
drogenase of heart. 111. Action of in-
hibitors. J. Biol. Cheni. 208:225-230,
1954.
19. King, E. J. and Moss, D. W.: Inter-
national enzyme units and isoenzyme
nomenclature. J. Clin. Path. 16:391-
393, 1963.
20. Vesell, E. S., Osterland, K. C., Bearn,
A. G. and Kunkel, H. G.: Isozymes
of lactic dehydrogenase; their altera-
tions in arthritic synovial fluid and
sera. J. Clin. Investig. 41:2012-2019,
1963.
21. Barland, P. and Hamernian, D.: Studies
on oxidative and hydrolytic enzymes
in synovial membrane of normal and
arthritic patients. Bull. N. Y. Acad.
Med. 38: 507-508, 1962.
22. Wroblewski, F. and Wroblewski, R.:
The clinical significance of lactic de-
hydrogenase activity of serous effu-
sions. Ann. Int. Med. 48:813-822,
1958.
23. Erickson,. R. J.: Lactic dehydrogenase
activity of effusion fluids as an aid
LDH AND GOT ACTIVITY OF SYNOVIAL FLUID 501

to differential diagnosis. J.A.M.A. 3:152-157, 1960.

176:794-796, 1961.
24. Richterich, R., Zuppinger, K. and Rossi,
E.: Diagnostic significance of hetero-
geneous lactic dehydrogenases in
malignant effusions. Nature 191:507-
508, 1961.
25. Erickson, R. J. and Morales, D. R.:
Clinical iiso of lactic dehydrogenase.
New Engl. J. Med. 265:47&482 and
531-534, 1961.
26. West, M., Poske, R. M., Black, A. B.,
Pilz, C. G. and Zimmerman, H. J.:
Enzyme activity in synovial fluid. J.
Lab. and Clin. Med. 62:175-183,
1963.
27. Markert, C. L. and Appella, E.: Physi-
cochemical nature of isozymes. Ann.
N. Y. Acad. Sci. 94:678-690, 1961.
28. Rodnan, G. P. and Maclachlan, M. J.:
The absorption of serum albumin and
gamma globulin from the knee ioint
of man and rabbit. Arth. and Rheum.
29. Ropes, M. W., Muller, A. F. and Bauer,
W.: The entrance of glucose and
other sugars into joints. Arth. and
Rheum. 3:496-514, 1960.
30. Ward, J., Cohen, A. S. and Bauer,
W.: The diagnosis and treatment of
acute infectious arthritis. Arth. and
Rheum. 3:522-535, 1960.
31. Vesell, E. S., Philip, 3. and Beam, A.
G.: Comparative studies of the iso-
zymes of lactic dehydrogenase in rab-
hit and man. J. Exp. Med. 116:797-
806, 1962.
32. Markert, C: L. and Appella, E.: Im-
munochemical properties of lactate
dehydrogenase isozymes. Ann. N. Y.
Acad. Sci. 103:915-929, 1963.
33. Kaplan, N. 0. and White, S.: Immuno-
logical characteristics of dehydro-
genases. Ann. N. Y. Acad. Sci. 103:
835-848, 1963.

Alan S . Cohen, M.D., Associate Professor of Medicine; Director,

Arthritis and Connective Tissue Disease Section, Massachusetts
Memorial Hospitals, Boston University School of Medicine,
Boston Uniuersity Medical Center, Boston, Mass.