Dactylitis: implications for clinical practice

High-resolution ultrasound imaging of elementary lesions in dactylitis

OBJECTIVE

The aim of the present study was to illustrate the (potential) diagnostic role of high resolution US images in assessing the elementary lesions of dactylitis.

METHODS

Using high-frequency US machines/probes, we matched the micro-anatomical cadaveric architecture of the digit with multiple sonographic findings of dactylitis. High-sensitive color/power Doppler assessments have also been performed to evaluate the digital microvasculature.

DISCUSSION

Modern US equipment/features guarantee prompt and in-depth B-mode and color/power Doppler imaging of tiny anatomical structures of the digit which are usually not properly visible with standard US machines. More specifically, hypervascularization of the digital subcutaneous tissue, fibrous pulleys of flexor tendons, dorsal synovial pads as well as pathological changes of the distal entheseal anchorage network can be accurately detected.

CONCLUSION

In clinical practice, high-end US equipment can be used to accurately assess the digits in patients with dactylitis. This way, simple and convenient sonographic diagnosis of different elementary lesions can be timely established.

Morphologic, dynamic and high-resolution microscopy MRI in early-onset spondyloarthritis finger dactylitis

OBJECTIVE

Up to now, the pathophysiology of SpA dactylitis has not been entirely clarified. It is not clear which are the involved tissues and which is the primary lesion of the "sausage-like" digit. The aim of our study was to examine the finger structures in early-onset finger dactylitis using high-resolution microscopy MRI together with morphologic and dynamic MRI.

SUBJECTS AND METHODS

In a 6-month period, 13 SpA patients (7 females and 6 males), mean age 54.07 years (range 37-73 years) and mean disease duration 7.07 years (range 1-44 years) with early-onset finger dactylitis (less than 3 months) were recruited. Nine patients had PsA, 3 HLA-B27-positive uSpA and 1 HLA-B27-negative uSpA. One patient had 2 dactylitis fingers. Ten healthy volunteers matched for age and sex with no personal and family history of SpA were enrolled. All dactylitis fingers and randomly selected fingers of the normal control subjects were imaged by morphologic, dynamic and high-resolution microscopy MRI.

RESULTS

We have found flexor tenosynovitis in all the 14 dactylitis fingers, joint synovitis in 5 and oedema in the finger soft tissue in 10. In 2 dactylitis fingers, there was oedema at the insertion of the joint capsule suggesting enthesitis. In 5 dactylitis fingers, there was only mild enhancement at the enthesis organ (collateral ligament, flexor and extensor tendons).

CONCLUSIONS

Our MRI study on early-onset dactylitis demonstrates that flexor tenosynovitis, joint synovitis and oedema of the digit soft tissue are the predominant alterations visible in the early phase of evolution of dactylitis and that, therefore, enthesitis may not be considered the primary lesion of dactylitis.

Acute Psoriatic Exacerbation Secondary to Infected Pacemaker With Staphylococcus aureus and Candida lusitaniae?

Psoriasis is a lifelong chronic hyperproliferative inflammatory immune-mediated disorder. There is a strong association of psoriasis exacerbation with infection of Staphylococcus and Streptococcus species. In the case of our patient, a psoriatic flare manifesting as dactylitis occurred secondary to methicillin sensitive Staphylococcus aureus bacteremia colonization of his pacemaker. If a patient is started on an antibiotic regimen, such as vancomycin, and has symptoms of rash, and swelling in the fingers, it is imperative to ask for a proper rheumatologic history, as vancomycin infusion reaction (previously known as Red Man Syndrome) may not be the cause of the flare-up, such as in the case of our patient. Inversely, patients with psoriasis are more likely to be colonized by S. aureus on the skin and in the nasal cavity, and this can lead to bacteremia and infection of hardware, such as an automatic implantable cardioverter-defibrillator (AICD).

Comparison of Clinical Manifestations in Rheumatoid Arthritis vs. Spondyloarthritis: A Systematic Literature Review

INTRODUCTION

Misclassification of spondyloarthritis (SpA) as rheumatoid arthritis (RA) may lead to delayed SpA diagnosis and suboptimal therapeutic outcomes. Here, we evaluate the literature on clinical manifestations in patients with SpA and RA, particularly seronegative RA, to understand the potential overlap, distinctions, and most reliable approaches to accurate diagnosis.

METHODS

In this systematic literature review, conducted according to PRISMA guidelines, we searched key biomedical databases for English-language publications of original research articles (up to July 23, 2020) and rheumatology conference abstracts (January 1, 2018-July 31, 2020) reporting key SpA clinical presentations in patients with SpA or RA. Publications were assessed for eligibility by two independent reviewers; discrepancies were resolved by a third. Studies were evaluated for publication quality using the Downs and Black checklist.

RESULTS

Of 4712 records retrieved, 79 met the inclusion criteria and were included in the analysis. Of these, 54 included study populations with SpA and RA, and 25 with seropositive and/or seronegative RA. Entheseal abnormalities were more frequently reported among patients with SpA than RA and with seronegative vs. seropositive RA. Psoriasis, nail psoriasis, and dactylitis were exclusively seen in SpA vs. RA. In most publications (70 of 79), advanced imaging techniques allowed for more accurate distinction between SpA and RA. Overlapping clinical characteristics occur in SpA and RA, including inflammation and destruction of joints, pain, diminished functional ability, and increased risk for comorbidities. However, of 54 studies comparing SpA and RA populations, only seven concluded that no distinction can be made based on the SpA manifestations and outcomes examined.

CONCLUSIONS

Typical SpA-related clinical symptoms and signs were observed in patients with RA, suggesting that misclassification could occur. Availability of advanced imaging modalities may allow for more prompt and comprehensive evaluation of peripheral manifestations in SpA and RA, reducing misclassification and delayed diagnosis.

Perceptions of Rheumatologists on Diagnosis of Psoriatic Arthritis in China

Objective

High prevalence of undiagnosed psoriatic arthritis (PsA) and prolonged diagnostic delay are key troubles in the appropriate management of PsA. To analyze the possible causes for this phenomenon, a web-based nationwide survey was conducted to investigate rheumatologists’ perceptions on PsA diagnosis in China.

Methods

The electronic questionnaire consisting of 38 questions were designed by an expert panel and distributed with the online survey tool Sojump, which is a professional online survey platform. The completed questionnaires by real-name rheumatologists were collected.

Results

A total of 1594 valid questionnaires were included. More than half of Chinese rheumatologists reported it was challenging to make a diagnosis of PsA. The four major challenges were “Difficulties in identification of atypical or hidden psoriasis”, “Absence of diagnostic biomarkers”, “No active self-report of history or family history of psoriasis” and “Various musculoskeletal manifestations”. In diagnosing PsA, minor participants had incorrect knowledge of inflammatory arthropathy (13.7%), acute phase reactant (23.8%), and rheumatoid factor (28.7%). There were no significant differences in the knowledge of PsA and practice habits in diagnosing PsA between modern western medicine (WM)- and traditional Chinese medicine (TCM)-rheumatologists. The part-time rheumatologists were not as good as full-time rheumatologists in diagnosing PsA.

Conclusions

About three quarters of Chinese rheumatologists are familiar with the elements in PsA diagnosis and have good practice habits in diagnosing PsA. Four main challenges in making PsA diagnosis are revealed. There was no significant difference in the knowledge of PsA between WM- and TCM-rheumatologists.

Psoriatic Arthritis With Dactylitis: A Case Report and Concise Review of Treatment Options

Dactylitis is characterized by generalized swelling of a finger or toe. Though it is commonly seen, the literature on psoriatic dactylitis is scant, with the majority consisting of solitary case reports. The literature on the treatment of dactylitis is considerably more limited. Dactylitis usually responds to non-steroidal anti-inflammatory drugs (NSAIDs) or traditional disease-modifying antirheumatic drugs (DMARDs). Numerous randomized studies have lately shown the effectiveness of different biological agents in the treatment and maintenance of psoriatic arthritis (PsA) and associated dactylitis. In primary care practice, a patient may present with dactylitis without a history of psoriasis. In such cases, an attempt should be made to detect the underlying psoriasis by looking for a psoriatic patch in hidden areas viz. skin folds, groin or scalp. Here, we describe a case of PsA with dactylitis in this case report, with an emphasis on treatment and outcome. We also attempted to focus on the various treatment options for dactylitis.

Corticosteroid injection treatment for dactylitis in psoriatic arthritis

Dactylitis – a hallmark clinical feature of psoriatic arthritis (PsA) – that occurs in 30–50% of PsA patients, is a marker of disease severity for PsA progression, an independent predictor of cardiovascular morbidity and impairs the motor functions of PsA patients. There is a paucity of evidence for the treatment due to the absence of randomized controlled trials assessing dactylitis as a primary endpoint and current practice arises from the analysis of dactylitis as a secondary outcome. Corticosteroid (CS) injections for dactylitis in PsA patients are a therapeutic treatment option for patients with isolated dactylitis or for patients with flares in tendon sheaths, despite stable and effective systemic treatment. The aim of this narrative review is to briefly illustrate the clinical aspects of dactylitis in PsA, the imaging and clinimetric tools used to diagnose and monitor dactylitis, the current treatment strategies and principally to provide a comprehensive picture of the clinical efficacy and safety with ultrasound-guide and blind techniques of CS injections for dactylitis in PsA patients.

Psoriatic Dactylitis: Current Perspectives and New Insights in Ultrasonography and Magnetic Resonance Imaging

Dactylitis, one of the most typical features of psoriatic arthritis (PsA), is the diffuse swelling of the digits and is determined by the involvement of different anatomic structures, including: the subcutaneous fibrous tissue “accessory pulley” system; flexor tendons, with their related structures; the articular synovium; the small enthesis of the hands. Dactylitis is currently considered both a marker of disease activity and severe prognosis and its importance in PsA is emphasized by the inclusion in the classification criteria of PsA. This review focuses on the role of imaging in the management of PsA patients with dactylitis in clinical practice and in a research setting. Furthermore, imaging could be a valuable tool to assist in unravelling some of the underlying mechanisms of the onset and chronicization of dactylitis in PsA patients.

Pathophysiology, assessment and treatment of psoriatic dactylitis

Dactylitis is diffuse swelling of the digits that is usually related to an underlying inflammatory or infiltrative disorder. Psoriatic arthritis (PsA) is the most common severe disease thought to cause dactylitis. Our understanding of the pathogenesis of PsA-related dactylitis comes from experimental animal models of PsA-like disease, as well as advances in imaging and other clinical studies. Clinical trials in PsA have increasingly included dactylitis as an important secondary outcome measure. These studies indicate that cytokines drive multi-locus microanatomical pan-digital pathology. Given the importance of pro-inflammatory cytokines, the pathogenesis of dactylitis is best understood as an initial aberrant innate immune response to biomechanical stress or injury, with subsequent adaptive immune mechanisms amplifying the dactylitis inflammatory response. Regarding the treatment of dactylitis, no studies have been conducted using dactylitis as the primary outcome measure, and the current knowledge comes from analysis of dactylitis as a secondary outcome measure.

Dactylitis: A pictorial review of key symptoms

Dactylitis refers to a global swelling of a finger or a toe giving it a clinical sausage-shape presentation. It is an extremely suggestive symptom as it guides the rheumatologist towards a shortlist of diagnoses. However, radiologists are less familiar with dactylitis. The aim of this review is to detail and illustrate the main causes of dactylitis using standard X-ray imaging, ultrasound, computed tomography and magnetic resonance imaging in order to make radiologists more familiar with this symptom by illustrating the various conditions that are associated with dactylitis including infection, peripheral spondyloarthritis, sarcoidosis, microcrystalline deposition, osteoid osteoma, and sickle cell disease.

Importance of the Conserved Carboxyl-Terminal CNOT1 Binding Domain to Tristetraprolin Activity In Vivo

Tristetraprolin (TTP) is an anti-inflammatory protein that modulates the stability of certain cytokine/chemokine mRNAs. After initial high-affinity binding to AU-rich elements in 3' untranslated regions of target mRNAs, mediated through its tandem zinc finger (TZF) domain, TTP promotes the deadenylation and ultimate decay of target transcripts. These transcripts and their encoded proteins accumulate abnormally in TTP knockout (KO) mice, leading to a severe inflammatory syndrome. To assess the importance of the highly conserved C-terminal CNOT1 binding domain (CNBD) of TTP to the TTP deficiency phenotype in mice, we created a mouse model in which TTP lacked its CNBD. CNBD deletion mice exhibited a less severe phenotype than the complete TTP KO mice. In macrophages, the stabilization of target transcripts seen in KO mice was partially normalized in the CNBD deletion mice. In cell-free experiments, recombinant TTP lacking its CNBD could still activate target mRNA deadenylation by purified recombinant Schizosaccharomyces pombe CCR4/NOT complexes, although to a lesser extent than full-length TTP. Thus, TTP lacking its CNBD can still act to promote target mRNA instability in vitro and in vivo These data have implications for TTP family members throughout the eukarya, since species from all four kingdoms contain proteins with linked TZF and CNOT1 binding domains.

Psoriatic arthritis for dermatologists

Psoriatic arthritis (PsA) affects up to one-third of patients with psoriasis. It is the major comorbidity of psoriasis because of the likelihood that loss of function and permanent disability will develop if initiation of treatment is delayed. Dermatologists are uniquely positioned to recognize early signs of PsA and be the first-line healthcare practitioners to detect PsA in patients with psoriasis. PsA can affect six clinical domains: peripheral arthritis, dactylitis, enthesitis, psoriasis, psoriatic nail disease, and axial disease. However, not every patient will have involvement of all domains and the domains affected can change over time. Complicating the diagnosis is the condition's similarity with other arthritic diseases and potential heterogeneity. In this article, we provide practical guidance for dermatologists for detecting PsA in patients with psoriasis. We also review the available treatment options by each clinical domain of PsA and give advice on how to interpret the results of PsA clinical trials. Through early recognition of PsA in patients with psoriasis and initiation of proper treatment, dermatologists can help to prevent PsA disease progression, irreversible joint damage, and resultant permanent disability, and improve quality of life.

Involvement of foot in patients with spondyloarthritis: Prevalence and clinical features

BACKGROUND

The purpose of this study was to evaluate the foot involvement in a group of patients with spondyloarthritis in regard to symptoms, type and frequency of deformities, location and radiological changes.

METHODS

We conducted a cross sectional study including 60 patients with spondyloarthritis over a period of six months. Anamnesis, clinical examination, podoscopic examination, biological tests and X-rays of feet were done for each patient.

RESULTS

Foot involvement was found in 31 patients (52%). It was symptomatic in 35% of cases and inaugural in 42% of cases. The most frequent site was the hindfoot (22 patients/31). Radiological findings were: erosion (17%), reconstruction (33%), erosion and reconstruction (50%). Forefoot involvement was found in 18/31 patients. Forefoot deformities were found in 9 patients. Two patients had sausage toe and feet skin abnormalities were observed in 12 patients. At podoscopic examination, 23 patients had abnormal footprints. Foot involvement was more frequent in peripheral spondyloarthritis (p=0.008). Patients with foot involvement had an advanced age of disease onset (p=0.05), a shorter disease duration (p=0.038) and more comorbidities (p=0.039). Foot involvement was correlated with C Reactive protein (p=0.043).

CONCLUSION

In our study, foot involvement and foot symptoms were seen frequently in spondyloarthritis and it is associated with late onset of the disease and with higher inflammation in blood tests.

Treatment of Dactylitis and Enthesitis in Psoriatic Arthritis with Biologic Agents: A Systematic Review and Metaanalysis

OBJECTIVE

Biologic agents with different mechanisms of action [inhibitors of tumor necrosis factor-α (TNF-α), interleukin (IL)-12/23, and IL-17] showed efficacy in randomized controlled trials (RCT) in the treatment of psoriatic arthritis. We conducted a pooled metaanalysis of these agents for treatment of dactylitis and enthesitis and compared results with the American College of Rheumatology 20 (ACR20) response and Health Assessment Questionnaire-Disability Index (HAQ-DI) scores.

METHODS

A systematic literature search was performed and a pooled metaanalysis of RCT with anti-TNF-α (infliximab, golimumab, adalimumab), anti-IL-12/23 (ustekinumab), and anti-IL-17 (secu kinumab, ixekizumab) was conducted using the random-effects model. Bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

Eighteen RCT were included in the pooled analysis (n = 6981). Both TNF-α inhibitors and novel biologics (ustekinumab, secukinumab, ixekizumab) demonstrated significant resolution of dactylitis at Week 24 with pooled risk ratios (RR) versus placebo of 2.57 (95% CI 1.36-4.84) and 1.88 (95% CI 1.33-2.65), respectively. For resolution of enthesitis at Week 24, RR for TNF-α inhibitors was 1.93 (95% CI 1.33-2.79) versus 1.95 (95% CI 1.60-2.38) for novel biologics. Both biologic categories showed overlapping ranges of ACR20 responses (TNF-α inhibitors: RR = 2.23, 95% CI 1.60-3.11; pooled IL-12/23 and -17: RR = 2.30, 95% CI 1.94-2.72) and similar quality of life improvement scores with mean HAQ-DI score changes of -0.29 (95% CI -0.39 to -0.19) and -0.26 (95% CI -0.31 to -0.22), respectively.

CONCLUSION

The pooled analysis demonstrated that anti-TNF-α agents have the same efficacy as novel agents (ustekinumab, secukinumab, and ixekizumab) in dactylitis and enthesitis.

Enthesitis and Dactylitis in Psoriatic Disease: A Guide for Dermatologists

Psoriatic arthritis (PsA) is an inflammatory arthritis that is estimated to affect approximately 30% of patients with psoriasis. Enthesitis and dactylitis, two hallmarks of PsA, are associated with radiographic peripheral/axial joint damage and severe disease. Clinical symptoms of enthesitis include tenderness, soreness, and pain at entheses on palpation, whereas dactylitis is recognized by swelling of an entire digit that is different from adjacent digits. Both ultrasound and magnetic resonance imaging can be used to diagnose enthesitis and dactylitis, especially in patients in whom symptoms may be difficult to discern. Delayed treatment of PsA can result in irreversible joint damage and reduced quality of life. Thus, it is recommended that dermatologists monitor patients with psoriasis for these two early and important manifestations of PsA.

A review of the musculoskeletal manifestations of sarcoidosis

Sarcoidosis is a systemic disease of unknown aetiology that is characterized by granulomatous inflammation that can develop in almost any organ system. Musculoskeletal manifestations are seen in up to one-third of patients, ranging from arthralgia through to widespread destructive bone lesions. Inflammatory tendon lesions and periarticular swelling are more common than true joint synovitis. Despite advances in our understanding of the pathophysiology of the disease, diagnosis remains challenging. Definitive diagnosis, irrespective of organ site involvement, hinges on histological confirmation of non-caseating granuloma combined with an appropriate clinical syndrome. Musculoskeletal involvement usually develops early in the disease course. Imaging modalities, particularly fluorodeoxyglucose PET, are helpful in delineating the extent of involvement and measuring disease activity. Bone involvement may only become apparent following isotope imaging. Corticosteroids remain the cornerstone of treatment. MTX is the steroid-sparing agent of choice unless there is renal involvement. Biologic therapies are sometimes used in severe disease, although the evidence base for efficacy is inconsistent.

Which Psoriasis Patients Develop Psoriatic Arthritis?

Psoriatic arthritis is a major comorbidity of psoriasis that significantly impairs quality of life and physical function. Because skin lesions classically precede joint symptoms, dermatologists are in a unique position to identify patients at risk for psoriatic arthritis before irreversible joint damage occurs. Here we review the literature to identify the clinical and genetic factors most highly associated with development of psoriatic arthritis, with the goal of assisting dermatologists in risk-stratifying their psoriasis patients.

Ultrasound and magnetic resonance imaging in the evaluation of psoriatic dactylitis: status and perspectives

OBJECTIVE

Dactylitis, a characteristic feature of the spondyloarthropathies, occurs in up to 48% of patients with psoriatic arthritis (PsA). No clear consensus on the underlying components and pathogenesis of dactylitis exists in the literature. We undertook a systematic review of ultrasound (US) and magnetic resonance imaging (MRI) literature to better define imaging elements that contribute to the dactylitic digit seen in PsA. Our objectives were to determine first the level of homogeneity of each imaging modality's definition of the components of dactylitis, and second, to evaluate the metric properties of each imaging modality according to the Outcome Measures in Rheumatology Clinical Trials (OMERACT) filter.

METHODS

Searches were performed in PUBMED and EMBASE for articles pertaining to MRI, US, and dactylitis. Data regarding the reported features of dactylitis were collected and categorized, and the metrological qualities of the studies were assessed.

RESULTS

The most commonly described features of dactylitis were flexor tendon tenosynovitis and joint synovitis (90%). Extratendinous soft tissue thickening and extensor tendonitis were described nearly equally as being present and absent. Discrepancy exists as to whether entheses proper contribute to the etiology of dactylitis. An increasing number of studies categorize abnormalities in several tissue compartments including the soft tissue, tendon sheaths, and joints, as well as ligaments.

CONCLUSION

The understanding of which tissues contribute to dactylitic inflammation has evolved. However, there is a lack of literature regarding the natural history of these abnormalities. This systematic review provides guidance in defining elementary lesions that may discriminate dactylitic digits from normal digits, leading to development of a composite measure of activity and severity of dactylitis.

Ultrasound Imaging Module: Report from the GRAPPA 2012 Annual Meeting

At previous annual meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members resolved to develop dactylitis and enthesitis ultrasound research projects. Sonography can depict many anatomic alterations in the digits of patients with dactylitis and can also study vascularity of these tissues noninvasively. At the 2012 GRAPPA meeting, the ultrasound workgroup outlined steps in developing a dactylitis outcome measure: determining sonographic elemental lesions; testing to see which of these are the most discriminant in separating dactylitic digits from normal digits; selecting final elements for a sonographic dactylitis index; and conducting validity and reliability testing. A brief update of the enthesitis project was also presented.

On defining musculoskeletal inflammation: a report from the GRAPPA 2011 annual meeting

At the 2011 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members discussed the need to develop a framework for defining inflammatory arthritis, enthesitis, dactylitis, and spondylitis, particularly as they relate to psoriatic arthritis (PsA). GRAPPA members first addressed this subject at their 2010 meeting, where the CASPAR (ClASsification of Psoriatic ARthritis) criteria were discussed. Although these are classification criteria, the CASPAR are also often applied as a diagnostic measure by clinicians screening for PsA, particularly its core criterion: recognizing the presence of inflammatory musculoskeletal disease. In breakout group discussions, GRAPPA members discussed the difficulties in recognizing overlapping or mimicking features that may result in underdiagnosing or misdiagnosing PsA.

Differential diagnosis and management of ankylosing spondylitis masked as adhesive capsulitis: a resident's case problem

STUDY DESIGN

Resident's case problem.

BACKGROUND

Ankylosing spondylitis is a potentially debilitating seronegative spondyloarthropathy, with inflammatory low back pain as the most commonly reported symptom. In the absence of low back pain, identification of other diagnostic criteria or associated impairments and joint involvement, such as involvement of the hip or shoulder, may be beneficial.

DIAGNOSIS

A 32-year-old man with right shoulder pain and decreased range of motion was referred with a diagnosis of adhesive capsulitis. He had been managed by multiple healthcare providers for 3 years before being referred to a physical therapist. Glenoid labral pathology was evident on prior magnetic resonance imaging, which had led to a persistent focus on the shoulder. The evaluation by the physical therapist revealed significant mobility deficits in the cervical, thoracic, and lumbar spine. Radiographs and laboratory tests were ordered and a referral was made to rheumatology after the initial physical therapy assessment. The diagnostic work-up confirmed the diagnosis of ankylosing spondylitis and led to multidisciplinary management of the disease.

DISCUSSION

Low back pain is often the primary symptom of ankylosing spondylitis later in the disease process. Earlier indicators of ankylosing spondylitis, such as severely impaired mobility and spine stiffness, may help guide detection in the absence of spinal pain. In this case, an appropriate diagnosis led to improvement in the management strategy of what might have appeared to be unrelated shoulder pain. Early differential diagnosis is important, as emerging interventions show promise when used earlier in the disease process.

Tuberculosis of the hand

There has been recent interest in tuberculosis of the hand because of a rising incidence owing to increasing numbers of immigration, an aging population, and immunosuppressed people including affected patients with human immunodeficiency virus. In this article, we review the epidemiology, bacteriology, pathophysiology, diagnosis, and principles of treatment of tuberculosis of the hand. The second part of the report emphasizes the classification of hand tuberculosis (cutaneous lesions, tenosynovitis, bursitis, osteomyelitis, arthritis, and tuberculous hypersensitivity reactions) along with the classic presentations of each of these hand lesions.

Inflammatory musculoskeletal disease: identification and assessment

Diagnosis of psoriatic arthritis (PsA) is complex because not all patients with psoriasis and musculoskeletal symptoms of pain, stiffness, and dysfunction have PsA. Instead, they may have other inflammatory conditions such as rheumatoid arthritis, gout, or septic arthritis, or noninflammatory conditions such as osteoarthritis, recurrent tendonitis, mechanical back pain, or a myriad other musculoskeletal conditions. To acquire skill in diagnosing and monitoring the disease course of PsA, a clinician must recognize that there are multiple clinical domains that may be affected, including peripheral joints, entheseal insertion sites, dactylitis, and the spine. They must also appreciate the clinical features (history and physical examination) that are characteristic of immunologic inflammation and know how to utilize and interpret laboratory and imaging studies. Rheumatologists are expected to be skilled in these assessments. It is also helpful for dermatologists, primary care physicians, and other clinicians who work with psoriasis patients to have a working knowledge of assessments in PsA in order to identify and triage the patient for optimal management. Features that assist identification and assessment of PsA are reviewed in this article.

Evaluation of nail disease in psoriatic arthritis by using a modified nail psoriasis severity score index

BACKGROUND

The Classification of Psoriatic Arthritis Study Group published new criteria for classifying psoriatic arthritis (PsA) which included nail psoriasis. Our aim was to clarify the clinical importance of nail disease in PsA patients.

METHODS

We investigated the types and severity of nail disease by using the modified nail psoriasis severity score index (mNAPSI) in 23 PsA patients and 23 patients with uncomplicated psoriasis. We analyzed the relationships of mNAPSI with nail fold psoriasis, psoriasis area and severity index score, swollen and/or tender joint counts, distal interphalangeal (DIP) joint disease, acute phase reactants and the score on the Japanese version of the standard health assessment questionnaire.

RESULTS

The mNAPSI in 23 PsA patients was higher than that of controls (4.8 ± 5.3 vs. 2.3 ± 3.7, P < 0.05). The severity of fingernail disease in PsA patients was significantly associated with DIP joint disease (8.6 ± 5.9 vs. 3.1 ± 3.3, P < 0.05) and nail fold psoriasis (6.7 ± 5.2 vs. 3.5 ± 5.2, P < 0.05). There were no correlations between the mNAPSI and other systemic involvements.

CONCLUSIONS

The nail involvement and prolonged nail bed psoriasis were common in PsA patients. Nail fold psoriasis and DIP joint arthritis were associated with nail involvement in PsA patients. Nail psoriasis would be related to the Koebner phenomenon and local inflammatory DIP joint arthritis in PsA patients, and we suggested that nail involvement in PsA was among the disorders indicative of distal phalanx enthesitis.

Classification criteria for psoriatic arthritis and ankylosing spondylitis/axial spondyloarthritis

The concept of spondyloarthritides (or spondyloarthropathies, SpAs) that comprises a group of interrelated disorders has been recognised since the early 1970s. While the European Spondyloarthropathy Study Group (ESSG) criteria and the Amor criteria have been developed to embrace the entire group of SpAs, new criteria for psoriatic arthritis have been developed recently. The Classification of Psoriatic Arthritis (CASPAR) study, a large one of more than 1000 patients, led to a new set of validated classification criteria for psoriatic arthritis. Since their publication in 2006 the CASPAR criteria are widely used in clinical studies. In ankylosing spondylitis, the 1984 modified New York criteria have been used widely in clinical studies and daily practice but are not applicable in early disease when the characteristic radiographical signs of sacroiliitis are not visible but active sacroiliitis is readily detectable by magnetic resonance imaging (MRI). This led to the concept of axial SpA that includes patients with and without radiographical damage; candidate criteria for axial SpA were developed based on proposals for a structured diagnostic approach. These criteria were validated in the Assessment of Spondyloarthritis International Society (ASAS) study on new classification criteria for axial SpA, a large international prospective study. In this new criteria, sacroiliitis showing up on MRI has been given as much weight as sacroiliitis on radiographs, thereby also identifying patients with early axial SpA. Both the CASPAR and the ASAS criteria for axial SpA are likely to be of use as diagnostic criteria.

Rheumatologic manifestations of sarcoidosis

Sarcoidosis is a systemic, clinically heterogeneous disease characterized by the development of granulomas. Any organ system can be involved, and patients may present with any number of rheumatologic symptoms. There are no U.S. Food and Drug Administration-approved therapies for the treatment of sarcoidosis. Diagnosing sarcoidosis becomes challenging, particularly when its complications cause patients' symptoms to mimic other conditions, including polymyositis, Sjögren syndrome, or vasculitis. This review presents an overview of the etiology of and biomarkers associated with sarcoidosis. We then provide a detailed description of the rheumatologic manifestations of sarcoidosis and present a treatment algorithm based on current clinical evidence for patients with sarcoid arthritis. The discussion will focus on characteristic findings in patients with sarcoid arthritis, osseous involvement in sarcoidosis, and sarcoid myopathy. Arthritic conditions that sometimes coexist with sarcoidosis are described as well. We present two cases of sarcoidosis with rheumatologic manifestations. Our intent is to encourage a multidisciplinary, translational approach to meet the challenges and difficulties in understanding and treating sarcoidosis.

A case of psoriasis vulgaris with diffuse idiopathic skeletal hyperostosis involved with ossifications of posterior and anterior longitudinal ligament

Diffuse idiopathic skeletal hyperostosis (DISH) is difficult to distinguish from various forms of inflammatory arthritis, including psoriatic arthritis (PsA), rheumatoid arthritis, and ankylosing spondylitis. A 67-year-old Japanese male had been treated for psoriasis vulgaris for 13 years. Numbness of his right arm and lower limbs and spinal stiffening had developed 7 years prior to his initial evaluation at our facility. He noticed pain mainly while exercising. There were symmetrical marginal syndesmophytes in the spine, from the thoracic vertebrae to the upper lumbar vertebrae, on radiological examinations. We therefore suspected DISH. Furthermore, ossifications of the posterior and anterior longitudinal ligaments were noted in the cervical spine. Laboratory examinations revealed a normal peripheral white blood cell count, serum C-reactive protein, and erythrocyte sedimentation rate, and he was negative for rheumatoid factor. We detected human leukocyte antigen B39 but not B27. All distal interphalangeal joints were swollen but without pain. X-ray imaging showed narrowing of the joint space, and the consolidation of the joint was recognized, but there was no new juxta-articular bone formation. Based on clinical and radiological findings, we concluded that he had DISH and not PsA. DISH was indicated by marked radiological features of the axial skeleton, particularly the thoracic spine, but may also have involved the peripheral joints. DISH is one of the entheseal disorders, and 10% of Japanese middle-aged and elderly men have DISH. Therefore, the differentiation of DISH from PsA is necessary in psoriasis patients with spinal involvement.

Dactylitis, a term for different digit diseases

Dorland's Illustrated Medical Dictionary gives the following definition of dactylitis (deltaalphachitauupsilonlambdaomicronsigma = digit): 'inflammation of a finger or toe'. Although any inflammatory process involving the fingers or toes may be called dactylitis, the term has entered in current use only in some well-defined entities. These differ in the involved tissue of the digit and in the type of involvement. Tuberculous dactylitis is the variant of tuberculous osteomyelitis affecting the short tubular bone of the hands and feet. Radiographs typically show a central, lytic, cystic, and expansive lesion known as spina ventosa. Syphilitic dactylitis is a manifestation of congenital syphilis. Radiological findings mimic those of tuberculous dactylitis but the involvement is bilateral and symmetric. Sarcoid dactylitis is due to typical non-caseating granulomas invading the phalanges and the adjacent soft tissue. Blistering distal dactylitis is an infection of the anterior fat pad on the volar surface of the distal portion of a single finger or more rarely a toe, mostly caused by group A beta-haemolytic streptococci. Sickle cell dactylitis, also known as 'hand-foot syndrome', is due to localized bone marrow infarction of the carpal and tarsal bones and phalanges. Spondyloarthritis dactylitis, also called 'sausage-like' digit, is a diffuse painful swelling of the fingers and toes. Recent ultrasonography (US) and magnetic resonance imaging (MRI) studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and that the enlargement of the joint capsule is not an indispensable condition for the 'sausage-like' feature. There is no evidence of enthesitis of flexor digitorum tendons and joint capsule.

Epidemiology and clinical pattern of psoriatic arthritis in Germany: a prospective interdisciplinary epidemiological study of 1511 patients with plaque-type psoriasis

BACKGROUND

Because psoriatic arthritis (PsA) usually develops years after the first manifestation of skin symptoms, in many cases the initial diagnosis of PsA depends on the dermatologist.

OBJECTIVES

To investigate the prevalence and clinical pattern of PsA in a daily practice population of patients with psoriasis.

METHODS

Patients were enrolled in an observational prospective cross-sectional cohort study at 48 community and academic centres. Demographic and medical parameters were recorded, including severity of skin symptoms (Psoriasis Area and Severity Index, PASI), previous and current treatments, concomitant diseases, and the impact of psoriasis on productivity and health-related quality of life (Dermatology Life Quality Index, DLQI). Patients with joint symptoms were referred to a rheumatologist for diagnosis and to record the activity and pattern of arthritis.

RESULTS

Among 1511 patients 20.6% had PsA; in 85% of the cases PsA was newly diagnosed. Of these patients more than 95% had active arthritis and 53.0% had five or more joints affected. Polyarthritis (58.7%) was the most common manifestation pattern, followed by oligoarthritis (31.6%) and arthritis mutilans (4.9%). Distal interphalangeal involvement was present in 41.0% and dactylitis in 23.7% of the patients. Compared with patients without arthritis, patients with PsA had more severe skin symptoms (mean PASI 14.3 vs. 11.5), a lower quality of life (mean DLQI 11.6 vs. 7.7) and greater impairment of productivity parameters.

CONCLUSIONS

The findings are consistent with a high prevalence of undiagnosed cases of active PsA among patients with psoriasis seen by dermatologists. As many of these patients also have significant skin symptoms, treatment strategies are required that are equally effective in the control of skin and joint symptoms of psoriasis.

Gout, have we met before? No, not like this

LEARNING OBJECTIVES

Extra-articular symptoms could be the first manifestation of gouty arthritis (GA); polyarticular GA can mimic an infectious arthritis; infection can complicate GA.

CASE

A 66-year-old male with a history of gout presented with high fever and excruciating bilateral calf pain for 1 day. Examination revealed chronic knee effusions; range of motion in both knees was limited by calf pain. Joint aspiration showed negatively birefringent intracellular crystals and normal gram stain.

HOSPITAL COURSE

While receiving empiric antibiotics fever continued and he developed bilateral knee, right ankle, and shoulder pain. After demonstration of urate crystals and exclusion of infection, antibiotics were discontinued and steroids initiated. Fever, calf pain, and polyarthritis quickly resolved.

DISCUSSION

Polyarticular gouty attack is an uncommon presentation of gout, and can mimic several other conditions. An exceptional presentation of this entity is excruciating calf pain, probably caused by tenosynovitis or referred pain preceding an acute polyarticular gouty attack.

Dactylitis: Pathogenesis and clinical considerations

Dactylitis is considered a hallmark feature of psoriatic arthritis (PsA), but it is found in other spondyloarthropathies, especially reactive arthritis, and other conditions (eg, sarcoidosis, gout, sickle cell disease, and a variety of infections). Dactylitis is difficult to define and assess with any level of consensus and consistency in PsA. A new objective measure has been developed to make assessment more uniform for clinical trials. The underlying pathophysiology has also been difficult to determine in spondyloarthropathy: synovitis, tenosynovitis, and enthesitis have all been recognized. The pathophysiology in other conditions varies but usually involves soft tissue and sometimes involves bone or joint. In non-spondyloarthropathies,treatment is determined by the underlying cause. Research on dactylitis treatment in PsA suffers from a paucity of trials and inconsistent outcome measurement. The only drug with good evidence of benefit from randomized controlled trials thus far is infliximab.

Psoriatic arthritis: One or more diseases?

Psoriatic arthritis (PsA) is a common, debilitating auto-immune disease with diverse clinical features. In this paper, published evidence is examined, which addresses the issues that (a) PsA exists; and (b) PsA can or cannot be viewed as a distinct rheumatic disease from other spondyloarthritides. Evidence derived from epidemiological, clinical, genetic and immunohistological studies is included. Summarizing the evidence, it is clear that PsA does indeed exist, with the prevalence of rheumatic disease in patients with psoriasis (Ps) higher than would be expected. Certain clinical features also occur more commonly in PsA, although none can differentiate consistently from other arthropathies. Both genetic and immunohistological studies suggest that PsA, both oligo- and polyarticular disease, can be clearly separated from rheumatoid arthritis and that it belongs to the family of spondyloarthritides. The presence of Ps may confer a more severe clinical phenotype with poor radiological outcome. It may be that, with time, a specific genetic marker or diagnostic feature will emerge; additional, more detailed pathogenic studies are required. In the meanwhile, particularly with new treatments being evaluated, it is important to continue to develop specific classification or diagnostic criteria and to define both clinical and laboratory-based outcome measures.

Dactylitis in psoriatic arthritis: a marker for disease severity?

AIM

To describe dactylitis in a large cohort of patients with psoriatic arthritis followed prospectively in a specialist clinic, and identify whether it is associated with a worse prognosis.

METHODS

Between 1979 and 1999, 537 patients were registered in the psoriatic arthritis clinic and entered onto a longitudinal database. Patients were followed prospectively at six to 12 month intervals according to a standard protocol, and all information was entered onto a database. The database was searched for patients with dactylitis. Descriptive statistics were used to describe the population and chi(2) tests to relate dactylitis to radiographic changes.

RESULTS

Dactylitis was documented in 260 patients (48%); 69% of the episodes were recorded at presentation to the clinic. Dactylitis affected feet only in 65% of cases, hands only in 24%, and both hands and feet in 12%. Recurrent dactylitis occurred in 44% of the patients. Increased radiological progression was noted in digits showing dactylitis compared with those without dactylitis (50% v 38%, respectively; p<0.0001).

CONCLUSIONS

Dactylitis is common among patients with psoriatic arthritis. It most often affects the feet, in an asymmetrical distribution. It is associated with a greater degree of radiological damage than occurs in digits not affected by dactylitis.

Unusually prolonged course of tuberculous dactylitis with osteitis

We report a case of tuberculous dactylitis that was unusual in two regards: the bone was infected, and the course was prolonged and atypical, with a spontaneous clinical remission followed by a recurrence that led to the diagnosis.

Dactylitis in a patient with brucellosis

Dactylitis is an important feature of inflammatory arthritis and unusual complication of osteoarticular brucellosis. We report a case of dactylitis of the index finger in a female patient with brucellosis.

Psoriatic arthritis and the spectrum of syndromes related to the SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome

During the past year, the increasing use of nuclear magnetic resonance imaging techniques, with their ability to delineate cartilage and ligamentous structures and to identify edema, are providing a radical improvement in ascertainment of musculoskeletal abnormalities, although their significance remains incompletely delineated. A second theme has come from the study of spondyloarthropathies in different ethnic groups and societal environments, revealing that the Northern European and North American form of the disease, with its powerful association with HLA-B27, is little evident in the rest of the world's population and that different susceptibility genes and environmental factors operate in other regions and peoples. Related to this theme is the compelling evidence of the marked influence of HIV infection on the development of spondyloarthropathies in Africa. Two areas of immune recognition are discussed as examples of emerging fields that may provide useful paradigms for the experimental approach to mechanisms in psoriatic arthritis. One of these is the three-cell model of CD8 T-cell interaction, in which a dendritic cell presents a peptide from an immunogenic protein to both a CD4 and CD8 T-cell clone, providing a cognitive interaction that disrupts tolerance and results in the expansion of the cytotoxic T-cell clone. In this respect, the combination of an activated dendritic cell, together with enhanced availability of arthritogenic microbial antigens caused by microbial persistence, are interesting candidates to explore as the basis of the HIV-associated rheumatic diseases. The second area of immune recognition is the growing understanding of the outline of the solution to the problem of the association of a spondyloarthropathy with several

Clinical aspects, outcome assessment, disease course, and extra-articular features of spondyloarthropathies

Much has been written over the years regarding the clinical aspects and disease course of the spondyloarthropathies, but publications relating to outcome assessment that attempt to relate measures of process with outcome are few. Extra-articular features of the spondyloarthropathies, eg, uveitis, colitis, and aortitis, are well described, but in the past few years there has been an increasing interest in the incidence of osteoporosis in this group of patients, particularly those with ankylosing spondylitis. In rheumatoid arthritis functional indices have been developed, such as the Health Assessment Questionnaire score, which has been shown to be robust in monitoring response to therapy, but the situation is quite different in a condition such as ankylosing spondylitis. In the last few years a number of functional indices have been developed that are now beginning to be applied to monitor response to treatment in the spondyloarthropathies. The impact of ankylosing spondylitis in women is an area that has been neglected in the past, and a recent review addresses the effects of the disease on the reproductive capacity in women. This overall review of the past year's publications from the clinical aspects of ankylosing spondylitis confirms that clinical research still has much to contribute to this fascinating group of disorders.