Psoriatic Arthritis - PDF Document

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  1. Original Article Psoriatic Arthritis CP Rajendran*, SG Ledge**, Kanaka P Rani*, Radha Madhavan** Abstract Aim of the study : To evaluate the clinical pattern of psoriatic arthritis in patients attending a tertiary referral centre in South India. Methodology : Case records of one hundred and sixteen patients with psoriatic arthritis (PsA) who had attended our Rheumatology Department were analysed using demographic, clinical, laboratory and radiographic variables and the data were compared with other studies. Results : Among 116 patients, 78 were males and 38 were females (ratio 2:1). Peak incidence (69%) was in the fourth and fifth decades. One patient had juvenile psoriatic arthritis (onset <16 years of age). Symmetric polyarthritis (48.3%) was the commonest subtype. Arthritis followed the skin lesions in 50.8% of patients, preceded in 12.1% and occurred simultaneously in 37.1%. Knee (66.4%) was the commonest joint involved. Extra-articular features like sausage digits (19%), enthesitis (7.8%) and eye manifestations (1.7%) like conjunctivitis and uveitis were observed. Psoriasis vulgaris (81%) was the commonest psoriatic lesion. Scalp (57.8%) was the most common hidden site. All the three patients with DIP arthritis alone had nail lesions. ESR and C-reactive protein were elevated in 51.7% and 43.9% of patients respectively. Rheumatoid factor was positive in 3.4 % and antinuclear antibody (ANA) was present in 5.4% (3/56) of patients. HIV infection was detected in 2.3% (1/44) of patients. Radiographic features like sacroiliitis (11.2%), calcaneal spur (7.8%), erosions (5.2%) and syndesmophytes (5.2%) were observed. One patient had ‘pencil-in-cup deformity’. Conclusion : Psoriatic arthritis is more common in males. Symmetric polyarthritis is the commonest subtype. Arthritis commonly follows the skin lesions. Psoriasis vulgaris is the most common skin lesion and scalp is the commonest hidden site. ESR and CRP can be normal in psoriatic arthritis. proximal interphalangeal and distal interphalangeal joint arthritis along with dactylitis i.e. capsulitis, enthesitis, tenosynovitis and periosteitis) and eye manifestations like conjunctivitis or anterior uveitis. Arthritis may precede, follow or occur simultaneously with the skin lesion. In 1973 Moll and Wright6 classified PsA into five subtypes viz. 1. Distal interphalangeal (DIP) arthritis alone 2. Arthritis mutilans (destructive) 3. Symmetric polyarthritis. 4. Asymmetric oligoarthritis. 5. Spondyloarthropathy. In 1994 Veale et al included SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) as a distinct subgroup.7 Previous studies showed the asymmetric oligoarthritis being the commonest subtype.8,9 But recent surveys suggest that the commonest manifestation is the symmetric polyarthritis resembling rheumatoid arthritis(RA).3,10 Because of this changing pattern of psoriatic arthritis in different studies, we have analysed the clinical pattern of psoriatic arthritis as seen in our clinic and have compared with other studies. MATERIAL AND METHODS This is a retrospective data analysis. Case records of all INTRODUCTION P arthritis and psoriasis was first described by Alibert in 1818.1 The prevalence of PsA in western population is 0.67%.2 It is equally distributed in both sexes, presenting commonly in the 3rd or 4th decade.3,4 The exact aetiology of PsA is unclear. Genetic, immunologic and environmental factors are thought to play a role in the perpetuation of the inflammatory process.5 Psoriatic arthritis is characterised by typical psoriatic skin lesions, nail lesions, large and small joint arthritis including DIP arthritis, sacroiliitis, sausage digits (‘sausage’ like swelling of a finger or a toe is due to metacarpophalangeal, soriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis. The association between *Professor and Head of the department; **Postgraduate student; *Assistant professor; **Additional professor of immunology; Department of Rheumatology, Madras Medical College and Government General Hospital, Chennai, Tamil Nadu, India. Received : 6.5.2003; Revised : 14.7.2003; Re-revised : 10.9.2003; Accepted : 25.9.2003 JAPI • VOL. 51 • NOVEMBER 2003 1065

  2. patients of psoriatic arthritis (all age groups included), seen at the Department of Rheumatology, Madras Medical College and Government General Hospital, Chennai between August 1991 and July 2001 were analysed. A total of one hundred and sixteen patients of PsA were seen during this period. They form the basis of this study. No case was dropped due to incomplete data. Patients were diagnosed according to Moll and Wright’s criteria6 for adults and Vancouver criteria11 for children of below 16 years of age. Demographic features like age, sex and the duration between the arthritis and the skin lesion were recorded. The patients were classified according to Moll and Wright’s criteria.6 Apart from the extra- articular features of PsA, skin lesions and nail lesions of psoriasis were also noted. Investigations included haemoglobin (Hb), erythrocyte sedimentation rate (ESR) by Westergren method, rheumatoid factor (RF), C-reactive protein (CRP), anti-streptolysin-O (ASO), anti-nuclear antibody (ANA), ELISA for HIV infection and x-ray data as recorded. RF, CRP and ASO were done by latex agglutination method and ANA was done by indirect immunofluoresence test using mouse liver as substrate. RESULTS Out of 116 patients studied, 78 were males and 38 were females. The age of onset ranged from 10-65 years. The mean age was 40.9 years. Other demographic features are given in Table 1. 71% of females (27/38) and 68% of males (53/78) had disease onset in the 4th and 5th decades. Seventy three patients developed either arthritis or skin lesion initially (asynchronous onset) and 52 of them developed skin or joint manifestation respectively within 5 years. Psoriatic arthritis subtypes and the pattern of joint involvement are given in Tables 2 and 3 respectively. Thirteen patients had sacroiliac joint involvement and thirty-eight had DIP arthritis of fingers. Isolated DIP arthritis was seen in three patients. Other features of PsA are given in Table 4. Fig. 2 : Duration between skin lesion and arthritis in asynchronous onset.. Fourty two out of 59 patients (71.2%) with initial skin lesion, developed arthritis within five years. Ten out of 14 patients (71.4%) with initial arthritis, developed skin lesion within five years. Among 22 patients with sausage digits, eight had more than one digit involvement (range:2-10). Out of two patients with eye involvement, one had conjunctivitis and the other had anterior uveitis. Thirty-five patients had nail lesions (pitting, ridging, onycholysis and subungual hyperkeratosis). All the three patients with only DIP arthritis, had nail lesions. Regarding psoriatic skin lesions, psoriasis vulgaris was noted in 94 patients (81%), exfoliative type in 10 patients (8.6%) and pustular psoriasis in five (4.3%). Guttate and flexural psoriasis were seen in one patient each. Overall nail lesions were observed in 35 patients (30.2%). But only nail lesions without skin lesions were seen in five patients (4.3%). Even- though five patients had pustular psoriasis, no one had developed SAPHO syndrome. Scalp was the commonest (57.6%) hidden site of psoriatic lesions. Anaemia (Hb<10g%) was found in four patients (3.4%), elevated ESR (>20mm/hr) in 60 patients (51.1%) and elevated CRP (>0.6mg%) in 51 patients (43.9%). RF and ANA were positive in 3.4% and 5.4% (3/56) of patients respectively. Serum uric acid and ASO titer were elevated in 1.7% and Table 1 : Demographic features Our study Shah et al12Pranesh et al15Nadkar et al14 Features (n=116) (n=102) (n=12) (n=54) Mean age (yrs) 40.9 38.17 40 39.9 Sex ratio(M:F) 2:1 1.8 :1 1:2 1.45 :1 Mean duration bet. 2.8 2.5 — — arthritis and skin (yrs) Arthritis before 12.1 5.8 8.3 35.2 skin lesion (%) Fig. 1 : Peak age incidence. Arthritis after 50.8 63.8 50 57.4 In males 28 out of 78 patients (35.9%) and 25 out of 78 patients skin lesion (%) (32.1%) had psoriatic arthritis in the 4th and 5th decades Arthritis along 37.1 19.7 41.7 7.4 respectively. In females 16 out of 38 patients (42.1%) and 11 out of with skin lesion (%) 38 patients (28.9%) had psoriatic arthritis in the 4th and 5th decades respectively. 1066 JAPI • VOL. 51 • NOVEMBER 2003

  3. DISCUSSION Table 2 : Psoriatic arthritis - subtypes Until 40 years ago PsA was considered to be a variant of rheumatoid arthritis (RA).4 But subsequent studies showed it as a distinct arthritis different from RA.4,9 However Helliwell et al have suggested that the joint involvement in PsA resembles that of RA.12 The prevalence of PsA in patients with psoriasis ranges from 7% to 42%.13 Unlike the studies of Kammar et al8 and Gladman et al3 showing equal sex distribution in PsA, our study shows a male preponderance. Shah et al12 and Nadkar et al14 have reported similar finding while Pranesh et al15 have reported a female preponderance. Like other studies12,14,15 skin lesion preceded arthritis in half of our patients. In asynchronous onset, the other component of the disease occurs mostly within 5 years. While Kammar et al8 and Robert et al9 have reported that the asymmetric oligoarthritis is the commonest subtype, other studies3,10 have reported that symmetric polyarthritis occurs most frequently in PsA. Knee was the commonest joint involved in our study. Robert et al9 have reported that metatarsophalangeal joint is more frequently involved and Backer et al16 noted shoulder as the commonly involved joint. Danda et al have noted disproportionate swelling of interphalangeal joint of thumb in 28.7% of 176 patients of psoriatic arthropathy and claimed that any patient with this finding had 84% chance of having psoriatic arthropathy.17 But we didn’t come across with such observation. As reported by Oriente et al,18 we too observed psoriasis vulgaris as the commonest skin lesion and there was no significant relation between arthritis subtypes and skin subtypes. Scalp is the most common hidden site but we have also seen skin lesions in other hidden areas like umbilicus, natal cleft, behind the ear and beneath the breasts. Nail dystrophy and sausage digits were other common features in our study as in other studies.12,19 Even though PsA is an inflammatory arthritis, ESR and CRP were found to be normal in many of our patients and similar observations had also been made in other studies.3,20 In summary, psoriatic arthritis is a male predominant disease, occurring more commonly in the 4th and 5th decades. Arthritis usually succeeds the skin lesion. If only arthritis or skin lesion develops initially, the other component of the disease (either skin lesion or arthritis respectively) mostly appears within 5 years. Symmetric polyarthritis is the commonest subtype and in the presence of sausage digits or DIP arthritis, one should suspect psoriatic arthritis even in the absence of psoriatic skin or nail lesions, as skin lesions may appear later in 10-20% of patients. Psoriasis vulgaris is the most common skin lesion. The commonest hidden site is the scalp where one should search for the skin lesion. ESR and CRP can be normal in psoriatic arthritis. Gladman et al3 Singh et al10 Subtypes Our study (n=116) (n=220) (n=33) (%) (%) (%) Symmetric 48.3 45 75.8 polyarthritis Asymmetric 37.1 21 — oligoarthritis Spondylo- 11.2 2 12.1 arthropathy DIP arthritis 2.6 16 6.1 alone Arthritis mutilans 0.86 16 6.1 Table 3 : Joints involved in psoriatic arthritis Baker et al16 Robert et al9 Joints involved Our study (n=116) (n=53) (n=168) (%) (%) (%) Upper limb DIP 32.8 29 26 } PIP 52.6 49 41 MCP 34.5 51 Wrist 35.3 30 40 Elbow 30.2 30 23 Shoulder 25.9 47 29 Lower limb DIP & PIP 33.6 — 26 MTP 19.8 — 53 Ankle 50 26 34 Knee 66.4 36 32 Hip 5.2 7 6 Table 4 : Other features of psoriatic arthritis Shah et al12 Jarallah et al19 Features Our study (n=116) (n=102) (n=40) (%) (%) (%) Inflammatory back pain 25.9 - 40 Sausage digit 19 29.4 30 Enthesitis 7.8 2.9 7.5 Tenosynovitis 2.6 - - Eye lesions 1.7 2 - Deformities 3.4 - - 12.7% of patients respectively. ELISA for HIV infection was positive in one patient (2.3%) out of 44 patients tested. Regarding radiographic features, 13 patients had sacroiliitis (11.2%) of which six had bilateral involvement. In the lumbar spine, non-marginal syndesmophytes were noted in six patients (5.2%) and squaring of the vertebrae in one patient (0.86%). Of the six patients with joint erosions (5.2%), five had it in the PIP/ DIP of their hands and one in the MTP of the foot. In four patients tendoachilles calcification (3.5%) was observed. One patient had ‘pencil-in-cup’ deformity (0.86%). The mean duration was 34.2 months for the peripheral joint erosions to occur in our patients. REFERENCES 1. Alibert JL. Precis therique sur les maladies de la peau. Paris, Caille et Ravier 1818 2. Lawrence RC, Hochberg MC, Kelsey JL, et al. Estimates of JAPI • VOL. 51 • NOVEMBER 2003 1067

  4. the prevalence of selected arthritis and musculoskeletal arthritis - a study of 102 patients. J Indian Rheumat Assoc diseases in the United States. J Rheumatol 1989;16:427-41. 1995;3:133-36. 3. Gladman DD, Schuckett R, Russel ML, Thorne JC and 13. Dafna D. Gladman, Proton Rahman. Psoriatic arthritis. In: Schachter RK. Psoriatic arthritis an analysis of 220 patients. Shaun Ruddy, Edward D. Harris, Clement B. Sledge, Ed., Quart J Med 1987;62:127-41. Kelly’s textbook of Rheumatology - 6th edition. W. B. Saunders company. 2001;2:1071-79. 4. Defna D Gladman. Psoriatic arthritis. In: Maddison PJ, David A. Icenberg, Patricia Woo and David N Glass Ed., Oxford 14. Nadkar MY, Kalgikar A, Samant RS, Borges NE. Clinical profile Text Book of Rheumatology- 2nd edition. Oxford University of psoriatic arthritis. J Indian Rheumat Assoc 2000;8(supple.1):S Press 1998;2:1071-83. 40. 5. Abu - Shakra M, Gladman DD. Aetiopathogenesis of psoriatic 15. Pranesh Nigam, Anil KR, Srivastac, Uxa AK, Muhija RD, Jain arthritis. Rheumatol Rev 1994;3:1-7. RX. Psoriatic arthritis: A clinico- radiological study. J Indian Rheumat. Assoc 1998;6: 89. 6. Moll JMH, Wright V. Psoriatic arthritis. Semin Arthritis Rheum 1973;3:55-78. 16. Baker H, Golding DN, Thompson M. Psoriasis and arthritis. Ann Int Med1963;58:909-25. 7. Veale D, Rogers S, Fitzgerald O. Classification of clinical subsets in psoriatic arthritis. Br J Rheum 1994;33:133-8. 17. Debashish Danda, Cherian AM, Jayaseelan L. Disproportionate swelling of interphalangeal joint of thumb: 8. Kammer GM, Soter NA, Gibson DJ, Schur PH. Psoriatic Is it unique to psoriatic arthropathy? J Indian Rheumat Assoc arthritis: A clinical, immunologic and HLA study of 100 2000;8:1-4. patients. Semin Arthritis Rheum 1979;9:75-97. 18. Oriente P, Biondi Oriente C, Scarpa R. Psoriatic arthritis: 9. Robert MET, Wright V, Hill AGS, Mehra AC. Psoriatic arthritis Clinical manifestations. In: Wright V and Helliwell P. Ed., - follow up study. Ann Rheum Dis 1976;35:206 -19. Clinical Rheumatology. Bailliere Tindall 1994;8:277-94. 10. Singh YN, Verma KK, Ashok kumar, Malaviya AN. 19. Al-Jarallah KF, Al-Awadi A, Shehab D, Al-Salim I, Al-Saeid Methotrexate in psoriatic arthritis. J Assoc Physicians India KM, Malaviya AN. Pattern of psoriatic arthritis in Kuwait- A 1994;42:860-62. hospital based study. APLAR J Rheumatol 1997;1:6-9. 11. Southwood TR, Petty RE, Malleson PN, et al. Psoriatic arthritis 20. Gladman DD, Anhorn KAB, Schachter RK, Mervart H. HLA in children. Arthritis Rheumat 1989;32:1007-13. antigens in psoriatic arthritis. J Rheumatol 1986;13:586-92. 12. Shah NM, Mangat G, Balakrishnan C, Joshi VR. Psoriatic DOCTOR 2002 Software A highly advanced, easy to use, economical and revised medical software package made just for you. Clinical : Case sheets and speciality sheets; Prescription Autodose, AutoAllergy, contraindication, interaction alert, Fonts option (Hindi/Tamil etc). Allows auto filling with very little typing needed. Detailed Lab, PDR, Auto Casesummary, Certificates, letters; Detailed Diet adviser; Administrative : Appointment scheduler; Finance billing; Salary, room manpower management; Drugstore, Detailed Pt. Statistics, and inventory. Secure, and NETWORK ready. Others : Web Compatible-send case summary, reports by e-mail etc. Educative : Disease guidelines and Journal reference; Medical photographs and graphs; patient education videos and printouts. Widely used, Reliable. Saves Life, Time and Money. No learning required. Hospital pack, excl. medicine, surgery, OBG, clinic packs available. Address : MEDISOFT, Achutha Warrier Lane, Cochin, Kerala 682035 Ph 09847294414 E-M : OR Web : Rs 8000 only. 1068 JAPI • VOL. 51 • NOVEMBER 2003