Relationship of psoriatic arthritis with the other spondyloarthropathies

Paediatric Calcaneal Osteochondroma: A Case Report and a Literature Review

BACKGROUND

Heel pain in children is a common condition. The aetiology can be ascribed to fractures, osteochondrosis, tendinitis, calcaneal-navicular or talo-calcaneal coalition, osteomyelitis, rheumatic diseases, anatomic variants, malignant tumours (osteosarcoma, Ewing's sarcoma), and benign lesions (bone cyst, aneurismal bone cyst, osteoid osteoma, or exostosis). In particular, this manuscript focuses on a case of calcaneal exostosis in the paediatric age, aiming to highlight its rarity. Osteochondromas are benign tumours of the surface of the bone and the overlying cartilage. They grow until skeletal maturity and can cause stiffness, pain, cosmetic alterations, tendinitis, and neuro-vascular compression. The calcaneus is an extremely rare site for these tumours. Only two case reports of paediatric exostosis of the calcaneus bone are available.

METHODS

We describe a case of a girl of 16 years of age, affected by multiple cartilaginous exostosis, who presented with a painful mass on the inferior margin of the foot in the calcaneal region, which was diagnosed as an exostosis. The neoformation was excised, and the girl underwent clinical follow-up.

RESULTS

The patient was promptly discharged in good condition, and on the 25th postoperative day, she was completely pain-free and allowed weight bearing.

CONCLUSIONS

In the case of heel pain resistant to conservative treatment, the presence of an osteochondroma should be considered after excluding more common causes. If symptomatic, calcaneal osteochondromas could require surgical excision.

Psoriatic arthritis in patients with psoriasis: A clinical-epidemiological study at a dermatology center in western Mexico

BACKGROUND/OBJECTIVE

Psoriatic arthritis (PsA) is a chronic inflammatory illness. Approximately, 15% of psoriasis patients have undiagnosed PsA. In Mexico, we found no related studies. Our objective was to investigate the clinical-epidemiological characteristics of PsA in psoriasis patients in western Mexico.

METHODS

A cross-sectional study including Mexican patients with clinical and histopathological diagnosis of psoriasis. Physical examination, rheumatoid factor analysis and radiographies of axial and peripheral skeleton were performed. The prevalence of PsA using the CASPAR criteria, age, sex; clinical variants of PsA, psoriasis type and the Psoriasis Area and Severity Index (PASI), were assessed. Descriptive and inferential statistics were used.

RESULTS

Of 90 patients with psoriasis, 48 met the criteria for PsA, with a prevalence of 53%, and average age of 50 ± 15 years. Predominating were, the female sex in 29 (60%), the axial variant of PsA in 24 (50%), and psoriasis plaques in 40 (83%). The average PASI was 12 ± 11. All cases were rheumatoid factor negative. These variables were not significantly different when comparing subjects with and without PsA, except for the female sex (60% vs. 7%; P < 0.001).

CONCLUSIONS

Patients with psoriasis should intentionally be evaluated jointly Dermatologists and Rheumatologists searching joint involvement given the high prevalence of PsA previously undiagnosed.

Juvenile Spondyloarthropathies

Juvenile spondyloarthropathies represent a clinical entity separate from the adult disease. Initial clinical signs of juvenile spondyloarthropathies often include lower extremity arthritis and enthesopathy, without axial involvement at the disease onset. Asymmetrical oligoarthritis of lower extremities is typically seen in this type of arthritis. Enthesopathy, which is the hallmark of the disease, is most commonly seen in the Achilles tendon, being manifested by heel pain. Anterior uveitis and HLA-B27 positivity are seen in a proportion of cases. Sacroiliitis is generally asymptomatic in the pediatric population. Ineffective treatment of childhood disease results in disease progression to typical adult form of ankylosing spondylitis. Therefore, early diagnosis and classification remains one of the most relevant questions in pediatric rheumatology. It should be kept in mind that the disease could be misdiagnosed as FMF or Behçet's syndrome in countries with a high incidence of those conditions. This review revises available classification criteria, clinical manifestations and therapeutic options for patients with juvenile spondyloarthropathies.

Gastrointestinal comorbidities in patients with psoriatic arthritis

Comorbidities associated with psoriatic arthritis (PsA) include cardiovascular diseases, diabetes mellitus, and obesity. This study evaluated the association between PsA and common gastrointestinal (GI) diseases. A retrospective study was performed in Israel's largest health care provider database between 2002 and 2013. 3161 PsA patients were matched for age and sex with 31610 randomly selected patients. We searched these patients' records for the presence of peptic ulcer disease (PUD), reflux esophagitis, Crohn's disease, ulcerative colitis, irritable bowel syndrome (IBS) and celiac disease. T-test was used to compare continuous variables and a Chi-square test was used for categorical variables. Multivariate logistic regression models were used to assess the association between PsA and GI comorbidities. PsA was associated with Crohn's disease (OR 2.4, 95 %CI: 1.75-3.32, p < 0.0001), ulcerative colitis (OR 2.1, 95 %CI: 1.33-3.26, p = 0.001), reflux esophagitis (OR 1.6, 95 %CI: 1.44-1.78, p < 0.0001), PUD (OR 1.5, 95 %CI: 1.31-1.63, p < 0.0001) and IBS (OR 1.4, 95 %CI: 1.01-1.86, p = 0.045). After controlling for known risk factors, the association remained significant between PsA and Crohn's disease (OR 2.2, 95 %CI: 1.59-3.03, p < 0.0001), ulcerative colitis (OR 1.9, 95 %CI: 1.21-3.00, p = 0.005), reflux esophagitis (OR 1.5, 95 %CI: 1.31-1.63, p < 0.0001), and PUD (OR 1.3, 95 %CI: 1.12-1.47, p < 0.0001). No significant association was found between PsA and celiac disease. In the current study PsA was associated with gastrointestinal morbidities including Crohn's disease, ulcerative colitis, PUD and IBS. Physicians treating patients with PsA should be aware of these associations.

Psoriatic arthritis and sacroiliitis are associated with increased vascular inflammation by 18-fluorodeoxyglucose positron emission tomography computed tomography: baseline report from the Psoriasis Atherosclerosis and Cardiometabolic Disease Initiative

Introduction

Psoriasis and psoriatic arthritis (PsA) increase cardiovascular disease (CVD) risk, but surrogate markers for CVD in these disorders are inadequate. Because the presence of sacroiliitis may portend more severe PsA, we hypothesized that sacroiliitis defined by computed tomography (CT) would be associated with increased vascular inflammation defined by 18-fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT), which is an established measure of CVD.

Methods

Participants (n = 65) underwent whole-body FDG-PET/CT. Metabolic activity of the aorta was measured using the maximal standardized uptake value (SUV_max), a measure of atherosclerotic plaque activity. The primary outcome was aortic vascular inflammation. Linear regression (with β-coefficients (β) and P-values reported for PsA and sacroiliitis) was used to adjust for CVD risk factors to determine associations of PsA or sacroiliitis with vascular inflammation. Likelihood ratio testing was performed to evaluate the contribution of sacroiliitis to vascular disease estimation compared to the effects of PsA and traditional CVD risk factors.

Results

Vascular inflammation (measured as SUV_max) was greater (P < 0.001) in patients with sacroiliitis (mean ± SD = 7.33 ± 2.09) defined by CT compared to those without sacroiliitis (6.39 ± 1.49, P = 0.038). There were associations between PsA and aortic inflammation (β = 0.124, P < 0.001) and between sacroiliitis and aortic inflammation (β = 0.270, P < 0.001) after adjusting for CVD risk factors. Sacroiliitis predicted vascular inflammation beyond PsA and CVD risk factors (χ² = 124.6, P < 0.001).

Conclusions

Sacroiliitis is associated with increased vascular inflammation detected by FDG-PET/CT, suggesting that sacroiliac joint disease may identify patients at greater risk for CVD. Large, ongoing prospective studies are required to confirm these findings.

Electronic supplementary material

The online version of this article (doi:10.1186/ar4676) contains supplementary material, which is available to authorized users.

The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

Assessment of anti-cyclic citrullinated peptide in psoriatic arthritis

BACKGROUND

Anti-cyclic citrullinated peptides (anti-CCP) are highly specific diagnostic and prognostic markers for rheumatoid arthritis (RA). They have been also found in psoriatic arthritis (PsA), with controversies as regards clinical and radiological associations. The current study assessed anti-CCP in PsA and determined its clinical and radiological associations.

METHODS

Four groups contributed to this study. 40 PsA, 40 psoriasis without arthritis, 40 RA and 40 healthy controls. They were tested for anti-CCP. Clinical and radiological data were collected and statistically compared between anti-CCP-positive and -negative PsA patients.

RESULTS

Seven PsA (17.5%) and 34 RA (85%) were seropositive for anti-CCP. Patients of other groups were anti-CCP-negative. Regarding anti-CCP concentrations, highly significant difference existed between different groups and between anti-CCP-positive and -negative PsA. Significantly higher numbers of involved, swollen and tender joints, deformities and functional impairment of peripheral joints and radiological changes were found in anti-CCP-positive PsA.

CONCLUSION

Anti-CCP may be found in PsA and are associated with higher number of involved, swollen and tender joints, with deformities and functional impairment of peripheral joints and with erosive arthritis.

Psoriasis and psoriatic arthritis: separate or one and the same?

The presence and severity of skin and joint symptoms in patients with psoriasis and psoriatic arthritis frequently do not correspond, a discrepancy that has raised the question of whether they represent two related but different disease processes. The fact that some agents seem to work preferentially in one state over the other reinforces this idea. However, there are also several agents with combined efficacy against cutaneous and articular inflammation that appear to support the existence of a common aetiology. Here we review the clinical, epidemiological and genetic evidence for and against a common pathogenesis for the two diseases. We then discuss the cellular and molecular targets of their selected therapies and how they potentially implicate effector pathways as a common immunopathogenic mechanism. Finally, we examine a recently proposed model of psoriasis pathogenesis involving type 1 interferon-producing plasmacytoid dendritic cells and how it may provide further clues to the aetiological links between psoriasis and psoriatic arthritis.

Polyarticular psoriatic arthritis is more like oligoarticular psoriatic arthritis, than rheumatoid arthritis

BACKGROUND

and objective: Since the original description of psoriatic arthritis (PsA) subgroups by Moll and Wright, there has been some discrepancy in the precise prevalence of the different subgroups and in particular the proportion of patients with polyarthritis. The higher prevalence of the polyarthritis subgroup may be due to the inclusion of patients with seronegative rheumatoid arthritis with coincidental psoriasis. The classification of psoriatic arthritis (CASPAR) study database provided an opportunity to examine this question.

METHODS

The CASPAR study collected clinical, radiological and laboratory data on 588 patients with physician-diagnosed PsA and 525 controls with other inflammatory arthritis, 70% of whom had rheumatoid arthritis. Patients with PsA were divided into two groups: polyarthritis and non-polyarthritis (which included the Moll and Wright subgroups of spinal disease, distal interphalangeal predominant and arthritis mutilans) and were compared with patients with rheumatoid arthritis. Comparisons were made between all three groups and, if a significant difference occurred, between the two groups with PsA.

RESULTS

The three groups differed significantly with regard to all clinical and laboratory variables except duration of disease. Significant differences were also found between the two groups of PsA in terms of age, sex, total number of involved joints, disability score and symmetry. However, no differences were found between the groups of patients with PsA in terms of seropositivity for rheumatoid factor and antibodies to cyclic citrullinated peptide, enthesitis, and spinal pain and stiffness. Further, dactylitis was commonly seen in patients with PsA (57% in the polyarticular group and 45% in non-polyarticular group), and uncommonly found in patients with rheumatoid arthritis (5%). With the exception of entheseal changes, syndesmophytes and osteolysis, typical radiological features of PsA could not be used to distinguish between the PsA subgroups.

CONCLUSIONS

The evidence suggests that the changing prevalence of the polyarticular subgroup of PsA is not because doctors include patients with seronegative rheumatoid arthritis with coincidental psoriasis.

Classification of the spondyloarthropathies

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.

Anti-citrullinated peptide antibodies may occur in patients with psoriatic arthritis

BACKGROUND

Anti-cyclic citrullinated peptide (anti-CCP) antibodies are considered highly specific markers of rheumatoid arthritis. Despite the high specificity of the test, anti-CCP antibodies have also been observed in psoriatic arthritis.

OBJECTIVE

To determine the frequency of anti-CCP antibodies in psoriatic arthritis and to describe the clinical characteristics of such patients.

METHODS

Serum samples from 192 patients with psoriatic arthritis were analysed for anti-CCP antibodies. A previously defined cut off point was applied at a specificity level of > or =98.5% (42 U/ml). Antibodies against pepA and pepB (two synthetic citrullinated peptides) were determined on samples containing anti-CCP antibodies by line immune assay. The swollen joint count and the numbers of affected joints (present or past) were recorded. Clinical features were noted and if available radiographs of hands and feet were scored for erosions. Rheumatoid factor was determined in all samples.

RESULTS

Anti-CCP antibodies were found in 15 patients (7.8%); 13 of 15 anti-CCP2 positive samples were also positive for anti-pepA or pepB antibodies. The prevalence of anti-CCP antibodies was higher than expected in view of the highly specific cut off applied in the test. Detailed analysis of the clinical and radiological features makes it improbable that the high prevalence of anti-CCP antibodies resulted solely from concomitant psoriasis and rheumatoid arthritis or from misclassification.

CONCLUSIONS

Anti-CCP antibodies may be present in patients with psoriatic arthritis. Although some of the present cohort could have had psoriasis with concomitant rheumatoid arthritis, a proportion at least had the typical characteristics of psoriatic arthritis as the primary diagnosis.