Introduction
Psoriatic arthritis (PsA) is one of the major inflammatory diseases of the joints and spine. This disease, associated with skin psoriasis, is characterized by a chronic progressive course and leads to the development of destructive arthritis with various types of bone resorption, sacroiliitis and spondylitis, as well as numerous systemic manifestations. PsA are included in the group of HLA-B27-associated joint diseases, united in the group of seronegative spondylitis (SSA). At the same time, this disease differs from ankylosing spondylitis and other spondylitis with a particularly diverse clinical picture and the existence of only the syndromes inherent in it, for example, intermittent synovitis, palindromic rheumatism, or mutilating arthritis.
Skin psoriasis and PsA are ubiquitous. Psoriasis affects from 1% to 3% of the world's population, and arthritis, spondylitis or enthesopathy are observed in 14 to 47% of patients with this dermatosis [1, 3, 7]. The prevalence of PsA in the general population ranges from 0.04% to 1.4% [2, 5, 11]. The inflammatory process is limited not only to damage to the skin, nails and joints, but also extends to the tendon-ligament apparatus and internal organs, especially the heart, liver, kidneys [6, 7 ,8].
Often, PsA have an aggressive evolution already at an early stage of its appearance. Some patients with PsA have a persistent disability during the first 5 years of the disease. In general, this disease has a 59% increase in mortality in men and 65% in women, compared to the population level [4, 9]. It is known that 55% of patients with PsA with persistent continuous inflammatory activity after 10 years have 5 or more deformed joints, while they are already at an early stage of PsA, namely in the first two years of the disease, 27% of patients have erosive arthritis, and after another 2 years - in 47% [6, 11, 13, 14]. The rather rapid progression of this disease, difficulties in early diagnosis, disability, and decreased quality of life in the first years of the disease are the reason for detailed research of the early stage of PsA, and this problem seems especially relevant.
Purpose of the study
Research of clinical heterogeneity of early psoriatic arthritis and the possibility of early diagnosis.
Objectives of the study
Identification of the characteristics of joint syndrome and skin lesions in patients with early psoriatic arthritis;
Determining the variants of the joint syndrome and tracking their dynamics in the first 2 years of the disease;
Appreciation of the diagnostic significance of laboratory and instrumental methods in the early diagnosis of psoriatic arthritis;
Determination of the sensitivity of existing criteria for psoriatic arthritis at an early stage of the disease.
Materials and methods
General characteristics of patients
The current study included 104 patients with PsA who were admitted to the rheumatology and arthrology wards of the Republican Clinical Hospital „Timofei Moşneaga” from 2003 to October 2021. The diagnosis of PsA was established on the basis of the specialized opinion of two qualified rheumatologists, the total evaluation of the individual manifestations of the disease, as well as the generally accepted criteria for CASPAR PsA [3, 12, 14] and particular, developed by a regressive method of experts (Table 1).
The main signs of CASPAR criteria include arthritis, spondylitis or enthesitis. The greatest diagnostic difficulty (2 points) of the additional criteria has psoriasis detected at the time of examination, the remaining signs, which include onychodystrophy, dactylitis, seronegativity for rheumatoid factor (RF)/anti-CCP antibodies and radiological signs of periarticular proliferation are estimated at 1 point. APs can be confirmed if the patient has one or more main signs and 3 points of the additional ones.
Out of the contingent of patients 2 groups were formed (Table 2). The first group consisted of patients with early PsA (PsA-e) with a duration of the disease of less than 2 years (n=51), the second - late PsA (PsA-t), in which the duration of the disease was more than 2 years (n=53).
Clinical, instrumental and laboratory research methods
Generally accepted modern criteria have been used to analyze inflammatory activity, including TJC, SJC, the DAS28 combined index and BASDAI spondylitis activity index. The visual-analog scale (VAS) was used for subjective evaluation of pain by the patient. Skin syndrome was evaluated using the activity PASI index and the prevalence of psoriasis [2 ,6, 10, 11].
Also, very sensitive signs of PsA were taken into account, such as digital arthritis (damage to three joints of one finger) and dactylitis (diffuse thickening of the entire finger). When evaluating the dactylitis, attention was paid to the location of the affected fingers (hands and/or plants), the number (multiple dactylitis >3), as well as the duration of the inflammatory process (acute evolution < 3 months, chronic > 3 months.).
In the evaluation of enthesopathy, the score of the MASES enthesitis (Maastricht Ankylosing Spondylitis Enthesitis Score) [12, 13, 14] was used. The maximum score was 13 points. Pain was also taken into account in the region of plantar aponeurosis.
The studies of the general, biochemical clinical parameters of blood and urine tests were carried out by unified methods in the department of the clinical and diagnostic laboratory of the RCH „Timofei Moşneaga”. Immunological examination of patients was carried out in the laboratory of immunology and molecular biology.
Radiological examination of the hands, plants, pelvis, as well as according to the present indications of other joints and spine was carried out in the department of radiology. The radiological stage was determined according to the Steinbroker stages. To quantify the severity of bone cartilage damage, the modified Sharp/van der Heijde method for PsA was used to calculate the total number of erosions (maximum 5 points in the hands and 10 points in the legs) and the narrowing of the cracks in the joints of the hands and plants (maximum 4 points). The maximum score of erosion and narrowing of articular spaces in hands and plants in PsA was 518 points.
The ultrasound examination was performed in the rheumatology laboratory of the RCH „Timofei Mosneaga”. Ultrasound of the heel areas was carried out on the „Toshiba” apparatus using a linear sensor of several frequencies (4-13MHz) in the gray scale mode and with the Doppler energy technique. To assess pathological changes, a reduced GUESS account was used, which took into account the thickening of the Achilles tendon >5.29 mm, thickening of the planting aponeurosis >4.4 mm, preachillus bursitis, erosion of the posterior and lower surface of the heel bone, entesophytes of the posterior and lower surface of the heel bone. Bilaterally, the pathological changes of each study point were estimated at 1 point, while the maximum score was 14 points.
Magnetic resonance imaging (MRI) of the distal parts of the hands/plants was performed in the department of radiology, tomography and magnetic resonance using the Artoscan 0.2 T device (ESAOTE Biomedica, Italy) with the production of T1 and T2 weighted images (without/ with contrast with gadolinium) with the following parameters for the T1 weighted image: TR 500 ms, TE 18 ms, matrix size 256 x 192, FOV 200mm, section thickness 1 mm, distance 0.1. MRI was performed in coronal projection of metacarpal joints (MCF), proximal interphalangeal joints (IFP) and distal interphalangeal joints (IFD) at the same time. An evaluation of synovitis, tenosynovitis, edema of soft tissues, edema of the bone marrow, cysts, erosions was carried out.
Statistical analysis of the data was carried out on a personal computer using Microsoft Excel, the statistical package Statistics 9.0 and Epilnfo, version 5 using simple descriptive statistics. For quantitative traits that have a normal distribution, the results are presented in the form of mean values and standard average deviations (M±SD). For signs that do not correspond to the normal distribution, the median (Me) and the interquartile interval (25%; 75%) were used. To determine the reliability of differences in the average values of numerical parameters, the T-Student test was used, and in the absence of a normal distribution and the presence of a large data dispersion, the nonparametric method - the Mann-Whitney criterion. The analysis of the relationship between the two characteristics was carried out using the analysis of the non-parametric correlation using the Spearman method.
Results
1. Features of clinical expression of early psoriatic arthritis
The frequency of expression of individual clinico-anatomical variants of joint syndrome was different in patients with PsA-e and PsA-t (in PsA-e compared to PsA-t, the oligoarticular variant was significantly more likely to be observed (43.1% and 19%, respectively, p=0.01) and less often the variant of spondyloarthritis (7.8% and 19%, p=0.1), while the variant of polyarthritis (33.3% and 38%, p = 0,6) and distal interphalangeal (15,7% and 15%, p=0,9) were detected with the same frequency, as regards the mutilating variant, this was observed only in PsA-t.
The clinical expression of PsA-e in the first 2 years was not only different in polymorphism, but also changed as the disease developed (Table 4). In the first 3 months in PsA most often involved metatarsophalangeal joints (MTF) (41.2%) and IFP (37.3%) in plants. By the end of the 2nd year of the disease, damage to the joints of the hands and plants occurred with approximately the same frequency. Thus, DIP arthritis of the hands was detected in 33.3% of patients and plants - in 42.9%, PIP arthritis - in 47.6% and 52.4%, respectively, MCF - in 52.4% and MTF - in 57.1%.
In the first 3 months PsA recorded isolated cases of damage to the large joints of the upper extremities, and quite often - large joints of the lower extremities (knees and talocrural). As the disease develops, involvement in the pathological process of the joints of the upper extremities occurs with approximately the same frequency as the lower ones.
DIP arthritis was detected in 18 (35.3%) patients with PsA-e, while the distal variant of the joint syndrome (more than 50% of the joint lesions of this localization) was observed in 8 (15.7%) patients with PsA-e. In patients with DIP lesions, in addition to arthritis of this localization, multiple lesions of the small joints of the hands and plants were observed, while high inflammatory activity was observed more often according to the DAS28 indicator. Patients with DIP arthritis were characterized by more severe destruction of bone cartilage. Thus, in the group of patients with DIP lesions, erosion of this localization was detected in 4 (22,2%) patients, while in the group of patients without DIP lesions - only in 1 (2,7%), p = 0,03.
2. Clinical significance of dactylitis in early psoriatic arthritis
Dactylitis is an extremely sensitive and frequent sign of PsA both in the advanced and early stages of the disease. They were a diffuse thickening of the fingers of the hands and / or feet, often with a significant restriction of flexion, slight pain and with a characteristic bluish-purple color of the skin above them.
When analyzing the relationship of dactylitis with clinical and laboratory indicators of PsA-e, their association with the inflammatory activity of the disease (r=0.29, p=0.03), a destructive process was revealed in the joints of hands and plants (r=0.33, p=0.02), as well as with enthesitis according to MRI data (r=0.70, p=0.0001). In addition, in PsA-e there was not only a direct correlation of dactylitis with enthesitis according to MRI data (r=0.51 p=0.0001), but also an association with TJC (r=0.34, p=0.01), psoriatic skin lesion (r=0.36, p=0.01).
3. Clinical features of enthesitis in early psoriatic arthritis
Very specific symptoms of PsA are enthesitis, and as a particular expression of them - slight edema of the hands and / or plants. These symptoms were detected in patients with PsA in the first months of the disease and over time, their frequency increased.
The enthesitis by the MASES method with the inclusion of plantar aponeurosis were determined with approximately the same frequency, both in the PsA-e group and in the PsA-t group, namely in 22 (43,1%) and 23 (43,4%) patients, respectively, p=0,5%. The value of the MASES score ranged from 1 to 8 points in the PsA-e group and from 1 to 12 in the PsA-t group. The average values of this index were higher in the PsA-e group than in the PsA-t group and amounted to 4.03±0.8 and 2.6±0.5 (p=0.04), respectively..
To study the significance of the MASES score, a correlative analysis was performed, which highlighted the relationship of this score with some clinical and laboratory indicators of PsA. The prevalence of enthesopathy correlated more importantly with clinical and laboratory indicators at the early stage of PsA than late. Thus, in patients with PsA-t, the MASES index was associated with the indices TJC (r=0.31 p=0.03), SJC (r=0.29 p=0.04), BASDAI indices (r=0.34 p=0.02) and BASFI (r=0.39 p=0.02), as well as the disease inflammatory activity score - DAS28 (r=0.31 p=0.03). In patients with long-term current PsA, the mases index correlation determined only with the BASFI index (r=0.35 p=0.02).
4. Radiological symptoms of early and late psoriatic arthritis
According to our data, minimal radiological changes have been observed, such as periarticular osteoporosis and osteoporosis in combination with narrowing of the joint slits (stage I and IIA) in 74.5% of patients with PsA-e. Despite the fact that erosive arthritis was observed more often in patients with PsA-t than in patients with PsA-e (in 64% and 13.7% of patients, respectively, p=0.0001), single superficial erosion in combination with periarticular osteoporosis and narrowing of the articular slits (stage IIB) was observed with approximately the same frequency in both groups (9.8% and 18.9%, respectively p=0,2).
5. The importance of magnetic resonance imaging in the diagnosis of early psoriatic arthritis
At MRI of the hands and distal parts of plants, inflammation of the synovial membrane (82.5%) was most often detected. Tenosynovitis was observed in 59% of patients, and almost half of them revealed tenosynovitis and subclinical synovitis. Swelling of the soft tissues of the hands and / or plants was observed in 23.5% of patients, osteitis was less common (14%).
In order to study the clinical significance of the MRI data, a correlative analysis was performed, which revealed the interdependence of tenosynovitis with TJC (r=0.46 p=0.001), SJC (r=0.47 p=0.001), dactylitis (g=0.80 p=0.0001), ESR (r=0.29 p=0.03), CRPhs (r=0.38 p=0.01), DAS28 (r=0.44 p=0.001). A direct correlation of synovitis with ESR (r=0.35 p=0.01), CRPhs (r=0.33 p=0.01), DAS28 (r=0.43 p=0.002), as well as with the destruction of bone cartilage according to the Sharp/van der Heijde index (r=0.32 p=0.02) was also found.
For a more detailed description of dactylitis, they were divided into acute (lasting up to 3 months) and chronic (lasting more than 3 months). With the help of MRI, only 35 acute and 70 chronic dactyls have been studied for PsA-e and PsA-t (Table 5).
6. The clinical significance of ultrasound in the diagnosis of early psoriatic arthritis
Ultrasound examination of the calcaneal areas was performed in 51 patients with PsA-e and 48 – PsA-t (Table 6). Ultrasound proved a more sensitive method for the detection of enthesitis, and at PsA-e enthesitis was clinically detected in 31% of patients, and according to ultrasound data - in 69%, in addition, association of achillodynia and plantar fasciitis, preachillus bursitis, enthesophitis and erosion of the calcaneal bone were detected.
In order to evaluate the ultrasonographic entisitities, the GUESS score was used. In the PsA-e group, the fluctuations of this index ranged from 1 to 6 points, in the PsA-t group- from 1 to 8 points. The average value of the index was higher in the PsA-e group and was 3.6±0.3 points than in the PsA-t group, where the average value of this indicator was 2.43±0.2 points (p=0.02). The GUESS index at PsA-e correlated with indicators of inflammatory activity of the disease TJC (r=0.35 p=0.01), SJC (r=0.49 p=0.001), ESR (r=0.57 p=0.0001), CRPhs (r=0.51 p=0.0001), DAS28 (r=0.59 p=0.0001)), as well as with DIP (r=0.40 p=0.001) and destruction of bone cartilage according to the Sharp/van der Heijde index (r=0.33 p=0.02).
7. Sensitivity of elaborate and international diagnostic criteria in patients with early and late psoriatic arthritis
The varied clinical spectrum of PsA, different variants of evolution, the presence of cross-symptom with other rheumatic diseases, makes it difficult to create reliable and user-friendly diagnostic and classification criteria.
The approval of the criteria proposed by us was carried out on the studied groups of patients. They have been shown to have an increased sensitivity to both PsA-e (98%) and PsA-t (100%). The most informative signs in both groups with high sensitivity (83.6% - 94.1%) were tegumentary psoriasis, seronegativity and asymmetry of joint lesions. At an early stage of PsA, typical periarticular phenomena (70.6%), which are analogues of dactyls and enthesitis, also had a high sensitivity, while for PsA-t this symptom was detected significantly less often, but at a high rate of cases (52.8%). In PsA-t, on the contrary, onychodystrophy, inflammatory pain in the spine and radiological signs of sacroiliitis turned out to be more specific. The approval of the criteria also demonstrated a relatively high sensitivity of the relationship between psoriasis and PsA at any evolutionary stage of the disease (about 50%).
According to the results of our study, the CASPAR criteria have marked sensitivity in both PsA-e (96.1%) and PsA-t (96.2%). Among the main signs of diagnosis at both stages of the disease, arthritis (100% and 100% respectively) and enthesis (78% and 88%) had a marked sensitivity, and seronegativity after rheumatoid factor (92% -96.2%). Signs of spondylitis were of great importance only in PsA-t (68%). Psoriasis in the anamnestic or in relatives of the 1st and 2nd degree demonstrated a reduced diagnostic significance, but allowed to check PsA even in the absence of dermatosis at the time of examination. As mentioned above, dactyls were of quite high importance at both stages of the disease, at the same time, onychodystrophy was more often observed in PsA-t, as well as bone remodeling.
Discussions
In the first 3 months the oligoarticular variant of the joint syndrome was observed in the vast majority of patients (75,4%), while the polyarticular variant was detected significantly less often (13,7%) (Table 3). As the disease progressed, the incidence of oligoarthritis decreased, and polyarthritis increased significantly. After 3 and 6 months from the beginning of the clinical presentation of PsA, limited joint lesions were observed in 74.5% and 58% of patients, respectively, and by the end of the 2nd year, oligoarthritis was observed in 28.6% of patients and polyarthritis in 47.6%. The prevalence of distal (5.8% to 14.3%) and spondylartritic (5.8% to 9.5%) variants also increased, although the differences were uncertain.
In a detailed study of the clinical significance of DIP arthritis in patients with PsA-e, its relationship with NAD (r=0.43 p=0.001), NAT (r=0.47 p=0.0001), ultrasonographically confirmed enthesitis (r=0.40 p=0.001), DAS28 (r=0.30 p=0.002) was revealed. In addition, an association with the Sharp/van der Heijde index was revealed (r=0.45 p=0.001).
In the present study, periostitis, as well as dactylitis with enthesitis, were observed more often in long-term active PsA than with PsA-t (28.3% and 17.6%, p=0.1%, respectively). This fact indicates the importance of these symptoms, their interdependence and a fairly high prevalence not only in the late stages, but also in the early stages of the disease. In radiological examination of the pelvis, sacroiliitis was detected in 37.3% of patients with PsA-e, and in 64.2% - PsA-t (p=0.004).
In PsA-e, acute dactylitis (n=17) was characterized by isolated tendinitis without concomitant synovitis (53% in acute dactylitis and 2.1% in chronic, p=0.0001), while chronic dactylitis (n=48) was accompanied by tendinitis with synovitis (52.1% in chronic dactylitis and 11.8% in acute, p=0.01). Thus, acute dactylitis were associated with isolated tendinitis, while for a longer evolution of dactylitis it was characterized by a combination of synovitis with tendinitis. A similar pattern has been observed in acute and chronic dactylitis MRI in PsA-t.
Our study found that the CASPAR criteria had an increased sensitivity in both PsA-e (96.1 %) and PsA-t (96.2%). At the same time, some signs that characterize enentesopathy depending on the clinical and radiological examination had a low diagnostic significance for PsA-e and PsA-t (25.5% and 45.3%). Monoarthritis, as well as oligoarthritis, had a low sensitivity, especially for PsA-t (13.7% - 40.4% and, respectively, 43% - 18.9%).
We found that the criteria also had a high sensitivity in both PsA-e (94.1%) and PsA-t (94.3%). The diagnostic value of the main signs of these criteria, such as skin psoriasis at the time of examination or in anamnestic and onychodystrophy, as well as additional - arthritis, spondylitis or sacroiliitis is significantly important. These criteria provide for the exclusion of other rheumatic diseases, such as rheumatoid arthritis (rheumatoid nodules), erosive osteoarthritis of the hands (radiological stage III-IV), reactive arthritis, enteropathic arthritis, gout, systemic lupus erythematosus, which have been excluded in our patients.
Conclusions
The early stage of psoriatic arthritis (PsA-e) is characterized by pronounced heterogeneity of the manifestations of joint syndrome and damage to the tendon-ligament apparatus. In PsA-e oligoarthritis and polyarticular variants are the most common, less often - distal interphalangeal and spondyloarartritic variants. In the first 3 months after the onset of clinical manifestations of PsA, oligoarthritis was observed in 75.4% of patients and polyarthritis in 14% (p=0.0001), and after 6 months - 63% and 26.6% respectively (p=0.001). With a progression of the duration of the disease, the number of patients with arthritis increased, and by the end of the 2nd year was determined in 47.6% of patients, and oligoarthritis - in 28.6%.
In the first 3 months of the disease most often arthritis localized at the metatarsophalangeal joints (41,2%), proximal interphalangeal of plants (37,3%), less often - the knee (27,5%) and much less often - the elbow (2%) and the shoulder (4%). By the end of the 2nd year of the disease, damage to the joints of the hands and plants occurred with the same frequency (metacarpal joints - 52.4% and metatarsophalangeal - 57.1%).
Arthritis of the distal interphalangeal joints was associated with marked inflammatory activity (r=0.30 p=0.002), determined ultrasonographic enthesopathy (r=0.40 p=0.001), erosive arthritis (r=0.45 p=0.001). With such a localization of arthritis, psoriatic onychodystrophy was detected significantly more frequently than in patients without DIP (72.2% and 39.4%, p=0.01%, respectively).
Enthesitis and enthesopathy are characteristic manifestations of PsA-e and in the first 2 years it was observed in 37.6% of patients. According to the ultrasound examination, the enthesities in the calcaneal region were more frequent compared to the clinical data (69% and 31%, respectively, p=0.0002). Guess score correlated with inflammatory activity (r=0.59 p=0.0001), arthritis of distal interphalangeal joints (r=0.40 p=0.001) and degradation of articular cartilage (r=0.32 p=0.02).
Dactylitis were determined in 49% of patients with PsA-e with predominant localization on plants (planar dactylitis - in 35.3% of patients, hands - in 5.9%). Acute dactylitis (up to 3 months) is characterized by isolated tendinitis without concomitant synovitis, and only in chronic dactylitis (which lasts more than 3 months) tendonitis has been associated with synovitis. Dactylitis was associated with a marked inflammatory activity of the disease (r=0.34 p=0.01), mutilating arthritis (r=0.33 p=0.02), enthesitis confirmed by MRI (r=0.80 p=0.0001).
The radiological picture of PsA-e was characterized by juxtaarticular osteoporosis (in 25,5% of patients), narrowing of the articular slits (in 49%), bone erosion (in 13,7%), periostitis (in 17,6%). Uni- and bilateral sacroiliitis (stage II according to Dale and more) was detected in 37.3% of patients. The combination of radiological symptoms of damage to peripheral joints and axial skeleton with a high degree of probability made it possible to diagnose PsA at an early stage.
Competing interests
None declared
Authors' contribution
Study conception and design: ER, LG. Data acquisition: ER, LC, VC, LR. Analysis and interpretation of data: ER, VC. Drafting of the manuscript: ER. Significant manuscript review with significant intellectual involvement: ER, VC. Approval of the „ready for print” version of the manuscript: ER, LG, LC, VC, LR.
Authors’ ORCID IDs
Eugeniu Russu - https://orcid.org/0000-0001-8957-8471
Liliana Groppa - https://orcid.org/0000-0002-3097-6181
Lia Chișlari - https://orcid.org/0000-0002-7088-568X
Victor Cazac - https://orcid.org/0000-0001-9293-4481
Larisa Rotaru - https://orcid.org/0000-0002-3260-3426
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Tabelul 1. Criteriile de diagnostic și pragurile de diagnostic pozitiv pentru categoriile pacienților cu APs Table 1. Diagnostic criteria and positive diagnostic thresholds for PsA patient categories | |||
№ criteriului № criterion | CRITERII CRITERIA | Numărul de puncte Number of points | |
1 | Erupții cutanate psoriazice Psoriatic rashes Psoriazisul unghial Nail psoriasis Psoriazisul la rudele apropiate (gradul I) Psoriasis in close relatives (I degree) | 5
2
1 | |
2 | Artrita articulațiilor interfalangiene distale Arthritis of distal interphalangeal joints | 5 | |
3 | Artrita a trei articulații ale unui deget Arthritis of three joints of a finger | 5 | |
4 | Artrita asimetrică Asymmetric arthritis | 2 | |
5 | Fenomene paraarticulare tipice Typical paraarticular phenomena | 5 | |
6 | Dactilită Dactylitis | 3 | |
7 | Subluxații multidirecționale ale articulațiilor degetelor mâinilor Multidirectional subluxations of the joints of the fingers of the hands | 1 | |
8 | Durere și redoare matinală la nivelul coloanei vertebrale Morning pain and stiffness in the spine | 5 | |
9 | Osteoliza la nivelul articulațiilor Osteolysis in the joints | 5 | |
10 | Anchiloza articulațiilor interfalangiene distale (mâini, plante) și metatarsofalangiene Ankylosis of the distal interphalangeal (hands, plants) and metatarsophalangeal joints | 5 | |
11 | Semne radiologice ale sacroiliitei definite Radiological signs of defined sacroiliitis | 2 | |
12 | Sindesmofite sau osificare paravertebrală tipică Syndesmophyte or typical paravertebral ossification | 4 | |
13 | Seronegativitate după factor reumatoid și anticorpii anti-CCP Seronegativity by rheumatoid factor and anti-CCP antibodies | 2 | |
14 | Relația manifestărilor cutanate cu exacerbarea sindromului articular sau apariția acestuia The relationship of cutaneous manifestations with exacerbation of joint syndrome or its appearance | 4 | |
Notă: În prezența unor semne precum seropozitivitatea factorului reumatoid anticorpii anti-CCP, nodulii reumatoizi, tofi, relația strânsă dintre apariția sindromului articular sau exacerbarea acestuia cu infecția urogenitală sau intestinală, absența psoriazisului în momentul examinării sau al istoricului, 5 puncte pentru fiecare simptom sunt excluse din cantitatea totală. Note: In the presence of such signs as seropositiveness of rheumatoid factor anti-CCP antibodies, rheumatoid nodules, tophi, the close relationship between the appearance of joint syndrome or its exacerbation with urogenital or intestinal infection, the absence of psoriasis at the time of examination or history, 5 points for each symptom are excluded from the total amount. | |||
Categoria de diagnostic Diagnostic category | Praguri numerice diagnostice (puncte) Diagnostic numerical thresholds (points) | ||
APs clasică Classic PsA | 16 și mai mult 16 and more | ||
APs definită Defined PsA | 11-15 | ||
APs probabilă Probable PsA | 8-10 | ||
APs respinsă PsA rejected | 7 și mai puțin 7 and less | ||
Tabelul 2. Caracteristicile comparative ale pacienților cu artrită psoriazică precoce și tardivă Table 2. Comparative characteristics of patients with early and late psoriatic arthritis | |||
| APs-p n=51 PsA-e n=51 | APs-t n=53 PsA-t n=53 | Р |
Sex b/f Sex m/f | 26/25 | 21/32 | 0,3 |
Vârsta medie, ani Average age, years | 41,0±12,9 | 43,7±12,6 | 0,3 |
Durata Ps, ani Ps duration, years | 10,5±1,5 | 19,7±3,0 | 0,03 |
Durata APs, ani Duration of PsA, years | 1,0±0,6 | 15,4±2,4 | 0,0001 |
Varianta clinico-anatomică a sindromului articular: Clinical-anatomical variant of the joint syndrome> Oligoartrită Oligoarthritis Poliartrită Polyarthritis Interfalangiană distală Distal interphalangeal Spondiloartrită Spondyloarthritis Mutilantă Mutilant |
22/ 43,1%
17/33,3%
8/ 15,7%
4/7,8%
0 |
9/17%
21/40%
8/15%
10/19%
5/9,4% |
0,004
0,5
0,9
0,1
0,03 |
Activitatea inflamatorie: DAS28 Inflammatory activity: DAS28 | 4,7±1,5 | 5,4±1,5 | 0,06 |
Stadiul radiologic al artritei (Steinbroker): Radiological stage of arthritis (Steinbroker): I IIA IIB III IV |
13/ 25,5% 25/ 49% 5/ 9,8% 2/ 3,9% 0 |
3/5,6% 14/26,4% 10/18,9% 20/ 37,7% 4/ 7,5% |
0,01 0,02 0,2 0,0001 0,05 |
Stadiul sacroiliitei (Dale): Stage of sacroiliitis (by Dale): I II III IV V |
10/19,6% 16/31,4% 3/ 5,9% 0 0 |
10/ 18,9% 15/26,3 % 6/11,3% 7/ 13,2% 1/1,9% |
0,9 0,6 0,3 0,01 0,3 |
Notă: media M, deviație t-standard. Se utilizează criteriile Fisher (x2) și Wilcoxon. Note: M mean, t-standard deviation. Fisher (x2) and Wilcoxon criteria are used | |||
Tabelul 3. Frecvența afectării articulațiilor și coloanei vertebrale în artrita psoriazică precoce Table 3. The frequency of damage to the joints and spine in early psoriatic arthritis | ||||||||
Varianta sindromului articular Variant of joint syndrome | 0-3 luni 0-3 months n=51 | 4-6 luni 4-6 months n=45 | 7-12 luni 7-12 months n=30 | 12-24 luni 12-24 months n=21 | ||||
Oligoartrită Oligoarthritis | 38/ 74,5% | 26/ 57,8% | 10/ 33,3% | 6/28,6% | ||||
Poliartrită Polyarthritis | 7/13,7% | 12/26,6% | 12/40% | 10/47,6% | ||||
Interfalangiană distală Distal interphalangeal | 3/ 5,9% | 4/ 8,9% | 5/ 16,7% | 3/14,3% | ||||
Spondiloartrită Spondyloarthritis | 3/ 5,9% | 3/ 6,7% | 3/ 10% | 2/ 9,5% | ||||
Durere inflamatorie la nivelul coloanei vertebrale (total) Inflammatory pain in the spine (total) | 8/ 15,7% | 9/ 20% | 13/43,3% | 12/ 57,1% | ||||
Tabelul 4. Localizarea artritei în diferite etape ale artritei psoriazice Table 4. Localization of arthritis at different stages of psoriatic arthritis | ||||||||
Articulații Joints | I (0-3 luni) I (0-3 months) n=51 | II (4-6 luni) II (4-6 months) n=45 | III (7-12 luni) III (7-12 months) n=30 | IV (13-24 luni) IV (13-24 months) n=21 | ||||
IFD mâini DIP | 8/ 15,7% | 13/ 28,9% | 15/50% I vs III р=0,001 | 8/ 38,9% I vs IV р=0,04 | ||||
IFP mâini PIP hands | 14/27,5% | 12/26,7% | 14/ 46,7% | 11/52,4% I vs IV р=0,04 | ||||
MCF mâini MCF hands | 6/11,8% | 10/ 22,2% II vs IV р=0,01 | 11/36,7% | 11/52,4% I vs III р=0,01 I vs IV р=0,0004 | ||||
Radiocarpiene Radiocarpals | 9/17,6% | 8/17,8% | 6/ 20% | 7/ 33,3% | ||||
Coatelor Elbow | 1/ 2% | 2/ 4,4% II vs IV р=0,03 | 2/ 6,7% | 4/19% I vs IV р=0,01 | ||||
Articulațiile umărului Shoulder joints | 2/3,9% | 3/ 6,7% | 4/ 13,3% | 4/ 19% | ||||
Temporomandibulare Temporomandibular | 2/ 3,9% | 2/4,4% | 1/ 3,3% | 0 | ||||
Sternoclaviculare Sternoclavicular | 0 | 1/2,2% | 2/ 6,7% | 2/ 9,5% | ||||
Articulațiile coxofemurale Coxofemural joints | 1/2% I vs II р=0,02 | 6/13,3% | 2/ 6,7% | 1/4,8% | ||||
Articulațiile genunchiului Knee joints | 14/27,5% | 9/ 20% | 12/40% | 6/ 28,6% | ||||
Articulațiile talocrurale Talocrural joints | 15/29,4% | 11/24,4% | 9/ 30% | 9/42,9% | ||||
MTF MTF | 21/41,2% | 21/46,7% | 11/36,7% | 12/57,1% | ||||
IFP plantelor PIP plants | 19/37,3% | 19/ 42,2% | 15/50% | 11/52,4% I vs IV р=0,04 | ||||
IFD plantelor DIP plants | 16/31,4% | 17/ 37,8% | 12/40% | 9/ 42,9% | ||||
Notă: S-au utilizat criteriile Fisher (X2) și Wilcoxon.. Note: Fisher (X2) and Wilcoxon criteria were used | ||||||||
Tabelul 5. Caracteristicile RMN ale dactilitei acute și cronice la pacienții cu artrită psoriazică precoce și tardivă Table 5. MRI features of acute and chronic dactylitis in patients with early and late psoriatic arthritis | ||||||
| APs-p PsA-e (n=51) | Р | APs-t PsA-t (n=49) | Р | ||
Dactilita acută Acute dactylitis n=17 | Dactilita cronică Chronic dactylitis n=48 | Dactilita acută Acute dactylitis n=16 | Dactilita cronică Chronic dactylitis n=18 | |||
Tenosinovită izolată Isolated tenosynovitis | 9/53% | 1/2,1% | 0,0001 | 4/ 25% | 0 | 0,03 |
Tenosinovită + sinovită Tenosynovitis + synovitis | 2/11,8% | 25/ 52,1% | 0,01 | 2/12,5% | 9/ 50% | 0,03 |
Sinovita Synovitis | 1/5,9% | 12/ 25% | 0,1 | 2/ 12,5% | 4/22,2% | 0,5 |
Edemul țesuturilor moi Edema of soft tissues | 5/29% | 0 | 0,002 | 8/ 50% | 1/5,6% | 0,01 |
Sinovita + Edemul țesuturilor moi Synovitis + Edema of soft tissues | 0 | 2/4,2% | 0,4 | 0 | 4/22,2% | 0,05 |
Patologie nu s-a depistat Pathology was not detected | - | 8/16,7% | - | - | - | - |
Notă: S-au utilizat criteriile Fisher (X2) și Wilcoxon. Note: The Fisher (X2) and Wilcoxon criteria were used. | ||||||
Tabelul 6. Frecvența detectării entezitei la pacienții cu artrită psoriazică precoce și tardivă Table 6. The frequency of detection of enteritis in patients with early and late psoriatic arthritis | |||
Manifestare Manifestation | APs-p PsA-e n=51 | APs-t PsA-t n=48 | Р |
Achilodinie: Achillodynia: total total subclinic subclinical |
15/ 29%
6/11,8% |
25/ 52,1%
18/ 37,5% |
0,01 |
Bursita preachiliană Preachillian bursitis | 4/7,8% | 5/10,4% | 0,7 |
Fasciita plantară: Plantar fasciitis: total total subclinic subclinical |
27/52,9%
19/37,3% |
25/ 52,1%
22/ 45,8% |
0,9 |
Entesofite Entesophyte | 20/ 39,2% | 24/ 50% | 0,9 |
Eroziuni Erosions | 3/5,6% | 9/18,8% | 0,05 |
Total Total | 35/ 68,6% | 40/ 83,3% | 0,6 |
Notă: S-au utilizat criteriile Fisher (X2) și Wilcoxon. Note: The Fisher (X2) and Wilcoxon criteria were used. | |||