Quantification of radiological damage in inflammatory arthritis: rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis

Quantification of radiological damage in inflammatory arthritis is important. It has proven its value in clinical trials, but its use in clinical practice is becoming more important as well. Scoring methods for rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis are available. These differ in the joints and features assessed. This results in differences in the scoring range, but also in the method of performance. The various methods for the three diseases are detailed in this chapter. Most information is available for rheumatoid and for this disease the relationship between radiological damage and long-term outcome is summarised.     

A case of psoriatic arthritis without the appearance of psoriatic skin or nail lesions for 21 years

In some patients with psoriatic arthritis, arthritis may precede psoriatic skin lesions. In fact, psoriatic skin lesions may not develop for more than 10 years after the onset of arthritis. Making diagnostic and therapeutic decisions in such patients is therefore challenging. We describe a case with classic features of psoriatic arthritis without psoriatic skin or nail lesions for 21 years. We suggest that recognition of psoriatic arthritis sine psoriasis is important for selecting appropriate therapy to prevent joint damage.     

Clinical features of psoriatic arthritis

Psoriatic arthritis (PsA) is associated with decreased quality of life. As delayed diagnosis may lead to progressive joint destruction and long-term disability, the key clinical features of PsA should be recognizable to a wide range of clinicians to facilitate early diagnosis. In addition to assessment and identification of skin and nail lesions, which occur in up to 85% of those with musculoskeletal manifestations, clinicians should be aware of both the peripheral and axial manifestations of musculoskeletal disease reviewed here. Peripheral joint diseases include polyarticular, oligoarticular, distal, and arthritis mutilans subtypes, and cognizance of these patterns of disease, as well as periarticular manifestations, including dactylitis and enthesitis, is useful for swift diagnosis of PsA. Axial psoriatic arthritis (axial PsA), also known as the spondylitis subtype, may be limited to the spine and sacroiliac joints, but may also affect peripheral structures. Meticulous history-taking and physical examination and familiarity with appropriate imaging studies are often necessary to distinguish axial-PsA from other differential diagnoses. Swift diagnosis and treatment are necessary to both control PsA disease and mitigate the risks of the many associate comorbidities that may accompany it.     

Pattern of psoriatic arthritis in an Asian population (Malaysia)

Objective: To profile the pattern of psoriatic arthritis (PsA) and its relationship to disease duration. Methods: Forty‐six consecutive patients with PsA were entered into a cross‐sectional study. Demographic data, disease duration and disability were recorded. Joint involvement was documented at 6 months from onset and at presentation. X‐rays of the sacroiliac (SI) joints, thoracolumbar spine, and hands were taken. HLA B27 typing was done. Results: The male : female ratio was 2.3 : 1, mean age at onset of arthritis was 35.8 years and mean duration of PsA was 4.2 years. Oligoarticular involvement predominated (63%) at onset. Progression from oligoarthritis to polyarthritis occurred largely in the second year; 65.2% reported asymmetrical disease at onset while 50% had asymmetrical disease when disease duration was > 1 year. The frequency of involvement at onset was as follows: sausage toes, metatarsophalangeals (MTPs) and interphalangeals (IPs) in 50% (each), proximal interphelangeals (PIPs) in 47.8%, sausage fingers 34.7% and knees 30%. With mean duration of 4.2 years it was: sausage toe 71.1%, IP 69.5%, PIP and MTP 63%, knees 60.8%, distal interphalangeals (DIPs) 54.3%, sausage finger 52.1%, wrist 47.8%, followed by neck and back pain. Disability related to lower limb functions predominated and occurred early. Forty‐one percent had radiological sacroiliatis/spondylitis and 46% had erosive arthritis in the hands; 10.2% were HLA B27 positive. Conclusion: PsA was progressive, starting predominantly as an asymmetrical oligoarthritis and becoming largely polyarticular within 2 years from onset. Lower limb disability was evident early and erosive changes in hand X‐rays were seen in more than half the patients after 1 year.     

A method to score radiographic change in psoriatic arthritis

INTRODUCTION: Radiographic features of psoriatic arthritis (PsA) are very characteristic and differ from those observed in rheumatoid arthritis, especially in two aspects: 1) the distribution of affected joints (i.e. DIP joints), 2) the presence of destructive changes and bone proliferation at the same time. A scoring method for PsA, therefore, has to account for these characteristics of PsA. OBJECTIVE: To develop, describe and validate a method for scoring radiographic changes in patients with PsA. DESCRIPTION OF THE METHOD: Forty joints of the hands and feet are scored for destruction and proliferation. In the destruction score (DS) grading on a 0-5 scale is based on the amount of joint surface destruction: 0 = normal, 1 = one or more erosions with an interruption of the cortical plate of > 1 mm with destruction of the total joint surface up to 10%, 2 = 11-25%, 3 = 26-50%, 4 = 51-75%, 5 = > 75% joint surface destruction. The proliferation score (PS) sums up any kind of bony proliferation typical for PsA; graded 0-4: 0 = normal, 1 = bony proliferation of 1-2 mm or bone growth < 25% of the original size (diameter), 2 = bony proliferation 2-3 mm or bone growth 25-50%, 3 = bony proliferation > 3 mm or bone growth > 50%, 4 = bony ankylosis. The DS (0-200) and the PS (0-160) can be summed up to the total score (0-360). VALIDATION OF THE METHOD: To validate the method x-rays of 20 patients with active PsA taken 3 years apart were read twice in pairs, knowing the chronological order but not knowing demographic, clinical or laboratory data of the patients. The data were analyzed with a hierarchical analysis of variance model. RESULTS: There was good agreement between the first and the second reading of the same rater and between the two raters regarding the destruction score. The agreement regarding the proliferation score was lower but still acceptable. The reliability of the method to describe change over time--relation of progression (intra-patient variance) to the measurement error (inter-rater variance)--was 3.9 for the DS, 2.8 for the PS and 4.1 for the total score. The minimal detectable change when the readings of two raters were compared (inter-rater MDC) was 5.8, 5.0 and 4.6%, respectively of the maximum possible score for the destruction, the proliferation and the total score. These data compare very well with the results of standard scoring methods in rheumatoid arthritis. CONCLUSION: We propose a method for scoring radiographic change in psoriatic arthritis which reliably quantifies the progression of the disease seen on radiographs.     

Case series analysis of psoriatic arthritis: a two‐centre experience

Aim: To provide the first case series analysis for psoriatic arthritis (PsA) in Malaysia. Methods: Patient records were studied from rheumatology clinics in Universiti Kebangsaan Malaysia Hospital and Putrajaya Hospital in Malaysia. Results: Thirty‐one patients from two rheumatology centres were studied. Thirteen patients (41.9%) were male and 18 patients (58.1%) were female. Nineteen patients (61.3%) were Malays, four (12.9%) were Chinese, seven (22.6%) were Indians and one (3.2%) was a Sikh. The majority of patients were in the > 50 years age‐group (11 [35.5%]) followed by the 41–50 years age‐group (10 [32.3%]). Thirteen patients (41.9%) had the disease since 41–50 years of age. Twenty‐three patients (77.4%) had no family history of PsA. Twenty‐three patients (74.2%) had psoriasis first, seven (22.6%) had arthritis first and one (3.2%) developed psoriasis and arthritis at the same time. Twenty‐four patients (77.4%) had positive activity correlation for skin and arthritis. The majority of patients had symmetrical arthritis (20 [64.5%]) and chronic plaque‐like lesions (22 [71.0%]). These patients were on NSAIDS and methotrexate (14 [45.2%]). One patient (3.6%) needed surgery for joint replacement. Conclusion: Patients who were diagnosed as having PsA were Malays, age group of more than 50, disease onset at 41–50 years of age, no family history, had symmetrical and chronic plaque lesions, had psoriasis first and needed NSAIDS and methotrexate.     

A comparison of the performance characteristics of classification criteria for the diagnosis of psoriatic arthritis

OBJECTIVE: To compare the accuracy of published classification criteria for the diagnosis of psoriatic arthritis (PsA) and to see whether data-derived classification criteria would be more accurate. METHODS: Data were abstracted from case-note review and radiographic review of patients identified with PsA or rheumatoid arthritis (RA) from 2 clinical disease registers. Each patient was classified according to 7 criteria sets. The test performance characteristics were compared using conditional logistic regression analysis. In an attempt to overcome the problems of the diagnostic gold standard, latent class analysis also was used to calculate test-performance characteristics. Classification and regression-tree methodology was used to derive new criteria and to indicate the diagnostic importance of particular data items, especially rheumatoid factor (RF). RESULTS: Four hundred ninety-nine patients were identified with RA (n=156) or PsA (n=343). Excluding the criteria of Fournie, which could not be applied in 24% of subjects, 446 cases could be classified by all of the other 6 methods. The most sensitive criteria for the diagnosis of PsA were those of Vasey and Espinoza, McGonagle, and Gladman (99%), whereas the others were significantly less sensitive (between 56% and 94%). The specificity of the criteria was high and statistically similar (between 93% and 99%). The Fournie criteria were the most difficult to use, whereas the Vasey and Espinoza and Moll and Wright criteria were the easiest (98% of subjects were able to be classified). A 2-latent class model found very similar test-performance characteristics. Logistic regression and classification and regression-tree models suggested that negative RF was not necessary for diagnosis in the presence of other characteristic features of PsA. CONCLUSIONS: Apart from the Bennett and European Spondyloarthropathy Study Group criteria, which have inadequate sensitivity, the published classification criteria for PsA have similar test-performance characteristics. These data suggest that the criteria proposed by Vasey and Espinoza, Gladman, or McGonagle are the most accurate and feasible in distinguishing between PsA and RA. Relevance International agreement about classification criteria for PsA will assist the interpretation of clinical and epidemiologic research. However, further prospective studies on unselected patients with and without PsA, including controls with non-rheumatoid inflammatory arthritis, are required to confirm these findings.     

Prevalence and risk factors of atherosclerosis in patients with psoriatic arthritis

OBJECTIVES: To evaluate the extent of subclinical atherosclerosis by measuring the intima-media wall thickness (IMT) of the common carotid artery in patients with psoriatic arthritis (PsA) and to identify vascular risk factors associated with PsA. METHODS: Forty-seven patients with PsA were compared with 100 allegedly healthy subjects. Carotid duplex scanning was used to measure common carotid artery IMT. Traditional risk factors, such as gender, age, body mass index (BMI), hypertension, smoking, and lipids were checked. Assessment of PsA activity included clinical patterns of involvement, degree of severity, duration of morning stiffness, number of tender and swollen joints, degree of pain and fatigue, the Bath Ankylosing Spondylitis Disease Activity Index, the Psoriasis Area and Severity Index, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and fibrinogen. RESULTS: The average IMT (mean +/- standard deviation) for PsA patients was significantly higher compared with controls (0.76 +/- 0.11 versus 0.64 +/- 0.27, respectively, P < 0.00001) for the whole group and after adjustment for age, gender, BMI, hypertension, and hyperlipidemia. The PsA subjects had significantly higher levels of hypertension, hyperlipidemia, ESR, CRP, and fibrinogen, and their average IMT significantly correlated with age, BMI, duration of skin and joint disease, spine involvement, ESR, and fibrinogen. IMT did not correlate with the presence of oligo- or polyarthritis but was increased in patients with clinical spinal involvement. IMT was not associated with the degree of severity or the use of different therapies for PsA, including methotrexate or tumor necrosis factor-alpha-blocking agents. CONCLUSIONS: PsA patients exhibited greater IMT than healthy controls. Increased IMT independently correlated with parameters of disease activity and conventional risk factors of atherosclerosis.     

Cardiovascular risk profile of patients with spondylarthropathies, particularly ankylosing spondylitis and psoriatic arthritis

OBJECTIVE: To evaluate the cardiovascular risk profile of spondylarthropathy patients, particularly ankylosing spondylitis and psoriatic arthritis. METHODS: A Pubmed literature search was performed to collect English-language articles for this clinically orientated review. Studies were selected if they included (cardiovascular) mortality and morbidity and/or data about cardiovascular risk factors in spondylarthropathies. RESULTS: Ankylosing spondylitis as well as psoriatic arthritis appear to be associated with an increased cardiovascular mortality and morbidity. Several factors, ie, smoking, altered lipid profile, hypertension, increased fibrinogen level, enhanced number of platelets, and hypercoagulability might explain the enhanced cardiovascular risk. Moreover, a decline in physical activity, the presence of HLA-B27, and inflammation may play a role. Finally, undertreatment of cardiovascular morbidity also may contribute to the higher cardiovascular risk. CONCLUSIONS: The available data indicate an increased cardiovascular risk in spondylarthropathy patients, particularly those with ankylosing spondylitis and psoriatic arthritis. RELEVANCE: Rheumatologists should be aware of the enhanced cardiovascular risk in patients with ankylosing spondylitis and psoriatic arthritis. If modifiable cardiovascular risk factors are identified, treatment could ultimately result in a lower cardiovascular morbidity and mortality.