Laboratory findings in psoriatic arthritis

Psoriatic arthritis (PsA) has been classically defined as an inflammatory arthritis associated with psoriasis. However, in comparison with other relevant inflammatory arthropathies, in which a definite diagnosis is frequently possible only by means of laboratory investigations, in PsA true laboratory diagnostic markers are lacking. Some markers are utilised more to differentiate other diseases than to characterise PsA. For example in polyarticular PsA, which may be in some cases indistinguishable from RA, the rheumatoid factor (RF) or the more specific and recently introduced antibodies to cyclic citrullinated peptides (anti-CCP), may be useful to better identify RA. However, RF was found in 5% to 13% of patients with PsA, and anti-CCP may be observed in almost similar percentage. The determination of ESR and/or CRP is frequently disappointing in PsA, since they are both elevated in only half of the patients with PsA. However, ESR and/or CRP are included in the most utilised response criteria for RA, such as ACR and DAS, and, in addition are also considered reliable in the assessment of PsA. Furthermore, elevated levels of ESR have been proposed as one of the best predictors of damage progression and, in addition, a low ESR seems protective, while an ESR >15 mm/h is one of the factors associated with an increased mortality in PsA. The synovial fluid (SF) effusion is much higher in PsA, in comparison with other arthropathies. When available, SF analysis may offer additive information useful for the diagnosis, such as the increased number of leukocytes, which underlines the inflammatory nature of the effusion even in a patient with normal serum levels of acute phase response. We found that elevated IL-1 levels in SF of patients with early disease (<6 months), may be predictive of an evolution in polyarticular form at follow-up. This observation is in keeping with the crucial role that inflammatory cytokines play in PsA, probably related to a genetic predisposition. The recent introduction in PsA of anti-TNF-alpha agents and the demonstration of their efficacy in the management of many clinical disease expressions including peripheral arthropathy, axial involvement, enthesopathy and skin manifestations, have stimulated the research also in the field of the possible laboratory markers.

Articular manifestations in inflammatory bowel disease patients: a prospective study

BACKGROUND AND AIMS

Rheumatic manifestations are frequent in inflammatory bowel disease (IBD) and are associated with a wide range of clinical patterns.

METHODS

Articular symptoms and signs were investigated by questionnaire in a cohort of 651 pts, mean age 42+/-14 years, followed at two referral hospitals over a 12-month period.

RESULTS

142 ulcerative colitis (UC) and 120 Crohn's disease (CD) patients referred articular pain during their IBD history: in 46% this was associated with active IBD, in 56% symptoms were intermittent and in 19% symptoms preceded IBD diagnosis. 62 pts (28 UC, 34 CD) complaining of articular symptoms at the time of the interview, were investigated by the rheumatologist: arthropathy was axial in 52%, oligoarticular in 16% and polyarticular in 23%. Oligoarthritis commonly involved the lower limbs and was more commonly associated with UC. The mean number of small joints involved was significantly higher in CD than in UC pts (9.9+/-8.2 vs. 5.6+/-4.3; p<0.01). Bone scintigraphy was abnormal in 70% of pts.

CONCLUSIONS

Prevalence of self-reported articular symptoms in IBD patients exceeds 40% with 9.5% incidence during 1-year follow up. Symptoms predict entheropatic involvement of the locomotor system.

[Antinuclear, anti-dsDNA and anti-ENA antibodies in patients affected with rheumatoid arthritis or ankylosing spondylitis during treatment with infliximab]

OBJECTIVE

We evaluated the induction and clinical significance of ANA, anti-dsDNA and anti-ENA during infliximab therapy in patients with Rheumatoid Arthritis (RA) or Ankylosing Spondylitis (AS).

METHODS

We tested sera from 30 RA and 30 AS patients before and during treatment with infliximab. ANA and antidsDNA were determined by indirect immunofluorescence and anti-ENA by an "in house" counterimmunoelectrophoresis. Statistical analysis was performed by X2 and McNemar's tests and U-test of Mann-Whitney.

RESULTS

Eight of the 30 RA patients and 1 of the 30 AS patients were positive for ANA before treatment with infliximab. Eighteen of the 22 (81.8%) negative patients with RA and 11 of the 29 (37.9%) negative patients with AS became positive for ANA during infliximab treatment. No ANA positive patients became negative during the therapy. The difference between ANA before and after treatment resulted significant in both RA and AS patients (p=0.001). The frequency of anti-dsDNA and anti-ENA did not change significantly from baseline, in both RA and AS patients. Acquired ANA positivity was not associated with clinical signs of lupus syndrome and was not correlated with adverse events. The mean values of ESR and CRP in RA patients who became positive for ANA were significantly decreased (p=0.01 and p=0.02 respectively).

CONCLUSIONS

Infliximab treatment induced a significant increase in the frequency of ANA in RA and AS patients. The significance of ANA development in these diseases is at present unknown. The significant decrease of ESR and CRP in RA patients who became positive for ANA after treatment should be investigated in a larger number of patients.

[The enthesopathy of vitamin D-resistant osteomalacia in adults]

A case of an adult patient with vitamin D-resistant osteomalacia or X-linked hypophosphatemic osteomalacia (XLH) with diffuse calcification of entheses is reported. XLH is the most frequent cause of rickets in developed countries. It is characterized by an impaired renal transport of the phosphate and mutation of PFEX (phosphate regulating gene, with homologies to endopeptidase on the X-chromosome). In childhood, the classic clinical presentation includes short stature and bow leg. While at this age the main radiographic features are characterised by rickets, in adult life they are dominated by a generalised calcific enthesopathy. Concerning the pathogenesis of the enthesopathic lesions of XLH, no convincing hypothesis has yet been made. As in our patient, the extension and the severity of enthesopathy seems not related to the severity of the biochemical changes nor to the treatment with calcitriol. The calcified enthesopathy is an integral part of XLH and it is possible that it is found in adult because many years are necessary to produce it.

Autoinflammatory syndromes

The autoinflammatory disorders are a new and expanding classification of inflammatory diseases characterized by recurrent episodes of systemic inflammation in the absence of pathogens, autoantibodies or antigen specific T cells. These disorders are caused by primary dysfunction of the innate immune system, without evidence of adaptive immune dysregulation. Innate immune abnormalities include aberrant responses to pathogen associated molecular patterns (PAMPs) like lipopolysaccharide and peptidoglycan, prominent neutrophilia in blood and tissues, and dysregulation of inflammatory cytokines (IL-1beta, TNF-alpha) or their receptors. The autoinflammatory diseases comprise both hereditary (Familial Mediterranean Fever, FMF; Mevalonate Kinase Deficiency, MKD; TNF Receptor Associated Periodic Syndrome, TRAPS; Cryopyrin Associated Periodic Syndrome, CAPS; Blau syndrome; Pyogenic sterile Arthritis, Pyoderma gangrenosum and Acne syndrome, PAPA; Chronic Recurrent Multifocal Osteomyelitis, CRMO) and multifactorial (Crohn's and Behçet's diseases) disorders. Mutations responsible for FMF, TRAPS, CAPS, PAPA are in proteins involved in modulation of inflammation and apoptosis.

[Tenosynovitis of the ankles as onset of sarcoidosis in a patient with ulcerative colitis]

Arthritis and tenosynovitis are frequently reported as complications of inflammatory bowel diseases. About 10% of patients with ulcerative colitis presents articular inflammation, usually in the phases of activity of intestinal disease. Tenosynovitis is also a frequent complication of ulcerative colitis. We describe here a case of tenosynovitis of both ankles occurring in a patient affected by ulcerative colitis not in active phase. Chest X-ray and TC showed hilar lymph node enlargement and transbronchial biopsy confirmed the diagnosis of sarcoidosis. In this disease tenosynovitis is very rare, unlike arthritis that is rather common. In conclusion we observed a case of ankle bilateral tenosynovitis as onset manifestation of sarcoidosis.

Value of C reactive protein in the assessment of erosive osteoarthritis of the hand

OBJECTIVE

To investigate the value of serum C reactive protein (CRP) as a marker of erosive osteoarthritis (EOA) of the hand.

METHODS

Ninety eight patients, 67 with EOA and 31 with non-EOA of the hand, were included in the study and analysed for radiographic score (RS), number of erosions, and joint count (JC) at clinical observation and at bone scintigraphy. CRP was assayed in a serum sample by a highly sensitive immunonephelometric method.

RESULTS

The median (interquartile range) CRP level was 4.7 (2.4-6.9) mg/l in the EOA and 2.1 (0.5-4.9) mg/l in the non-EOA group (p = 0.001). In all patients, CRP correlated with RS (r(s) = 0.43, p<0.001), and mainly with JC at clinical observation (r(s) = 0.72, p<0.001) and at bone scintigraphy (r(s) = 0.47, p<0.001). The correlation of CRP with RS and JC was confirmed at clinical observation and at bone scintigraphy in the EOA subgroup, but only with JC at clinical observation in the non-EOA subgroup.

CONCLUSIONS

CRP levels are higher in EOA than in non-EOA patients. These levels probably reflect the disease activity of EOA, as suggested by correlations between CRP and JC at clinical observation and at bone scintigraphy.

[The prevalence of radiographic sacroiliitis in patients affected by inflammatory bowel disease with inflammatory low back pain]

Inflammatory bowel diseases (IBD), as Crohn's disease (CD) or ulcerative colitis (UC), are frequently complicated by joint complaints with prevalence that varies between 10 and 28%. The IBD related arthropathy may be expressed as peripheral arthritis or axial one frequently indistinguishable from the classical ankylosing spondylitis (AS). According to ESSG criteria for spondyloarthropathy, the presence of synovitis or the inflammatory back pain (IBP) in IBD patients is diagnostic for spondyloarthropathy, but for diagnosis of ankylosing spondylitis also radiological criteria must be fulfilled. There are few studies regarding the radiological prevalence of sacroiliitis in patients with IBD. We examined, by plain film radiograms of pelvis, 100 sacroiliac joints (SJ) of 50 IBD patients with IBP. The New York (1984) SJ radiological score with gradation from 0 to 4 was applied. Total sacroiliac score (SJS) was summarized between left and right side (from 0 to 8). Fourteen patients fulfilled New York modified criteria for AS and 8 patients had unilateral 2nd grade sacroiliitis. Only 4 of 14 AS patients (28%) were HLA B27 positive. Thirty patients had localized IBP, 10 extended to buttock and 4 extended to sacrum. Sixteen patients had sciatica-like extension of back pain. A difference in SJS between left and right side was observed only in CD patients (1.3 +/- 0.8 and 0.8 +/- 0.9 respectively; p < 0.05), but not in UC (1.5 +/- 1.2 vs 1.5 +/- 1.3; p = ns) nor in total IBD patients (1.4 +/- 1.0 vs 1.2 +/- 1.2; p = ns). Total SJS was higher in UC respect CD, but not significantly (2.9 +/- 2.3 vs 2.1 +/- 1.5; p = ns). Our data confirm the importance of these symptoms in patients with IBD, who need to be carefully investigated also for these aspects.

Serum human cartilage glycoprotein 39 as a marker of arthritis associated with inflammatory bowel disease

BACKGROUND

Common blood markers of arthritis are difficult to interpret in arthritis associated with inflammatory bowel disease (IBD) owing to the coexistence of two inflammatory events. No specific serological disease marker is available for IBD.

OBJECTIVE

To determine a value of serum human cartilage glycoprotein 39 (HC gp39) as a marker of arthritis associated with IBD.

METHODS

Serum levels of HC gp39 and ultrasensitive C reactive protein (CRP) were determined in 121 patients with IBD: 58 without arthritis (IBD-nonA) and 63 with arthritis (IBD-A), and in 20 healthy controls. IBD was classified as active (aIBD) and non-active (naIBD), and patients with IBD-A were classified as type I, II, and III arthritis by clinical activity indices.

RESULTS

HC gp39 was higher in IBD-A than in IBD-nonA (p<0.001) and controls (p<0.01), while no difference was found between IBD-nonA and controls. CRP was increased in both IBD-A and IBD-nonA compared with the controls (p<0.01 and <0.05, respectively) and in aIBD-nonA v naIBD-nonA (p<0.05), but no difference in CRP was found between aIBD-A and naIBD-A. Finally, a correlation was found between the number of affected joints (NAJ) and HC gp39 (r = 0.6, p<0.001).

DISCUSSION

Increased serum levels of HC gp39, which were higher in IBD-A than in IBD-nonA, suggest that this substance might be a marker of arthropathy in IBD. HC gp39, because of its relationship with NAJ in IBD-A, may also be proposed as a disease activity marker in arthritis associated with IBD.

[Osteochondritis dissecans of the scaphoid (Preiser's syndrome): 2 case reports]

Preiser's syndrome is a rare osteochondrosis affecting the carpal scaphoid, frequently related with an avascular necrosis. Osteoarthritic changes of the articular cartilage, local synovitis, and loose fragments are the most common findings associated with this syndrome. We report here two patients with Preiser's syndrome, one with and one without a traumatic history, both presenting with pain, swelling and functional impairment of the wrist. In one patient radiography was sufficient for the diagnosis, in the other NMR was necessary to clearly establish type and extension of the lesion. Differential diagnosis may be sometimes difficult and the therapeutic approach depends on several aspects, including etiology and type of occupational activity.

[Cardiac tamponade preceding skin involvement in progressive systemic sclerosis]

The frequency of pericardial involvement in Systemic Sclerosis (SSc) is high on autoptic or echocardiographic studies, but the clinical recognition of pericarditis with or without effusion is rare. We describe a case of a 71-year-old female with no previous history of heart disease, who presented with a large pericardial effusion and tamponade that required pericardial drain. She had suffered from Raynaud's phenomenon since 25 years. Six weeks after hospital discharge she complained of skin hardening on left leg. Pericardial tamponade is a very rare manifestation of SSc and occurs both early or late in the course of the disease, but in our case it preceded the recognition of scleroderma. We have only identified two other cases of pericardial effusion preceding cutaneous involvement in scleroderma.