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Winchester R, Minevich G, Steshenko V, Kirby B, Kane D, Greenberg DA, FitzGerald O. HLA associations reveal genetic heterogeneity in psoriatic arthritis and in the psoriasis phenotype. ACTA ACUST UNITED AC 2011; 64:1134-44. [PMID: 22006066 DOI: 10.1002/art.33415] [Citation(s) in RCA: 161] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Rigorously ascertained cases of psoriatic arthritis in subjects presenting to a rheumatology unit were compared with cases of psoriasis in subjects presenting to a dermatology unit, where subjects with musculoskeletal features were excluded, to address 1) the extent to which the contribution of the major histocompatibility complex (MHC) to psoriatic arthritis susceptibility resembles that in psoriasis, and 2) whether MHC genes determine quantitative traits within the psoriatic arthritis phenotype. METHODS Separate discovery and validation subcohorts of patients recruited from a relatively homogeneous population were studied by sequence-based HLA typing, in which frequencies of the HLA-B and HLA-C alleles and haplotypes were compared. RESULTS In patients with psoriatic arthritis, the frequency of C*06:02 was lower than that in patients with psoriasis (28.7% versus 57.5%; P = 9.9 × 10(-12) ). Three haplotypes containing B*27:05 or B*39:01 were significantly increased in frequency in patients with psoriatic arthritis, but not in those with psoriasis. The structurally related B*39:06 allele was not increased in frequency. B*27 was associated with an interval of 0.98 years between skin and musculoskeletal disease (P = 2.05 × 10(-6) ), compared with an interval of 10.14 years for C*06. Preliminary evidence suggested that B*38:01 and B*08 may be associated with psoriatic arthritis susceptibility, and that allotypes encoding P2 pockets that bind side chains opposite in charge from those encoded by the B*27 and B*39 molecules may exert a protective role. CONCLUSION These findings suggest that the psoriasis phenotype results from two patterns of MHC effect. The first involves the classic psoriasis susceptibility gene C*06, which confers more penetrant skin disease with less prevalent and more time-dependent musculoskeletal phenotype development. The second pattern appears to be mediated by HLA-B alleles, notably B*27, and includes temporally more coincident musculoskeletal involvement that is nearly equivalent in penetrance to that of the skin disease.
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Rudwaleit M, Taylor WJ. Classification criteria for psoriatic arthritis and ankylosing spondylitis/axial spondyloarthritis. Best Pract Res Clin Rheumatol 2011; 24:589-604. [PMID: 21035082 DOI: 10.1016/j.berh.2010.05.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The concept of spondyloarthritides (or spondyloarthropathies, SpAs) that comprises a group of interrelated disorders has been recognised since the early 1970s. While the European Spondyloarthropathy Study Group (ESSG) criteria and the Amor criteria have been developed to embrace the entire group of SpAs, new criteria for psoriatic arthritis have been developed recently. The Classification of Psoriatic Arthritis (CASPAR) study, a large one of more than 1000 patients, led to a new set of validated classification criteria for psoriatic arthritis. Since their publication in 2006 the CASPAR criteria are widely used in clinical studies. In ankylosing spondylitis, the 1984 modified New York criteria have been used widely in clinical studies and daily practice but are not applicable in early disease when the characteristic radiographical signs of sacroiliitis are not visible but active sacroiliitis is readily detectable by magnetic resonance imaging (MRI). This led to the concept of axial SpA that includes patients with and without radiographical damage; candidate criteria for axial SpA were developed based on proposals for a structured diagnostic approach. These criteria were validated in the Assessment of Spondyloarthritis International Society (ASAS) study on new classification criteria for axial SpA, a large international prospective study. In this new criteria, sacroiliitis showing up on MRI has been given as much weight as sacroiliitis on radiographs, thereby also identifying patients with early axial SpA. Both the CASPAR and the ASAS criteria for axial SpA are likely to be of use as diagnostic criteria.
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Affiliation(s)
- Martin Rudwaleit
- Department of Medicine, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany.
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Weckbach S, Schewe S, Michaely HJ, Steffinger D, Reiser MF, Glaser C. Whole-body MR imaging in psoriatic arthritis: Additional value for therapeutic decision making. Eur J Radiol 2011; 77:149-55. [DOI: 10.1016/j.ejrad.2009.06.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Revised: 05/24/2009] [Accepted: 06/16/2009] [Indexed: 11/28/2022]
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Magnetic resonance imaging in spondyloarthritis – how to quantify findings and measure response. Best Pract Res Clin Rheumatol 2010; 24:637-57. [DOI: 10.1016/j.berh.2010.06.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Dalbeth N, Pool B, Smith T, Callon KE, Lobo M, Taylor WJ, Jones PB, Cornish J, McQueen FM. Circulating mediators of bone remodeling in psoriatic arthritis: implications for disordered osteoclastogenesis and bone erosion. Arthritis Res Ther 2010; 12:R164. [PMID: 20796300 PMCID: PMC2945067 DOI: 10.1186/ar3123] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Revised: 08/04/2010] [Accepted: 08/26/2010] [Indexed: 12/17/2022] Open
Abstract
Introduction Diverse bone pathologies are observed in patients with psoriatic arthritis (PsA). Uncoupling of bone remodeling with disordered osteoclastogenesis has been implicated in the pathogenesis of PsA. The aim of this study was to examine the role of soluble mediators of bone remodeling within the circulation of patients with PsA. Methods Patients with PsA (n = 38), with psoriasis (n = 10), and healthy controls (n = 12) were studied. Serum was obtained for testing of Dikkopf-1 (Dkk-1), macrophage-colony stimulating factor (M-CSF), osteoprotegerin (OPG), and receptor activator of nuclear factor-κB ligand (RANKL) with ELISA. Patients with PsA also had bone densitometry, plain radiographs of the hands and feet, and assessment of peripheral blood osteoclast precursors. Radiographs were scored for erosion, joint-space narrowing, osteolysis, and new bone formation. Results Compared with those with psoriasis and healthy controls, patients with PsA had higher circulating concentrations of Dkk-1 and M-CSF. In patients with PsA, M-CSF and RANKL, but not Dkk-1, concentrations positively correlated with radiographic erosion, joint-space narrowing, and osteolysis scores. Mediators of bone remodeling did not correlate with the number of joints with new bone formation or with total hip-bone mineral density. Peripheral blood CD14+/CD11b+ cells, and the number of osteoclast-like cells and resorptive pits after culture with RANKL and M-CSF also correlated with radiographic damage scores. Circulating M-CSF concentrations correlated with the percentage of peripheral blood CD14+/CD11b+ cells. Conclusions Systemic expression of soluble factors that promote osteoclastogenesis is disordered in patients with PsA and may contribute to periarticular bone loss in this disease.
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Affiliation(s)
- Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland 1010, New Zealand.
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Stoll ML, Bhore R, Dempsey-Robertson M, Punaro M. Spondyloarthritis in a pediatric population: risk factors for sacroiliitis. J Rheumatol 2010; 37:2402-8. [PMID: 20682668 DOI: 10.3899/jrheum.100014] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Pediatric rheumatologists may have an opportunity to diagnose sacroiliitis in its early stages, prior to the development of irreversible radiographic changes. Early diagnosis frequently requires magnetic resonance imaging (MRI), the use of which is limited by expense and requirement for sedation. We set out to identify features of juvenile spondyloarthritis (SpA) associated with the highest risk of sacroiliitis, to identify patients who may be candidates for routine MRI-based screening. METHODS We reviewed the charts of 143 children seen at Texas Scottish Rite Hospital for Children diagnosed with SpA based on the International League of Associations for Rheumatology criteria for enthesitis-related arthritis or the Amor criteria for SpA. We performed logistic regression analysis to identify risk factors for sacroiliitis. RESULTS A group of 143 children were diagnosed with SpA. Consistent with the diagnosis of SpA, 16% had psoriasis, 43% had enthesitis, 9.8% had acute anterior uveitis, and 70% were HLA-B27+. Fifty-three children had sacroiliitis, of which 11 cases were identified by imaging studies in the absence of suggestive symptoms or physical examination findings. Logistic regression analysis revealed that hip arthritis was a positive predictor of sacroiliitis, while dactylitis was a negative predictor. CONCLUSION Children with SpA are at risk for sacroiliitis, which may be present in the absence of suggestive symptoms or physical examination findings. The major risk factor for sacroiliitis is hip arthritis, while dactylitis may be protective. Routine screening by MRI should be considered in patients at high risk of developing sacroiliitis.
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Affiliation(s)
- Matthew L Stoll
- Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
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Fernández Sueiro JL, González Díaz De Rábago E. [Axial psoriatic arthritis]. ACTA ACUST UNITED AC 2010; 6 Suppl 1:22-4. [PMID: 21794749 DOI: 10.1016/j.reuma.2009.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 12/15/2009] [Indexed: 11/25/2022]
Abstract
Spinal involvement in PsA is a controversial issue. Currently, in spite of clinical recognition of axial involvement in axial PsA, there is a lack of consensus that impedes elaborating a definition for axial Psa. Recent advances in classification, clinical features, outcome measures and therapeutics are reviewed in this paper.
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FERNÁNDEZ-SUEIRO JOSÉLUIS. The Challenge and Need of Defining Axial Psoriatic Arthritis. J Rheumatol 2009; 36:2633-4. [DOI: 10.3899/jrheum.091023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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McQUEEN FIONA, LASSERE MARISSA, DUER-JENSEN ANNE, WIELL CHARLOTTE, CONAGHAN PHILIPG, GANDJBAKHCH FRÉDÉRIQUE, HERMANN KAYGEERTA, BIRD PAUL, BØYESEN PERNILLE, PETERFY CHARLES, EJBJERG BO, HAAVARDSHOLM ESPENA, COATES LAURA, ØSTERGAARD MIKKEL. Testing an OMERACT MRI Scoring System for Peripheral Psoriatic Arthritis in Cross-sectional and Longitudinal Settings. J Rheumatol 2009; 36:1811-5. [DOI: 10.3899/jrheum.090351] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective.Magnetic resonance imaging (MRI) is increasingly used to measure articular inflammation and damage in patients with psoriatic arthritis (PsA). We evaluated the reliability of a new OMERACT PsA MRI scoring system, PsAMRIS, in PsA fingers.Methods.In 2 separate studies, MRI scans were obtained from patients with clinical evidence of synovitis or dactylitis of the fingers. For the first cross-sectional study, images were obtained at one timepoint. For the second longitudinal study, images were obtained at 2 timepoints, 6 weeks apart. Scans were scored using PsAMRIS in an international multireader setting, for synovitis, tenosynovitis, periarticular inflammation, bone edema, bone erosions, and bone proliferation.Results.Global status scores from both datasets revealed moderate to high reliability for scoring most features, although reliability was poor for periarticular inflammation in the cross-sectional study. Change scores that reflected inflammatory activity also exhibited moderate to good reliability in the longitudinal exercise, despite there being very little absolute change in MRI synovitis or tenosynovitis observed in this dataset. At the distal interphalangeal joints, reliability for change scores was acceptable only for synovitis and tenosynovitis.Conclusion.Further development and testing of the PsAMRIS is planned to improve its performance as a clinical and research tool to identify and measure pathology in peripheral joint PsA.
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Klauser AS, De Zordo T, Bellmann-Weiler R, Feuchtner GM, Sailer-Höck M, Sögner P, Gruber J. Feasibility of second-generation ultrasound contrast media in the detection of active sacroiliitis. ACTA ACUST UNITED AC 2009; 61:909-16. [DOI: 10.1002/art.24648] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Guglielmi G, Scalzo G, Cascavilla A, Carotti M, Salaffi F, Grassi W. Imaging of the sacroiliac joint involvement in seronegative spondylarthropathies. Clin Rheumatol 2009; 28:1007-19. [PMID: 19526194 DOI: 10.1007/s10067-009-1192-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 04/20/2009] [Accepted: 04/24/2009] [Indexed: 01/17/2023]
Abstract
Involvement of the sacroiliac joints is the first predominant finding of all seronegative spondylarthropathies (SpA) subsets, such as ankylosing spondylitis, psoriatic arthritis, and undifferentiated SpA. Although conventional radiography is indicated in the initial evaluation of sacroiliac joints diseases, it is often insensitive for demonstrating the early changes of sacroiliitis, so other imaging techniques typically are often necessary to clarify the pathology and for establishing the early diagnosis of seronegative SpA. Other imaging modalities, including computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US), and bone scintigraphy have improved visualization of inflammatory changes at the sacroiliac joints (SIJ). CT scans are indicated for disease processes in which bony destruction or ossification may occur. MRI has been proposed as an imaging method to detect sacroiliitis earlier. MRI can identify both inflammation and structural changes caused by inflammation, while radiographs show only structural changes. MRI may be particularly useful in making a diagnosis of SpA. Musculoskeletal US has an increasing and relevant role in the evaluation of SpA mainly for its ability to assess joint and periarticular soft tissue involvement and in particular for its capacity to detect enthesitis. US assessment in general is safe, noninvasive, and comparably cheap, showing itself as a complimentary tool to clinical evaluation in SpA; nevertheless, it is very user dependent. Bone scintigraphy is at most of limited diagnostic value for the diagnosis of established AS, including the early diagnosis of probable/suspected sacroiliitis. The main aim of this study is to introduce the clinical and radiological aspects of the SIJ involvement in SpA, particularly the contribution of the different imaging techniques.
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Gardner-Medwin JMM, Irwin G, Johnson K. MRI in juvenile idiopathic arthritis and juvenile dermatomyositis. Ann N Y Acad Sci 2009; 1154:52-83. [PMID: 19250231 DOI: 10.1111/j.1749-6632.2009.04498.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The use of MRI in the assessment of the musculoskeletal system in children has important differences from its use in adults. Growth in children has significant impact on the epiphysis and growth plate, which are important structures in the growing child, and there are radiological features that differ from those in adults: disease may alter structures during a period of growth; the pathologies themselves are a distinct group of diseases at variance with adult arthritis and myositis, with a different spectrum of differential diagnoses; and many technical issues are different when imaging a child. These are important considerations in choosing the appropriate imaging. MRI is a powerful and valuable imaging technique in pediatric musculoskeletal pathologies, with considerable potential for future developments to enhance its role in diagnosis, management, and therapeutic intervention for these children.
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Orchard TR, Holt H, Bradbury L, Hammersma J, McNally E, Jewell DP, Wordsworth BP. The prevalence, clinical features and association of HLA-B27 in sacroiliitis associated with established Crohn's disease. Aliment Pharmacol Ther 2009; 29:193-7. [PMID: 18945256 DOI: 10.1111/j.1365-2036.2008.03868.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Sacroiliitis is a recognized complication of Crohn's disease and may occur distinct from progressive ankylosing spondylitis (AS). AIM To estimate prospectively the prevalence of sacroiliitis in patients with established Crohn's disease, to characterize the clinical features and to correlate these with the presence of HLA-B27. METHODS All Crohn's disease patients under active follow-up of between 5 and 12 years duration were invited to participate. Patients underwent a clinical evaluation including symptom questionnaire, rheumatological examination and underwent HLA genotyping. Patients then underwent magnetic resonance imaging (MRI) of the sacroiliac joints. The clinical and radiological factors were correlated with HLA-B27 status. RESULTS 56 patients underwent initial assessment and 44 had MRI scans. Seventeen of 44 (39%) patients had MRI evidence of sacroiliitis, of whom 5 fulfilled the criteria for AS. Symptoms of low back pain were elicited in a majority of these patients--11/17 (65%) compared to 3 of 27 (11%) patients with normal scans (P = 0.003). There were no differences in functional indices with the exception of patients with AS. HLA-B27 was present in seven patients, and all seven had MRI evidence of sacroiliitis, five had AS. CONCLUSIONS Sacroiliitis is common in patients with established Crohn's disease and in the majority of cases, patients have symptoms of inflammatory low back pain if questioned carefully. HLA-B27 is not associated with isolated sacroiliitis, but is associated with AS. However, possession of HLA-B27 appears to convey a very high risk of developing axial inflammation in Crohn's disease.
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Affiliation(s)
- T R Orchard
- GI Unit, St Mary's Hospital, and Imperial College London, UK.
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MRI in psoriatic arthritis: Insights into pathogenesis and treatment response. Curr Rheumatol Rep 2008; 10:303-10. [DOI: 10.1007/s11926-008-0049-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Coates LC, Helliwell PS. Classification and categorisation of psoriatic arthritis. Clin Rheumatol 2008; 27:1211-6. [PMID: 18629574 DOI: 10.1007/s10067-008-0947-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Accepted: 06/04/2008] [Indexed: 12/15/2022]
Abstract
For over 30 years, investigators have used the simple but non-validated classification criteria suggested by Moll and Wright. Several authors have suggested modifications to these but most remain unvalidated or require human leukocyte antigen analysis. Now, a worldwide initiative has developed new criteria which include both clinical and radiological features. These will require further study before they are fully adopted but their improved performance should result in less variation between study cohorts. The recurring question of disease heterogeneity continues to occupy researchers in this field. Despite recent pleas to abandon the original five sub-groups, a case can be made for retaining at least the two sub-groups of peripheral and axial disease and, possibly, splitting the peripheral disease into oligo- and poly-arthritis.
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Akdeniz O, Alayli G, Tosun FC, Diren B, Cengiz K, Selçuk MB, Sünter T, Cantürk F. Early spondyloarthropathy: scintigraphic, biological, and clinical findings in MRI-positive patients. Clin Rheumatol 2007; 27:469-74. [PMID: 17874171 DOI: 10.1007/s10067-007-0730-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 08/03/2007] [Accepted: 08/28/2007] [Indexed: 01/17/2023]
Abstract
There are no specific diagnostic tests or a gold standard method for measuring disease activity and outcome in spondyloarthropathies (SpA). Many different methods have been developed to assess the signs and symptoms in SpA. The aim of this study was to evaluate the value of scintigraphy, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and Bath Ankilosing Spondylitis Disease Activity Index (BASDAI) in the evaluation of disease activity in early axial SpA diagnosed with magnetic resonance imaging (MRI). Thirty early MRI-positive axial SpA patients (23 males, 7 females) with a median age of 35 (18-55) years and a median duration of inflammatory low back pain of 24 (8-60) months were included in the study. In the patients with sacroiliitis, the sensitivity, specificity, and positive and negative predictive values of disease activity parameters were determined regarding MRI as the gold standard method. The sensitivities of quantitative scintigraphy, visual scintigraphy, ESR, CRP, and BASDAI were 32, 82, 35, 71, and 60%, respectively. The specificities of quantitative scintigraphy, ESR, CRP, and BASDAI were 100, 100, 50, and 100%, respectively. The positive predictive values of quantitative scintigraphy, visual scintigraphy, ESR, CRP, and BASDAI were 100, 92, 100, 95, and 100%, respectively. The negative predictive values of quantitative scintigraphy, ESR, CRP, and BASDAI were 9, 10, 11, and 15%, respectively. Regarding MRI as the gold standard in the evaluation of disease activity, combined visual and quantitative bone scintigraphy can be valuable in patients with MRI-incompatible implants. Additionally, use of cheaper, simple, and readily reproducible tests such as CRP and BASDAI together could be valuable and practical in detecting disease activity in long-term follow-up of these patients.
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Affiliation(s)
- Orhan Akdeniz
- Department of Physical Medicine and Rehabilitation, Medical Faculty, Ondokuz Mayis University, Samsun, Turkey
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McQueen F, Lassere M, Østergaard M. Magnetic resonance imaging in psoriatic arthritis: a review of the literature. Arthritis Res Ther 2006; 8:207. [PMID: 16569257 PMCID: PMC1526607 DOI: 10.1186/ar1934] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Psoriatic arthritis is a diverse condition that may be characterized by peripheral inflammatory arthritis, axial involvement, dactylitis and enthesitis. Magnetic resonance imaging (MRI) allows visualization of soft tissue, articular and entheseal lesions, and provides a unique picture of the disease process that cannot be gained using other imaging modalities. This review focuses on the literature on MRI in psoriatic arthritis published from 1996 to July 2005. The MRI features discussed include synovitis, tendonitis, dactylitis, bone oedema, bone erosions, soft tissue oedema, spondylitis/sacroiliitis and subclinical arthropathy. Comparisons have been drawn with the more extensive literature describing the MRI features of rheumatoid arthritis and ankylosing spondylitis.
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Affiliation(s)
- Fiona McQueen
- Department of Molecular Medicine and Pathology, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand.
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Abstract
PURPOSE OF REVIEW The spondyloarthropathies are a group of conditions which share similar clinical features. Classification criteria permit separation of the conditions, allow better targeting of therapies, better measurement of outcomes, and better prognostic information. Early diagnosis remains problematic, but validated criteria for established disease are now emerging. RECENT FINDINGS Histopathology and histochemistry are providing a better understanding of the underlying process of inflammatory arthritis in spondyloarthropathy and other inflammatory arthritides. Early disease, however, continues to challenge current criteria. Sophisticated imaging with magnetic resonance imaging is being increasingly used and is proving useful for early diagnosis as well as helping to understand the pathophysiology of disease. Juvenile idiopathic arthritis continues to provide problems and criteria have recently been modified to allow a greater clinical utility and inclusion of more patients. Poststreptococcal reactive arthritis appears to be a heterogeneous clinical entity, with a group looking more like rheumatic fever and a group with spondyloarthropathy traits. It may be that the association is not streptococcal, but is a throat infection. Currently available criteria for psoriatic arthritis have been evaluated in a large cohort. Four of the criteria performed well with high specificity and sensitivity whereas the other two had moderate specificity and low sensitivity. It was shown that rheumatoid factor positivity does not exclude a diagnosis of psoriatic arthritis--the single most important clinical feature of this condition being the presence of psoriasis. SUMMARY The spondyloarthropathy classification criteria continue to be an area of development. This is most apparent in juvenile arthritis and psoriatic arthritis. The latter is currently undergoing intense scrutiny to develop classification criteria and outcome measures.
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Affiliation(s)
- Paul J Healy
- Academic Unit of Musculoskeletal Medicine, University of Leeds, UK
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Conti F, Borrelli O, Anania C, Marocchi E, Romeo EF, Paganelli M, Valesini G, Cucchiara S. Chronic intestinal inflammation and seronegative spondyloarthropathy in children. Dig Liver Dis 2005; 37:761-7. [PMID: 16024303 DOI: 10.1016/j.dld.2005.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Accepted: 04/27/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND Spondyloarthropathy in adults has been shown to be associated with either clinical or subclinical intestinal inflammation, however this association has rarely been described in children. AIM To report paediatric patients primarily referred to a paediatric gastroenterology centre for suspected inflammatory bowel disease and found to be affected by a seronegative spondyloarthropathy. Intestinal inflammatory lesions and rheumatological features have been described in them. SUBJECTS During a 18-month period, 129 children were referred because of symptoms and signs suggesting an inflammatory bowel disease; 31 of them (range age: 5-17 years) were selected because they also had signs of axial and/or peripheral arthropathy and form the basis of our study. METHODS The investigated patients underwent ileo-colonoscopy with biopsy and rheumatological assessment that also included X-ray and magnetic resonance imaging of the sacroiliac joints. RESULTS Only seven children had a classical inflammatory bowel disease (four had ulcerative colitis, three had Crohn's disease), 12 had an indeterminate colitis, 12 a lymphoid nodular hyperplasia of the distal ileum as main feature. In the latter two groups, endoscopy and histology revealed an intestinal inflammation of chronic type distinct from the classical pattern found in inflammatory bowel disease. All were HLA B27 negative and fulfilled the European Spondyloarthropathy Study Group criteria for spondyloarthropathy (except five children classified as undifferentiated spondyloarthropathy). CONCLUSIONS In a group of children primarily investigated for suspected inflammatory bowel disease and also presenting a seronegative spondyloarthropathy we have described both intestinal and rheumatological features. The majority of them exhibited either an indeterminate colitis or a lymphoid nodular hyperplasia of the distal ileum as main feature. These patients may be a population at risk of developing a full inflammatory bowel disease phenotype.
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Affiliation(s)
- F Conti
- Department of Rheumatology, University of Rome La Sapienza, Rome, Italy
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Zapico-Fernández M, Torre-Alonso J. Artritis psoriásica: clasificación y evaluación de los pacientes en la actualidad. ACTA ACUST UNITED AC 2005; 1 Suppl 1:S21-5. [DOI: 10.1016/s1699-258x(05)72758-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kruithof E, Baeten D, De Rycke L, Vandooren B, Foell D, Roth J, Cañete JD, Boots AM, Veys EM, De Keyser F. Synovial histopathology of psoriatic arthritis, both oligo- and polyarticular, resembles spondyloarthropathy more than it does rheumatoid arthritis. Arthritis Res Ther 2005; 7:R569-80. [PMID: 15899044 PMCID: PMC1174942 DOI: 10.1186/ar1698] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2004] [Revised: 01/18/2005] [Indexed: 11/29/2022] Open
Abstract
At present only few biological data are available to indicate whether psoriatic arthritis (PsA) is part of the spondyloarthropathy (SpA) concept, whether it is a separate disease entity or a heterogeneous disease group with oligoarticular/axial forms belonging to SpA and polyarticular forms resembling rheumatoid arthritis (RA). To address this issue with regard to peripheral synovitis, we compared the synovial characteristics of PsA with those of ankylosing spondylitis (AS)/undifferentiated SpA (USpA) and RA, and compared the synovium of oligoarticular versus polyarticular PsA. Synovial biopsies were obtained from patients with RA, nonpsoriatic SpA (AS + USpA), and oligoarticular and polyarticular PsA. The histological analysis included examination(s) of the lining layer thickness, vascularity, cellular infiltration, lymphoid aggregates, plasma cells and neutrophils. Also, we performed immunohistochemical assessments of CD3, CD4, CD8, CD20, CD38, CD138, CD68, CD163, CD83, CD1a, CD146, alphaVbeta3, E-selectin, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, S100A12, intracellular citrullinated proteins and major histocompatibility complex (MHC)-human cartilage (HC) gp39 peptide complexes. Comparing SpA (PsA + AS + USpA) with RA, vascularity, and neutrophil and CD163+ macrophage counts were greater in SpA (P < 0.05), whereas lining layer thickness and the number of CD83+ dendritic cells were greater in RA (P < 0.05). In RA, 44% of samples exhibited positive staining for intracellular citrullinated proteins and 46% for MHC-HC gp39 peptide complexes, whereas no staining for these markers was observed in SpA samples. We excluded influences of disease-modifying antirheumatic drug and/or corticosteroid treatment by conducting systematic analyses of treated and untreated subgroups. Focusing on PsA, no significant differences were observed between PsA and nonpsoriatic SpA. In contrast, vascularity (P < 0.001) and neutrophils were increased in PsA as compared with RA (P = 0.010), whereas staining for intracellular citrullinated proteins and MHC-HC gp39 peptide complexes was exclusively observed in RA (both P = 0.001), indicating that the same discriminating features are found in PsA and other SpA subtypes compared with RA. Exploring synovial histopathology between oligoarticular and polyarticular PsA, no significant differences were noted. Moreover, intracellular citrullinated proteins and MHC-HC gp39 peptide complexes, which are specific markers for RA, were observed in neither oligoarticular nor polyarticular PsA. Taken together, these data indicate that the synovial histopathology of PsA, either oligoarticular or polyarticular, resembles that of other SpA subtypes, whereas both groups can be differentiated from RA on the basis of these same synovial features, suggesting that peripheral synovitis in PsA belongs to the SpA concept.
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Affiliation(s)
- Elli Kruithof
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Dominique Baeten
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Leen De Rycke
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Bernard Vandooren
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Dirk Foell
- Department of Pediatrics, University of Münster, Münster, Germany
| | - Johannes Roth
- Institute of Experimental Dermatology, University of Münster, Münster, Germany
| | - Juan D Cañete
- Department of Rheumatology, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | | | - Eric M Veys
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Filip De Keyser
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
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Abstract
PURPOSE OF REVIEW Psoriatic arthritis is an inflammatory arthritis associated with psoriasis that is more common and severe than initially appreciated. The success of biologic agents in psoriatic arthritis has sparked great interest in this disorder, although the disease pathogenesis is poorly understood. This review focuses on recent advances in the genetic factors and immune pathways that have been implicated in susceptibility to disease. In addition, recent studies examining the mechanisms that underlie angiogenesis, enthesitis, and bone resorption in psoriatic arthritis are discussed. RECENT FINDINGS Studies performed on several different populations indicate that the MHC class I allele Cw6 is associated with both early-onset psoriasis and psoriatic arthritis. Mutations in the caspase-activating recruitment domain 15 locus on chromosome 16 are also associated with psoriatic arthritis, providing support for a model involving innate immune mechanisms. Evidence for a CD8 antigen-driven acquired immune response in psoriatic synovium and blood was reported. The finding of elevated levels of vascular endothelial growth factor and angiopoietin 2 in psoriatic arthritis synovial vasculature may provide insights into events responsible for the tortuous vessel morphology, a histologic feature characteristic of psoriatic joints. Tumor necrosis factor (TNF)-alpha is a critical factor mediating inflammation in the synovium, enthesis, and bone. In particular, osteoclasts resorb bone via a receptor activator of nuclear factor kappaB-receptor activator of nuclear factor kappaB ligand signaling pathway that is potentiated by TNF-alpha. The lessening of bone marrow edema after anti-TNF therapy provides further support for the importance of this cytokine in disease pathogenesis. SUMMARY Recent studies provide additional support for distinct pathogenetic mechanisms in psoriatic arthritis that arise from a complex interplay between genetic and environmental factors. Histopathologic data and results from clinical trials highlight the predominance of TNF-mediated inflammation in psoriatic joint tissues.
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Affiliation(s)
- Allen P Anandarajah
- Allergy, Immunology and Rheumatology Unit, University of Rochester Medical Center, Rochester, New York 14642, USA
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77
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Abstract
PURPOSE OF REVIEW The seronegative spondyloarthropathies are a group of disorders sharing common clinical features, the hallmark of which is sacroiliitis. Despite the 40 years since psoriatic arthritis was recognized, controversy still exists about which patients to include within this disease group and the relation of psoriatic arthritis with the other spondyloarthropathies. RECENT FINDINGS Early disease can present difficulties because it is inappropriate to use criteria developed on established cases in early arthritis, in which many cases may be initially undifferentiated. The taxonomy of juvenile spondyloarthropathy remains a contentious issue, and further modifications of the Durban criteria have been suggested. The predictive value of the European Spondyloarthropathy Study Group criteria for spondyloarthropathy varies with the prevalence of the disease in the population under consideration, as has been demonstrated in ambulatory practice in France and Spain. It appears that physicians differ in their interpretation of the individual features, particularly of such clinical items as asymmetry and predominantly lower limb involvement. The combination of dactylitis of a toe, heel pain, and oligoarthritis appears to be strongly suggestive of psoriatic arthritis. However, solitary heel pain can be problematic, and ultrasonographic entheseal erosion at the calcaneum has been shown equally in rheumatoid arthritis and psoriatic arthritis. MRI may be more sensitive and quantitatively discriminative in psoriatic arthritis. Spinal involvement in psoriatic arthritis can be asymptomatic, as in classical ankylosing spondylitis. Importantly, psoriatic spondylitis has been observed in the absence of sacroiliitis. SUMMARY Clinicians generally agree that psoriatic arthritis constitutes a discreet subset within the spondyloarthropathy group, but the demarcation continues to be the subject of clinical research. The matter is confounded by the lack of agreed classification criteria for psoriatic arthritis; although in both adult and juvenile disease criteria for spondyloarthropathy exist, the place of psoriatic arthritis within this larger group requires further definition.
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Affiliation(s)
- Philip S Helliwell
- Rheumatology and Rehabilitation Research Unit, University of Leeds, Leeds, United Kingdom.
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78
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Wakefield RJ, Conaghan PG, Jarrett S, Emery P. Noninvasive techniques for assessing skeletal changes in inflammatory arthritis: imaging technique. Curr Opin Rheumatol 2004; 16:435-42. [PMID: 15201608 DOI: 10.1097/01.bor.0000130318.98451.05] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
New imaging techniques such as ultrasound and MRI are likely to play increasing roles in the future management of patients with inflammatory arthritis, particularly those with rheumatoid arthritis and spondyloarthropathies. Ultrasound has a number of distinct advantages including its ability to scan multiple joints, safety, and immediately availability in clinic. MRI, however, is more sensitive and has a greater field of view because of its tomographic nature. Both modalities have the added advantage over radiography in that they can image soft tissue as well as bone. Dual X-ray absorptiometry already has an established role to play in the assessment of osteoporosis, but new techniques such as digital radiogrametry, quantitative CT, and ultrasound potentially will have a more important role to play in the future.
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Affiliation(s)
- Richard J Wakefield
- Academic Department of Musculoskeletal Medicine, Leeds General Infirmary, UK
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79
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Williamson L, Dalbeth N, Dockerty JL, Gee BC, Weatherall R, Wordsworth BP. Extended report: nail disease in psoriatic arthritis--clinically important, potentially treatable and often overlooked. Rheumatology (Oxford) 2004; 43:790-4. [PMID: 15113998 DOI: 10.1093/rheumatology/keh198] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To examine the relationship between the severity of nail disease and characteristics of psoriatic arthritis (PsA). We also wished to assess the clinical management of nail disease in patients with PsA. METHODS We studied 69 patients with PsA at two visits. On the first visit, a rheumatology assessment of joint, skin and nail disease was made. On the second visit, a detailed dermatology assessment of skin and nails was made. Nail disease was analysed using a 20-nail psoriasis nail severity score (PNSS). RESULTS There were 57 (83%) patients with clinical evidence of psoriatic nail disease. Although 66 (96%) patients had been treated for skin disease, only one (1%) had received any treatment for nail disease. Severe nail disease measured by the PNSS correlated with severe skin psoriasis as indicated by the percentage of body surface area affected by psoriasis (r = 0.34, P = 0.004) and physician global assessment of psoriasis (r = 0.45, P<0.001). Patients with distal interphalangeal (DIP) joint disease had higher PNSS scores (P = 0.03). The PNSS was also associated with unremitting and progressive arthritis (P<0.001), and correlated with Stanford health assessment questionnaire (HAQ) (r = 0.34, P = 0.004), depression (r = 0.39, P<0.001) and anxiety (r = 0.34, P = 0.004) scores. Compared with dermatology assessment, the rheumatology examination of nail disease had a positive predictive value of 84% and negative predictive value of 83%. CONCLUSIONS In patients with PsA, the severity of nail disease correlates with indicators of severity of both skin and joint disease. Although rheumatologists can adequately screen for nail disease, the management of this aspect of PsA is often overlooked.
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Affiliation(s)
- L Williamson
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford, UK.
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80
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Abstract
Seronegative spondyloarthropathies comprise a group of inflammatory arthritides, which consists of ankylosing spondylitis, psoriatic arthritis, reactive arthritis (Reiter's syndrome), enteropathic arthritis, and undifferentiated spondyloarthropathy. All of them share common laboratory, clinical, and imaging findings, with characteristic involvement of the sacroiliac joints, spine, and, to various degrees, peripheral joints. For many years, conventional radiography was the mainstay for definitive diagnosis of sacroiliitis and for follow-up of the anatomic changes in the spine, peripheral joints, and entheses. Conventional radiographs remain the imaging investigation of choice; however, they are unable to detect early inflammatory changes of sacroiliitis, which are important for establishing a diagnosis without delay. Other imaging modalities, such as computed tomography, bone scintigraphy, magnetic resonance imaging, and ultrasonography have improved the capabilities of detecting early disease and became useful adjuncts to plain films. In addition, they also have enabled more accurate detection of pathology at various anatomic sites of the musculoskeletal system predominantly involved in spondyloarthropathies. This article will review and highlight the role of each of these modalities in the assessment of the axial and peripheral skeleton in seronegative spondyloarthropathies.
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Affiliation(s)
- Mikayel Grigoryan
- Osteoporosis and Arthritis Research Group, Department of Radiology, University of California at San Francisco, 350 Parnassus Avenue, San Francisco, CA 94117, USA
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