psoriatic arthritis
Introduction
Introduction to psoriatic arthritis Psoriasisarthritsi (PA), also known as arthropathicpsoriasis, is an inflammatory joint disease associated with psoriasis. The disease course is prolonged, easy to relapse, and the formation of joint rigidity in the late stage, leading to disability. Psoriasis is more common in patients with arthritis, 2 to 3 times more than the general population, and arthritis is more common in patients with psoriasis. In a 10-year investigation, Leczinsky found that the incidence of arthritis in psoriasis was 6.8%, much higher than the incidence of arthritis in non-psoriatic patients. Women are more likely to suffer than men, and according to Nobol, PA accounts for about 1% of patients with psoriasis. Because of this disease and Reiter syndrome, ankylosing spondylitis is associated with HLA-B27, and rheumatoid factor is negative, and clinical manifestations have similarities, so it is classified as seronegative spondyloarthropathy. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: rheumatic heart disease ulcerative colitis nephritis
Cause
Causes of psoriatic arthritis
Genetics (20%):
In the pathogenesis of psoriatic arthritis, genetic factors are of significant importance and show genetic polygenicity. Early family studies suggest that PA is a disease in families with predisposing patients with psoriasis. The rate was increased. In one study, 11 of 88 patients with a priori had PA, and recently found histocompatibility antigens HLA-A1, B16, B17, B27, B39, Cw6 and D7 with psoriatic joints. About inflammation, about half of the patients have HLA-B27, while the histocompatibility antigens of psoriasis alone are HLA-B13, B17, Cw6 and DR7, McHugh found that HLA-DR7 is associated with chronic severe peripheral arthropathy; HLA-B27 A significant association with spondylitis or axial disease, adolescent psoriatic arthritis involving the ankle joint.
Immune abnormality (45%):
(1) The existing research evidence suggests that the immune mechanism plays an important role in the pathogenesis of psoriasis. HLA-DR antibody and monoclonal antibody OKT6 double-labeled immunofluorescence assay prove that HLA-DR+keratinocyte is present in silver. In psicoid lesions and synovial cells, not on normal-looking skin, nor on Langerhans cells, HLA-DR expression is associated with disease activity, with HLA-DR+ keratin In patients with cells, the incidence of psoriatic arthritis is high, so the use of immunochemical staining to examine HLA-DR+ keratinocytes in psoriatic lesions may help predict arthritis in patients with smut disease. High risk, HLA-DR4 is associated with the occurrence of bone erosion in arthritis.
(2) Viral or bacterial infections can cause immune abnormalities: It has recently been found that in people infected with human immunodeficiency virus (HIV), the incidence of psoriasis is higher than in the general population, and arthritis can occur at any stage of HIV infection, and symptoms Seriously, some people isolated HIV from joint fluid and confirmed it in monocytes and lymph.
In the plaque of psoriasis, Gram-positive bacteria accumulate and anti-streptococcal antibodies are elevated; in patients with psoriasis and psoriatic arthritis, lymphocyte transformation in synovial fluid enhances response to streptococcus .
The above evidence suggests that immune interactions and immune factors in psoriasis and joint disease are involved, DR+ keratinocytes, Langerhans cells or other similar cells can process bacteria or other antigens, and interact with dermal T cells. The role of the disease, but these can not prove that immune abnormalities are the main cause of psoriatic arthritis.
Environmental factors (15%):
Cold, damp, seasonal changes, mental stress, depression, endocrine disorders, trauma, etc., have been considered as important environmental factors that promote PA in individuals with genetic predisposition, and cases of osteolysis of the extremities after local trauma have occurred. It is reported that the mechanism of joint damage causing arthritis is similar to the Koebner phenomenon of psoriasis skin.
Prevention
Psoriatic arthritis prevention
At present, there are no effective preventive measures. Early diagnosis, early prevention and early treatment are the key to the prevention and treatment of this disease. Pay attention to health, do a good job of safety protection, reduce and avoid the irritating and accidental damage of adverse factors, can play a certain preventive role.
Complication
Psoriatic arthritis complications Complications rheumatic heart disease ulcerative colitis nephritis
Common complications of the disease: may be associated with visceral damage, such as rheumatic heart disease, ocular ocular membrane inflammation, hepatosplenomegaly, ulcerative colitis, nephritis, etc.; about 80% with finger (toe) nail damage.
Symptom
Symptoms of psoriatic arthritis Common symptoms refers to (toe) nail-like depression morning stiffness joint swelling joints strong point bleeding bleeding heart hypertrophy
PA usually insidious onset, pain is often lighter than rheumatoid arthritis, occasionally acute gout-like onset, age of onset is between 30 and 40 years old, children under 13 years of age are less common, joint symptoms and skin symptoms can be At the same time, it can be aggravated or relieved; it can cause joint symptoms after repeated recurrence of psoriasis; or with pustular and erythrodermic psoriasis complicated with joint symptoms, Gladman analyzes 220 cases of PA, 68% of initial psoriasis In patients, arthritis occurred after an average of 12.8 years; 15% of patients developed psoriasis and arthritis within 1 year; 17% developed arthritis, with an average of 7.4 years of psoriasis.
1. Joint performance: Moll et al. and Andrews classified the disease into five clinical types based on the characteristics of psoriatic arthritis:
(1) a small number of finger (toe) type: the most common, about 70%, for one or several knuckles involved, asymmetry, with joint swelling and tenosynovitis, so that the finger (toe) is intestinal expansion.
(2) Rheumatoid arthritis-like type: 15%, symmetry, multiple arthritis with claw-like hands, patients can show clinical features like rheumatoid arthritis, morning stiffness, symmetry involvement, proximal knuckles The spindle shape is swollen, and the ulnar side is skewed in the late stage. Occasionally, rheumatoid nodules or rheumatoid factor are positive. Some cases are diagnosed. These cases belong to the overlap of rheumatoid arthritis and psoriasis.
(3) Asymmetry distal interphalangeal joint type: 5%, mainly involving the distal (toe) joint, showing redness and deformity, often starting from the toe, and later involving other joints, the phalanx without ulnar deviation Oblique, the pain is lighter than rheumatoid arthritis, often accompanied by nail malnutrition, more common in men.
(4) Destructive arthritis type: 5%, severe joint destruction, multiple invading hands, multiple joints and ankle joints, characterized by progressive para-articular erosion, resulting in osteolysis, with or without bone Sexual joints are tough, resembling neuropathic joint diseases, and are painless. This type of skin psoriasis is often extensive and severe, and is a pustular or erythrodermic type.
(5) ankylosing spondylitis type: 5%, manifested as simple spondylitis or spondylitis overlap with peripheral arthritis, spinal lesions are non-marginal ligaments, especially in the thoracic and lumbar spine, stenosis and sclerosis Erosion of the intervertebral disc junction and osseous hyperplasia of the anterior border of the vertebral body, mainly in the lower part of the cervical vertebrae, peripheral arthritis involving the distal finger (toe) joint, manifested as bilateral symmetry or unilateral asymmetrical erosive arthritis, inflammation In addition to the synovial membrane, it can also enter the bone area along the tendon attachment point. Some patients may be affected by the ankle joint. The clinical features of this type are spinal stiffness, after the venous state and in the morning, lasting for more than 30 minutes.
2. Finger (toe) change: According to statistics, 80% of patients with PA have an abnormality of A, and A is involved, which can provide early diagnosis clues. Because the nail bed and the phalanx have a common blood supply source, the chronic psoriatic damage of the nail Causes vascular changes, and ultimately affects the joints underneath. It has been found that the degree of bone change is closely related to the severity of nail changes, and both often occur in the same finger (toe). Common changes in nails are: point depression, transverse, Mediastinum, discoloration, hyperkeratosis, nail removal, etc.
3. Skin manifestations : Skin damage occurs in the scalp and extremities, especially in the elbows and knees. It is scattered or generalized. The lesions are papules and plaques. They are round or irregular and are covered with rich silver. White phosphorous chips, after the scales are removed, reveal a shiny film, but in addition to the visible bleeding of the film (Auspitz sign), these three characteristics have diagnostic significance.
4. Other manifestations : In psoriatic arthritis, other systemic damage may be associated with: common anterior uveitis, conjunctivitis, scleritis, sclerosing keratitis; inflammatory bowel disease and gastrointestinal tract Amyloidosis; spondylotic heart disease, characterized by aortic regurgitation, persistent conduction block, unexplained cardiac hypertrophy, and may have systemic symptoms such as fever, weight loss, and anemia.
Examine
Examination of psoriatic arthritis
There is no specific detection method for this disease, ESR is increased, mild anemia, and 2 globulin are elevated, all of which are non-specific changes. About 10% to 20% of patients have mildly increased uric acid in the blood and rheumatoid factor is negative. Lupus cells, antinuclear antibodies and their autoantibodies are negative, synovial fluid examination is also non-specific, white blood cell count is 2 ~ 15 × 109 / L, mainly neutrophils, occasionally a large number of leukocytes in the leukocyte count can be Up to 100 × 109 / L, the viscosity of the synovial fluid is reduced.
This disease is similar to rheumatoid arthritis, often involving the distal interphalangeal joint, ankle joint and spine. The common X-ray manifests as cartilage disappearance; articular surface erosion; joint space narrows; disfigured arthritis shows Significant bone dissolving and rigidity, can appear "pen marks"; isolated marginal or non-marginal ligament callus; villous periostitis; osteoporosis and cystic changes in bone tissue.
Diagnosis
Diagnosis and diagnosis of psoriatic arthritis
diagnosis
Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.
Differential diagnosis
1. Rheumatoid arthritis: for migratory multiple arthritis, occurs in the small joints of the extremities, symmetric involvement, late metacarpophalangeal joints to the ulnar side, rheumatoid nodules visible in the skin, rheumatoid factor positive.
2.Reite syndrome: typical cases have non-specific urethritis, conjunctivitis, arthritis (especially lower extremity weight joints) and skin lesions, intrinsic patients may be accompanied by crustacean-like psoriasis rash, joint symptoms and silver Scab arthritis is very similar, and such atypical cases require a period of follow-up to be diagnosed.
3. Ankylosing spondylitis: occurs in men under the age of 30. Early symptoms include low back pain, lumbosacral discomfort, intermittent or bilateral sciatica, stiffness in the lower limbs and lower back, and late spinal and lower limbs become tough. The bow shape, the X-ray shows a bamboo-like deformity of the spine.
4. Gout: Acute arthritis caused by gout is acute, more than nocturnal, lessened during the day, repeated attacks over several months to several years, the formation of chronic gout, joint deformity and stiffness, according to clinical symptoms, hyperuricemia, Gout stone discharge, synovial fluid detected urate crystals; colchicine, allopurinol treatment is effective, help to identify.
