Psoriatic arthritis and associated uveitis
Introduction
Introduction to psoriatic arthritis and its associated uveitis Psoriatic arthritis is a seronegative (ie, serum rheumatoid factor-negative) arthritis that typically manifests as chronic, recurrent, benign papular scaly skin lesions, nail damage, Chronic, relapsing, erosive polyarthritis [peripheral and/or spinal joints] and ocular inflammation in which uveitis and conjunctivitis are the main lesions. basic knowledge Sickness ratio: 0.0001% Susceptible people: no special people Mode of infection: non-infectious Complications: cataract, optic disc edema, glaucoma, retinal detachment
Cause
Psoriatic arthritis and its associated uveitis etiology
Immunity factor (30%):
The cause of the disease is unknown, but there are immunological manifestations, such as serum IgG, IgA, IgE increase; anti-IgG antibody (RF) is found in 45% of patients, so the disease may be considered an autoimmune disease, and found that serum immune complexes increased This immune complex may be the pathogenesis of uveitis, infiltration of the cornea, and the immune complex can activate complement and cause inflammation.
Histopathology (30%):
The skin characteristics of this disease are thickening of the epidermis, acanthosis, and elongation of the skin nipple, which may increase epidermal mitotic activity and keratinization and reduce epidermal granules. The inflammation is superficial, dermal mononuclear cell infiltration, Epidermal neutrophil infiltration can also be seen.
Immune genetics (20%):
HLA-B27 and B17 increased by 3 to 4 times and HLA-DRW4 increased in patients with this disease.
Prevention
Psoriatic arthritis and its associated uveitis prevention
Once the diagnosis of uveitis, active treatment should be actively treated, dilated sputum is necessary for the treatment of anterior uveitis, can prevent pupillary adhesions, avoid secondary glaucoma and complicated cataract. Hormone is a common drug for the treatment of uveitis, but it has side effects. Whether it is systemic or topical, it must be used under the guidance of a doctor. It should not be abused. Patients with uveitis should be reviewed regularly to prevent recurrence. If symptoms of recurrence are suspected, they should be diagnosed early.
Complication
Psoriatic arthritis and its associated uveitis complications Complications cataract optic disc edema glaucoma retinal detachment
Can be complicated by banded corneal degeneration, cataract, macular and optic disc edema, macular surface pleat-like changes, corneal edema, glaucoma, retinal detachment and other serious complications.
Symptom
Psoriatic arthritis and its accompanying symptoms of uveitis common symptoms Uveitis hyperemia tribes sclera outer inflammation (toe) swelling keratitis granuloma joint tonic macular cystic edema corneal ulcer
Skin lesion
The typical lesion of psoriasis is a well-defined skin plaque with a deep red color and a "silver" scale (scaly) on the periphery. Therefore, the disease is also called "psoriasis", and the amount of surface scale is related to the location of the lesion. On the extremities of the limbs (such as the elbows, knees, and cheekbones), there are often thick, dry yellow-white scales, but in the body's flexion, the scales become moist and less conspicuous due to sweating and sebum secretion.
The whole body skin can be affected, and the face is usually rare. This may be because the ultraviolet rays in the environment have inhibitory and preventive effects on skin lesions. Skin pustules and erythema are also a common manifestation, which may occur locally or in large areas. Can have fever, chills, burnout, limb edema and so on.
About 15% to 30% of patients with psoriasis have nail and toenail involvement. In patients with arthritis, nails can be up to 80%. A depression is a classic nail damage, nail fading, lysis or loosening. Deposition with or without the deposition of keratin fragments under the nail is also a common manifestation, occasionally yellow-white vesicular lesions under the nail (oil-drop lesions).
2. Joint disease
The joint lesions of psoriasis can be expressed in various types of arthritis, and some people divide them into the following five types.
(1) Asymmetric single arthritis: This type accounts for 5% to 10%, mainly manifested as inflammation of the interphalangeal joint of the distal finger (toe) of the finger and toe, showing a diffuse finger (toe) swelling, showing a sausage shape. At the same time, accompanied by damage to the nails.
(2) Chronic asymmetric oligoarthritis: This type accounts for 50% to 70%, which can affect 2 to 3 joints at the same time.
(3) Chronic symmetry polyarthritis: This type accounts for 15% to 25%, and the clinical manifestations are similar to rheumatoid arthritis, but serum rheumatoid factor is negative.
(4) Spinal arthritis: This type accounts for 20% to 30%, which is more common in male patients, typically manifested as sacroiliitis, with or without spondylitis, and is closely related to HLA-B27 antigen.
(5) Disabling arthritis: This type accounts for about 5%, and arthritis shows persistent progression and leads to osteolysis, severe deformity and joint rigidity.
In the above types of arthritis, disabling arthritis often causes significant pain, and the consequences are much more severe than the other four types. Compared with rheumatoid arthritis, in addition to disabling arthritis and its consequences are similar. The pain and consequences of the other four types are much lighter.
3. Eye lesions
(1) anterior uveitis: anterior uveitis usually occurs in patients with psoriasis with arthritis. Patients with uveitis are generally older, and patients with ankle involvement are prone to anterior uveitis, HLA-B27 Patients with antigen-positive disease are also prone to anterior uveitis.
Uveitis associated with psoriatic arthritis can be characterized as acute recurrent non-granulomatous anterior uveitis, typically characterized by ciliary congestion or mixed hyperemia, dusty KP, usually with severe anterior chamber reaction, Significant anterior chamber flash and a large number of anterior chamber inflammatory cells, even anterior chamber empyema and anterior chamber fibrinous exudation membrane; can also be manifested as chronic non-granulomatous anterior uveitis, occult occult, both eyes involved, Inflammation lasts for more than 6 months, and the posterior segment of the eye is generally not involved, but in patients with chronic uveitis, the posterior segment of the eye may occasionally be affected, and secondary cystoid edema may also occur.
Because of this recurrent uvitis, prone to post-iris adhesions, secondary glaucoma and complicated cataract, in patients with secondary glaucoma, visual prognosis is poor, so prevention of post-iris adhesion is this uveitis One of the most important aspects of treatment.
(2) eyelids, conjunctival lesions: eyelids can appear similar to other parts of the skin changes, there may be simple erythema and swelling, chronic blepharitis, seborrheic dermatitis, loss of eyelashes.
Conjunctivitis is a common disease that accounts for about 20% of psoriatic arthritis with arthritis. It is characterized by non-specific inflammation, sometimes with catarrhal or purulent secretions, or with eyelids. Granuloma lesions of the conjunctiva, conjunctival and orbital lesions can cause lashes, trichiasis, valgus, sacral adhesions, dry eye and other complications after healing.
(3) Scleritis: about 2% and 1% of patients with psoriatic arthritis develop scleral inflammation and scleritis. These lesions occur many years after the disease occurs. In scleritis, anterior scleritis is more common. Type, but anterior necrotizing scleritis and posterior scleritis can also occur.
(4) corneal lesions: the most common keratopathy is superficial punctate keratitis, corneal opacity in the surface or deep, corneal neovascularization, corneal ulcer, peripheral corneal infiltration and limbal vesicular lesions.
The diagnosis of psoriatic arthritis with uveitis is based on typical skin lesions, nail lesions, peripheral arthritis (with or without ankle arthritis and spondylitis), and acute recurrent non-granulomatous anterior uveal Diagnosis such as inflammation.
Examine
Examination of psoriatic arthritis and its associated uveitis
Uric acid, RF and HLA-B 27, HLA-B17 examination, sometimes seen high uric acid, RF positive and HLA-B27, HLA-B17 positive, but little help for diagnosis, HLA-B27 positive suggests that psoriasis is often accompanied by osteophytes Arthritis, spondylitis and anterior uveitis.
X-ray inspection can find:
1 erosion of the bone, widening of the joint space, and expansion of the bone substrate of the distal (toe) joint.
2 The distal finger (toe) bone is dissolved.
3 Osteolysis, especially the dissolution of the phalanges, can result in a "cup pencil" appearance or a "fishtail" deformity.
4 arthritis and spondylitis (same performance as ankylosing spondylitis), these findings are very helpful in the diagnosis of this disease.
Diagnosis
Diagnosis and diagnosis of psoriatic arthritis and its associated uveitis
Arthritis should be differentiated from other seronegative vertebral arthritis (ankylosing spondylitis, Reiter syndrome, inflammatory bowel disease). This type of identification is generally not difficult. Skin lesions of psoriatic arthritis are several other types. No, acute anterior uveitis associated with psoriatic arthritis is easily differentiated from acute anterior uveitis caused by several types described above.
Behcet's disease can also cause arthritis, skin lesions and acute anterior uveitis, but the affected arthritis is mostly large joints, no joint deformation, skin lesions are mostly nodular erythema, acne-like rash, eye performance in addition to acute anterior grapes In addition to membranous inflammation, there are often changes in retinitis, retinal vasculitis, and these characteristics are easily distinguished from acute anterior uveitis associated with psoriatic arthritis.
Scleritis associated with psoriatic arthritis should be differentiated from other diseases such as Reiter syndrome, inflammatory bowel disease, rheumatoid arthritis, etc. According to the history and clinical manifestations, it is generally not difficult to identify.
