Psoriatic Arthritis - Journal of the Association of Physicians of India

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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 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 Features

Fig. 1 : Peak age incidence. In males 28 out of 78 patients (35.9%) and 25 out of 78 patients (32.1%) had psoriatic arthritis in the 4th and 5th decades respectively. In females 16 out of 38 patients (42.1%) and 11 out of 38 patients (28.9%) had psoriatic arthritis in the 4th and 5th decades respectively. 1066

Our study Shah et al12 Pranesh et al15Nadkar et al14 (n=116) (n=102) (n=12) (n=54)

Mean age (yrs) 40.9 Sex ratio(M:F) 2:1 Mean duration bet. 2.8 arthritis and skin (yrs) Arthritis before 12.1 skin lesion (%) Arthritis after 50.8 skin lesion (%) Arthritis along 37.1 with skin lesion (%)

38.17 1.8 :1 2.5

40 1:2 —

39.9 1.45 :1 —

5.8

8.3

35.2

63.8

50

57.4

19.7

41.7

7.4

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Table 2 : Psoriatic arthritis - subtypes Subtypes

Symmetric polyarthritis Asymmetric oligoarthritis Spondyloarthropathy DIP arthritis alone Arthritis mutilans

DISCUSSION

Our study (n=116) (%)

Gladman et al3 (n=220) (%)

Singh et al10 (n=33) (%)

48.3

45

75.8

37.1

21



11.2

2

12.1

2.6

16

6.1

0.86

16

6.1

Table 3 : Joints involved in psoriatic arthritis Joints involved

Upper limb DIP PIP MCP Wrist Elbow Shoulder Lower limb DIP & PIP MTP Ankle Knee Hip

Our study (n=116) (%)

Baker et al16 (n=53) (%)

Robert et al9 (n=168) (%)

32.8 52.6

29

26 49

34.5 35.3 30.2 25.9

}

33.6 19.8 50 66.4 5.2

41 30 30 47

51 40 23 29

— — 26 36 7

26 53 34 32 6

Table 4 : Other features of psoriatic arthritis Features

Inflammatory back pain Sausage digit Enthesitis Tenosynovitis Eye lesions Deformities

Our study (n=116) (%)

Shah et al12 (n=102) (%)

Jarallah et al19 (n=40) (%)

25.9 19 7.8 2.6 1.7 3.4

29.4 2.9 2 -

40 30 7.5 -

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.

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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 al 8 and Gladman et al 3 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 al 9 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.

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

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the prevalence of selected arthritis and musculoskeletal diseases in the United States. J Rheumatol 1989;16:427-41.

arthritis - a study of 102 patients. J Indian Rheumat Assoc 1995;3:133-36.

3.

Gladman DD, Schuckett R, Russel ML, Thorne JC and Schachter RK. Psoriatic arthritis an analysis of 220 patients. Quart J Med 1987;62:127-41.

4.

Defna D Gladman. Psoriatic arthritis. In: Maddison PJ, David A. Icenberg, Patricia Woo and David N Glass Ed., Oxford Text Book of Rheumatology- 2nd edition. Oxford University Press 1998;2:1071-83.

13. Dafna D. Gladman, Proton Rahman. Psoriatic arthritis. In: Shaun Ruddy, Edward D. Harris, Clement B. Sledge, Ed., Kelly’s textbook of Rheumatology - 6th edition. W. B. Saunders company. 2001;2:1071-79.

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Abu - Shakra M, Gladman DD. Aetiopathogenesis of psoriatic arthritis. Rheumatol Rev 1994;3:1-7.

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Moll JMH, Wright V. Psoriatic arthritis. Semin Arthritis Rheum 1973;3:55-78.

7.

Veale D, Rogers S, Fitzgerald O. Classification of clinical subsets in psoriatic arthritis. Br J Rheum 1994;33:133-8.

8.

Kammer GM, Soter NA, Gibson DJ, Schur PH. Psoriatic arthritis: A clinical, immunologic and HLA study of 100 patients. Semin Arthritis Rheum 1979;9:75-97.

9.

Robert MET, Wright V, Hill AGS, Mehra AC. Psoriatic arthritis - follow up study. Ann Rheum Dis 1976;35:206 -19.

10. Singh YN, Verma KK, Ashok kumar, Malaviya AN. Methotrexate in psoriatic arthritis. J Assoc Physicians India 1994;42:860-62. 11. Southwood TR, Petty RE, Malleson PN, et al. Psoriatic arthritis in children. Arthritis Rheumat 1989;32:1007-13. 12. Shah NM, Mangat G, Balakrishnan C, Joshi VR. Psoriatic

14. Nadkar MY, Kalgikar A, Samant RS, Borges NE. Clinical profile of psoriatic arthritis. J Indian Rheumat Assoc 2000;8(supple.1):S 40. 15. Pranesh Nigam, Anil KR, Srivastac, Uxa AK, Muhija RD, Jain RX. Psoriatic arthritis: A clinico- radiological study. J Indian Rheumat. Assoc 1998;6: 89. 16. Baker H, Golding DN, Thompson M. Psoriasis and arthritis. Ann Int Med1963;58:909-25. 17. Debashish Danda, Cherian AM, Jayaseelan L. Disproportionate swelling of interphalangeal joint of thumb: Is it unique to psoriatic arthropathy? J Indian Rheumat Assoc 2000;8:1-4. 18. Oriente P, Biondi Oriente C, Scarpa R. Psoriatic arthritis: Clinical manifestations. In: Wright V and Helliwell P. Ed., Clinical Rheumatology. Bailliere Tindall 1994;8:277-94. 19. Al-Jarallah KF, Al-Awadi A, Shehab D, Al-Salim I, Al-Saeid KM, Malaviya AN. Pattern of psoriatic arthritis in Kuwait- A hospital based study. APLAR J Rheumatol 1997;1:6-9. 20. Gladman DD, Anhorn KAB, Schachter RK, Mervart H. HLA antigens in psoriatic arthritis. J Rheumatol 1986;13:586-92.

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