Clin Rheumatol DOI 10.1007/s10067-015-2927-9
CASE BASED REVIEW
Erosive osteoarthritis, psoriatic arthritis and pseudogout; a casual association? Ariela Hoxha 1 & Amelia Ruffatti 1 & Enrico Alberioli 2 & Mariagrazia Lorenzin 1 & Francesca Oliviero 1 & Elena Mattia 1 & Leonardo Punzi 1 & Roberta Ramonda 1
Received: 12 February 2015 / Accepted: 22 March 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract According to recent hypothesis, the inflammation has a pivotal role in the onset and progression of erosive hand osteoarthritis (EHOA), psoriatic arthritis (PsA) and chondrocalcinosis (CC)/pseudogout. Albeit, it has been recognised for years as an association between EHOA and radiographic evidence of CC, but there are few reports of coexistence of microcrystalline arthritis and PsA. This is the first report that described a clinical experience concerning two consecutive cases of patients presented with EHOA, PsA and pseudogout. Two Caucasian women of 71 and 85 years old with a history of OA and mild psoriasis are presented with tenderness and swelling of first interphalangeal (IP) and wrist joint, respectively. Arthrocentesis performed at the first IP and wrist joint, respectively, showed an inflammatory synovial fluid with presence of calcium pyrophosphate dehydrate crystals. X-rays of hands, feet and knees showed characteristic features of EHOA, PsA and CC. Furthermore, HLA typing evinces the presence of HLA C*06; DRB*01 07 and HLA C*07; DRB*01 *11 alleles, respectively, predisposing factors of these inflammatory diseases. The relationship between these aggressive rheumatic diseases along with their clinical, radiographic, laboratory and genetic features is discussed.
Keywords Chondrocalcinosis . Erosive hand osteoarthritis . Osteoarthritis . Pseudogout . Psoriatic arthritis
* Ariela Hoxha
[email protected] 1
Rheumatology Unit, Department of Medicine DIMED, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
2
Department of Medicine, Section of Radiology, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
Introduction Erosive hand osteoarthritis (EHOA), an uncommon variant of osteoarthritis (OA), is a prevalent, complex, disabling disease of the joints, characterised by inflammation and degeneration of the distal and proximal interphalangeal (IP) joints with subsequently degradation of the hyaline articular cartilage, erosions and remodelling of the subcondral bone with sclerosis and osteophyte formation leading to joint failure [1, 2]. Psoriatic arthritis (PsA), on the other hand, is an inflammatory arthritis, associated with psoriasis, which over the skin involvement target the spine, the peripheral joints and the entheses [3–5]. PsA can lead to destructive bone loss, and 67 % of PsA patients exhibit signs of erosive bone disease [3]. Pseudogout is an acute manifestation of chondrocalcinosis (CC); this latter is characterised by the deposition of calcium pyrophosphate dehydrate (CPP) crystals and calcification in X-rays [6]. The most commonly affected sites are knees, wrists, and symphysis pubis [6]. According to recent hypothesis [7], inflammation has a pivotal role in the onset and progression of all these diseases. In particular, EHOA called Binflammatory arthritis^ by Ehrlich [8, 9] focused on its inflammatory aspects. However, not all investigators agree that EHOA is a nosologic entity apart from the classic HOA; even some of them consider it a transitional form [10, 11]. Furthermore, PsA is considered the most intriguing inflammatory arthropathy in the differential diagnosis of EHOA [1], as both conditions preferentially affect distal (D) IP joints. Thus, it might be difficult to make the difference by clinical aspects, especially when in PsA, there is an absence of clear skin involvement or there is an exclusive involvement of DIP, as in Bclassic^ variant of Moll and Wright [3]. These assumptions lead to a possible relationship between these diseases. On the other hand, it has been reported [12] that CPP crystals may be found in joint diseases along with previous established
Clin Rheumatol
diagnosis. CPP crystals particularly may be found in synovial fluid (SF) of patients with OA who are relatively asymptomatic, as well as, from those who are experiencing an acute flare up of joint pain due to an attack of pseudogout [6]. Sometimes, these forms can be misinterpreted resulting on difficulties in the differential diagnosis. This is a report that describes a clinical experience concerning two consecutive patients presented with EHOA, PsA and pseudogout. The clinical, radiographic, laboratory and genetic features of EHOA, PsA and CC are shown in Table 1. The aim of this report is to evaluate the association and the relationship between these aggressive rheumatic diseases.
Materials and methods There are considered two consecutive cases with signs and symptoms common to the EHOA, PsA and pseudogout. The study is carried out in accordance with the principles outlined in the Helsinki Declaration, and all participants gave informed consent. Case 1 A 71-year-old woman with a history of 17 years of OA referred to Rheumatology Unit, University of Padua, with tenderness of first IP joint of the right hand. Physical examination revealed swelling and tenderness of first IP joint of the right hand and tenderness of several proximal (P) IP joints of the hands besides the fifth metatarsal phalangeal (MP) joint of left foot and tarsal-metatarsal (TM) bilateral joints. She referred mild psoriasis of scalp. Arthrocentesis performed at the first IP joint and, surprisingly, showed an inflammatory SF with the presence of CPP crystals as seen in Fig. 1. The X-rays of the hands showed calcifications of the first IP joint and triangular ligament of the carpus, peculiar of CC (Fig. 1). Moreover, marked asymmetric joint space narrowing (JSN), central erosion of the second DIP joints, the so-called gull wing appearance along with osteophytes and sclerosis and central collapse typical signs of EHOA were seen too (Fig. 1). To note, radiopaque deposits in meniscus and marked JSN, with large marginal osteophytes, peculiar of CC and OA were observed in the X-rays of the knees (Fig. 1). Interestingly, X-rays of feet showed characteristic findings of arthritis as symmetric JSN and marginal erosions of the TM joints with ankylosis as seen in Fig. 2. HLA typing, furthermore, evinces the presence of HLA C*06; DRB*01 07 alleles. Diagnosis of EHOA, PsA and pseudogout has been made, and therapy with low-dose methylprednisolone, hydroxychloroquine and colchicines was started. Actually, the patient is recovering quite well, by continuing the therapy with colchicines and low-dose methylprednisolone during arthritis relapses, while
hydroxychloroquine has been stopped due to mild impairment of macular pigmentation. Case 2 An 85-year-old woman, known affected by diffuse OA, admitted to Rheumatology Unit, University of Padua, because of acute arthritis of the left wrist. The patient presented appeared with tenderness, swollenness and warmth of left wrist along with high levels of C-reactive protein. Physical examination confirmed the arthritis of the left wrist. Moreover, onicopathy was been observed too. Ultrasound image of the left wrist showed mild intraarticular fluid-containing hyperecogenic foci and marked hypertrophy with hypervascularity of synovial membrane along with hyperecogenicity of triangular ligament. Aspiration joint was performed at the left wrist that showed an inflammatory SF with the presence of extracellular CPP crystals. Calcification of the triangular ligament of the carpus has been seen in the hand X-rays characteristic of CC along with signs of EHOA of DIP and PIP joints (Fig. 3). Surprisingly, characteristic findings of PsA (Fig. 3) such as symmetric JSN, subcondral sclerosis and marginal erosions determining the typically pencil in cup lesion at second and third DIP of the left hand were seen too. Furthermore, HLA typing showed the presence of HLA C*07 and DRB*01 *11 allele. Diagnosis of EHOA, PsA and pseudogout has been made, and therapy with methotrexate 7.5 mg per week, lowdose methylprednisolone and colchicines was started. Actually, the patient is recovering quite well by continuing the therapy with methotrexate and low-dose methylprednisolone, while colchicines has been suspended after 2 days due to diarrhoea.
Discussion Albeit, it has been recognised for years as an association between EHOA and radiographic evidence of CC, but there are few reports of coexistence of microcrystalline arthritis and PsA [16, 17]. This is the first report, as far as we know, that documents the co-occurrence of EHOA, PsA and pseudogout. The coexistence of these three different rheumatic disorders leads to assume a possible association or common predisposing condition. Classically, the OA is defined to be a non-inflammatory joint disease, in order to distinguish it from the so-called arthritides, characterised by the presence of an inflammatory arthritis. However, accumulating evidence [2] suggests that inflammation of various types plays a key role in the pathogenesis of OA, as demonstrated by the presence of inflammatory features in the synovial membrane of at least 50 % of patients with OA. The only OA variant proposed and classified as inflammatory is the one of the hand [7, 8]. In fact,
Frequently Frequently
Sometimes during flares Sometimes during flares
HLA C*6, C*7 [14]
Sometimes present Frequent Frequent Absent
HLA A23, DRB*01 07, 11 [13]
All joints (more frequently knee and wrist) Uncommon
All joints (DIPs involvement is Bclassic^ feature) Marginal erosions in proximal plate and marginal periostitis in the distal plate at DIPs
DIPs, PIPs Central erosion in the proximal plate and marginal proliferation in the distal plate of DIPs and PIPs Absent Frequent Sometimes Absent
SNPs for ANKH [15]
During acute attack During acute attack
Absent Absent Absent Present
During acute attack During acute attack During acute attack Uncommon Usually monoarthritis
Frequent Frequent, recurrent during flare Persistent (>30 min) Sometimes Oligo and/or poliarthritis
Silent/abrupt During acute attack During acute attack
Pseudogout
Frequent, recurrent during the flares Frequent, chronic, recurrent Frequent (
