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. According to Nobol, PA accounts for about 1% of patients with psoriasis. Because this disease and Reiter syndrome, ankylosing spondylitis are related to HLA-B27, and rheumatoid factor is negative, and the clinical manifestations are similar, it is classified as seronegative spondyloarthropathy. basic knowledge The proportion of sickness: 0.004% - 0.005% Susceptible people: no special people Mode of infection: non-infectious Complications: amyloidosis Aortic valve insufficiency
Cause
Causes of psoriatic arthritis
(1) Causes of the disease
The causes of this disease vary from country to family, including genetics, infection, metabolic disorders, endocrine effects, neuropsychiatric factors, and immune disorders.
Genetic factor
The disease often has a tendency to family aggregation. The prevalence of first-degree family members is as high as 30%, the risk of single-oval twins is 72%, and the domestic report has a family history of 10% to 23.8%, and foreign reports are 10% to 80%. %, generally considered to be about 30%, the disease is autosomal dominant inheritance, accompanied by incomplete penetrance, but some are considered autosomal recessive or sexually linked inheritance.
2. Infectious factors
(1) Viral infection: Some people have been treated with antiviral therapy for patients with psoriasis and viral infection, and the condition of psoriatic arthritis has also been alleviated.
(2) Streptococcal infection: It is reported that about 6% of patients have a history of pharyngeal infection and upper respiratory tract, and their anti-"O" titer is also increased.
(3) Metabolic disorders: Some people think that the three major metabolic disorders of fat, protein and sugar have pathogenic effects on this disease. Some people think that these three major metabolic abnormalities are following the discovery. Some people think that this disease and the three major substances It has nothing to do with metabolic disorders.
(4) Endocrine dysfunction The related role of psoriasis and endocrine gland function has long been paid attention to.
(5) Neuropsychiatric disorders: In the past, the literature often reported that mental factors are related to the disease. For example, trauma can sometimes cause the onset of the disease or aggravate the condition, and it is believed that this is due to the increase of vascular motor nerve tension after mental stimulation. However, during the Great Patriotic War of the former Soviet Union, there were many people with severe mental trauma, but the incidence of this disease was not seen.
(two) pathogenesis
1.Henseler et al. recommend that psoriasis be classified into type 2 type I as hereditary type (60% is autosomal dominant), and the onset age is light. The average male is 22 years old and the female is 16 years old. The disease course is irregular and can be pan. Hair, HLA-CW6 positive rate of up to 85% (relative risk of 4.5), 50% of patients with this type of father or mother with psoriasis, type II is sporadic, the peak age of onset is 60 years old, 15% of patients with HLA-CW6 related (relative risk is 7.3) This type of patients have no parents, recent studies suggest that HLA is closely related to the clinical type of psoriatic arthritis, such as asymmetric peripheral arthritis and HLA-B38, B17 , B13, CW6, etc., spondylitis is associated with B27 or B39. It is also found that early onset of arthritis is associated with HLA-DR4 and DRW53, disease severity is related to DQW3, joint space is narrowed and erosion is associated with HLA-A9 and B5 Related.
2. It has been confirmed that there are eosinophilic inclusion bodies in the nucleus of the spine cells. However, some people have denied the existence of such inclusion bodies. Although there seems to be some evidence for the pathogenic effect of viral infection, the specific virus causing the disease has not yet been isolated. Infants often have a history of acute tonsillitis or upper respiratory tract infection, and the symptoms are relieved after penicillin treatment and removal of the tonsils. These indicate that the infectious factors have a pathogenic effect on the disease.
3. It has been reported that there are two kinds of sesame-acetate dehydrogenase in combination with coenzyme II in the skin lesions of patients with this disease. These two enzymes are related to the formation and keratinization of the skin. The activity of hydrogenase and cytochrome oxidase is increased, and the succinate dehydrogenase is decreased. The changes of these enzymes are not certain to be primary or secondary, but they are definitely affected by the metabolism of sugar. Some studies have found that the patient's skin Lack of cyclic adenosine monophosphate in the lesion, the proliferation and division of the epidermis is caused by the lack of cyclic adenosine monophosphate, and adenosine monophosphate also activates the phosphorylase, which can affect the metabolism of sugar, if the epithelial ring The content of glycosides is decreased, the glycogen content is increased, the mitosis of epidermal cells is enhanced, the conversion rate is increased, the conversion time of normal epidermal cells is 4 weeks, and the conversion time of psoriasis can be reduced to 3 to 4 days, which indicates that the cyclic phosphate in the lesions Decreased adenosine content has a certain pathogenic effect.
4. Farber pointed out that about one-third of patients with psoriasis can be relieved during pregnancy, and the condition deteriorates after childbirth. It has also been reported in the country that pregnancy treatment is effective in treating this disease. Some patients may also have pituitary- Adrenal dysfunction, decreased urinary 17-ketosteroids, clinically treated with glucocorticoids, can achieve better results.
5. Pathology
(1) Skin pathology: According to the characteristics of skin lesions, it is generally classified into vulgaris, pustular and erythrodermic.
1 vulgaris type: the epidermis changes earlier, there is keratinous hyperplasia in the epidermis, mainly keratinization, keratinized cells can be combined into a sheet, which is filled with air and refraction, so it is observed by the naked eye as silvery white scales, at rest Period, hyperkeratosis may be more significant than parakeratosis. Under the keratinized or keratinized layer, small abscesses composed of neutrophils are sometimes seen. The neutrophils are from the upper capillaries of the dermal papilla. Caused by surface migration, more common in early damage, rarely seen in old damage, thinning or disappearing of the granular layer, thickening of the spinous layer, accompanied by epidermal extension, often thickened at the end, sometimes with adjacent epidermis The junction is connected, and there is obvious interstitial edema in the spinous cell layer at the top of the nipple. In the early lesions, neutrophils and lymphocytes are scattered in the spinous cell layer, and the dermal capillaries are dilated and distort. The wall is slightly thickened with mild to moderate inflammatory cell infiltration. In the old lesions, the infiltration is composed of lymphocytes and plasma cells, and the plasma cells are infiltrated with the most prominent milk head. The part can be elongated upwards and has edema, often extending to the surface keratinized layer, and the spinous cell layer at the top is thinned, leaving only 2 to 3 layers of cells, which often have no granulosa cells, so it is easier to scratch the nipple The small blood vessels at the top cause clinical punctiform hemorrhage. Due to the extension and widening of the epidermal process, the dermal papilla grows and narrows accordingly, and is rod-shaped or finger-like.
2 pustular type: its pathological changes are basically the same as the vulgaris, but there are large pustules in the keratinized layer, the vesicles are mainly neutrophils, the thickening of the spinous cell layer and the changes of the rod-shaped nipple are not obvious, the dermis layer Inflammatory infiltration is more serious, mainly lymphocytes, tissue cells and a small number of neutrophils.
3 erythrodermic type: except for the pathological features of psoriasis, other changes are similar to dermatitis, showing significant parakeratosis, thinning and disappearing of the granular layer, hypertrophy of the spinous cell layer, prolongation of the epidermal process, and obvious intracellular and extracellular Edema, but no blister formation, edema of the upper part of the dermis, vasodilatation and congestion, lymphocytes and neutrophils infiltration around the blood vessels, sometimes eosinophils, late infiltration of lymphocytes, tissue cells and plasma cells.
(2) Arthritis pathology: basically similar to rheumatoid arthritis, but lacks typical rheumatoid vasospasm. It may have synovial edema and congestion in the early stage. Later, the synovial cells are slightly hyperplasia, villi formation, and lymph nodes around the synovial blood vessels. Infiltration of cells and plasma cells, fibroblast proliferation in the long course of disease, fibrosis of the synovial membrane, typical change to osteolysis of the toe, non-inflammatory hyperplasia of the periosteum, resulting in intermittent loss of cortical bone, accompanied by The formation of mild new bone caused by enhanced osteoblast activity, but the whole process is mainly related to osteolytic bone, and the change of the metatarsophalangeal joint is obvious.
Prevention
Psoriatic arthritis prevention
Personal prevention
(1) Primary prevention:
1 Remove all possible predisposing factors, such as prevention and treatment of tonsillitis or upper respiratory tract infection, avoid trauma and trauma, irritation, excessive tension and other mental factors, maintain good eating habits, avoid spicy food.
2 strengthen physical exercise and improve the body's immunity.
3 life rules, maintain a comfortable mood, pay attention to hygiene, prevent skin infections.
4 to improve the understanding of psoriasis, the disease is not contagious, can be alleviated by active treatment.
(2) Secondary prevention:
1 Early diagnosis: psoriatic arthritis is characterized by both arthritis and psoriasis, and most patients have psoriasis first, especially about 80% of patients have nail deformation and damage, such as Inferior horny hyperplasia, thickened deck, turbidity, tarnish, blood nails, surface unequality; and this situation is only 20% of patients with psoriasis alone, for those who only have arthritis and no history of psoriasis The scalp and elbow joints should be carefully examined for the prone areas of the skin, and whether there are skin lesions that are not easily found, which is meaningful for the early diagnosis of the disease.
2 early treatment: the disease is chronic recurrent, joint disease, the cause is not completely clear, so far, there are many treatment methods, but there is still no satisfactory therapy, so comprehensive therapy should be adopted, integrated Chinese and Western medicine.
A. Internal drugs: such as methotrexate, vitamin A, E, C, D, etc., glucocorticoids, transfer factors, thymosin injection (thymosin), antibiotics, etc.
B. Topical drugs: 2% salicylic acid ointment, 5% coal tar ointment, etc.
C. Other methods:
1 bath therapy;
2 ultraviolet therapy;
3 photochemotherapy.
D. TCM syndrome differentiation and treatment.
(3) Level 3 prevention
1 Pay attention to clean skin and prevent recurrence of psoriasis.
2 Avoid mental stress and keep your mood comfortable.
3 Avoid feeling the wind, heat and cold.
Complication
Psoriatic arthritis complications Complications amyloidosis aortic regurgitation
The disease can be complicated by muscle wasting consumption and idiopathic consumption, extensor tendon effusion, gastrointestinal amyloidosis, aortic regurgitation, myopathy, Sjogren's syndrome and ocular inflammatory changes, It can also overlap with other seronegative polyarthritis, which is reported to constitute the following overlapping syndrome with other seronegative polyarthritic diseases:
1 psoriatic arthritis - Behcet's disease;
2 psoriatic arthritis-Rett syndrome;
3 psoriatic arthritis - Crohn's disease;
4 psoriatic arthritis - ulcerative colitis can also cause fatal complications such as severe infections, peptic ulcers and perforations.
Symptom
Symptoms of psoriatic arthritis Common symptoms Itching exfoliative dermatitis papules White nail joint effusion Joint stiffness pustules
PA usually attacks insidiously. Pain is often milder than rheumatoid arthritis, occasionally an acute gout-like onset. The age of onset is mostly between 30 and 40 years old, and children under 13 years old are less likely to occur. Joint symptoms and skin symptoms can be aggravated or alleviated at the same time; changes can occur in psoriasis after repeated iterations; or with pustular and erythrodermic psoriasis combined with joint symptoms. Gladman analyzed 72 cases of PA, 68% of patients with psoriasis, arthritis after an average of 12.8 years; 15% of patients developed psoriasis and arthritis within 1 year; 17% of patients developed arthritis, with an average of 7.4 years of silver 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) types: the most common, accounting for about 70%. For one or several knuckles involved, asymmetry, with joint swelling and tenosynovitis, the finger (toe) is intestinal expansion.
(2) Rheumatoid arthritis-like type: 15%, symmetry, multiple arthritis with claw-like hands. The patient may exhibit morning stiffness similar to the clinical features of rheumatoid arthritis, symmetry involved, fusiform swelling of the proximal knuckle, and skew to the ulnar side in the late stage. Occasionally rheumatoid nodules or rheumatoid factor positive. It has been diagnosed that this type of case is an overlap of rheumatoid arthritis and psoriasis.
(3) Asymmetric distal interphalangeal joint type: 5%, mainly involving the distal (toe) joint. It is characterized by redness and deformity, often starting from the toes and involving other joints later. The phalanx has no ulnar deviation, and the pain is lighter than rheumatoid arthritis, often accompanied by nail malnutrition, which is more common in men.
(4) Destructive arthritis type: 5%, which is severe joint destruction. More violations of the hands, feet and joints. It is characterized by progressive para-articular erosion, so that osteolysis, with or without bone joints, is similar to neuropathic joint disease and is 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. The vertebral lesions are non-marginal ligaments, especially in the thoracic and lumbar vertebrae, stenosis and sclerosis of the joints of the joints, erosion of the intervertebral disc and osseous hyperplasia of the anterior border of the vertebral body, mainly in the lower part of the cervical spine. Peripheral arthritis involves the distal finger joint, which is characterized by bilateral symmetry or unilateral asymmetrical erosive arthritis. In addition to inflammation in the synovium, inflammation can also enter the bone area along the tendon attachment point. Some patients may suffer from ankle joints. The clinical features of this type are spinal stiffness, which occurs after the venous state and in the morning, lasting more than 30 minutes.
2. Finger (toe) change: According to statistics, 80% of patients with PA have abnormalities of A and A, which can provide early diagnosis clues. Because the nail bed and the phalanx have a common source of blood supply, chronic psoriatic damage to the nail can cause vascular changes that ultimately affect the underlying joint. The extent of bone alteration has been found to be closely related to the severity of nail changes, and both often occur on the same finger (toe). Common changes in nails include: point depression, transverse, mediastinal, discoloration, hyperkeratosis, and nail removal.
3. Skin manifestations: Skin damage occurs in the scalp and extremities, especially in the elbows and knees, with scattered or generalized distribution. The lesions are papules and plaques, round or irregular, and are covered with rich silvery white phosphorus. The scales are removed to reveal a shiny film, but the spot is visible in the film (Auspitz sign). These three characteristics are diagnostic.
4. Other manifestations: In psoriatic arthritis, other systemic damage may be associated. Common are: acute anterior uveitis, conjunctivitis, scleritis, dry keratitis; inflammatory bowel disease and gastrointestinal amyloidosis; spondylitis heart disease, aortic regurgitation, persistent conduction Blocking, unexplained cardiac hypertrophy is characterized. There may also be systemic symptoms such as fever, weight loss, and anemia.
Examine
Examination of psoriatic arthritis
1. Blood routine and erythrocyte sedimentation rate in the active period of the disease, there are many degrees of leukocytosis, a small number of long course, serious condition or overlapping Crohn's disease, may have anemia and erythrocyte sedimentation rate.
2. Urine routine overlap Reiter syndrome can be seen in varying degrees of urethritis changes, but urine culture without bacterial growth, prostatic fluid microscopic examination of inflammatory cells.
3. Biochemical examinations generally have no change, but overlap with Crohn's disease may have low potassium, low calcium and hypoproteinemia, and increased alpha 2 and gamma globulin.
4. Immunological examination of rheumatoid factor, LE cells and anti-nuclear antibodies were negative, IgM decreased in light patients, but increased in critically ill patients, 2 / 3 patients with elevated IgA, 1/3 of patients with IgA, IgM Elevated, about 2/3 of the patients were positive for HLA-B27.
5. X-ray examination: This disease is most likely to involve the distal interphalangeal joints. It is common to involve all the interphalangeal joints. It is rare to involve one or two joints. In the early stage of the disease, the soft tissue around the joints is swollen. Joint cavity effusion, joint gap slightly widened; later with the destruction of articular cartilage, the distal end of the finger (toe) finger joint (toe) joint space is narrow, irregular edge of the joint, but generally mild, late involvement The joint may have subluxation or rigidity, the distal knuckle may have flexion deformity, and the distal finger (toe) may expand in a plexus, but the soft tissue does not widen, no clubbing, and the base of the distal finger (toe) Due to the thickening of the attached tendon, there is irregular bone hyperplasia, and the spur protrusions are formed on both sides to form a trumpet-like enlargement. Sometimes, at the bone end of the small joint of the hand and foot, a worm-like or small-sized worm is formed. Wearing a bone-like defect, the bone edge has obvious bone hyperplasia, the new bone density is uneven, the edge is not uniform, and it is flocculated, and the boundary of the original bone is unclear. Sometimes the bone end of the short bone of the (toe) can be Due to bone absorption, it becomes tapered and is adjacent to the distal end. Bone formation is like a pencil-like pen-like shape, similar to neurotrophic changes, localized bone erosion can occur in the finger bones, but there is no general osteoporosis, and sometimes uneven density can occur in the upper back of the calcaneus. Bone hyperplasia, similar to that seen in rheumatoid arthritis, when the wrist joint is involved, in addition to the narrow joint space and small cystic isolated phagocytic defects, there may be changes in the flocculent osteitis, sometimes in the sputum Osteitis-like changes can occur in the lower third of the tibia of the joint.
Diagnosis
Diagnostic identification of psoriatic arthritis
diagnosis
Diagnosis is based on typical psoriatic lesions and clinical symptoms, especially arthritis symptoms and typical X-ray findings. The diagnosis is not difficult. It is necessary to determine that the patient has psoriasis or psoriasis nail disease and then has joint damage. Serum rheumatoid factor is negative, you can make a diagnosis, but you must pay attention to the medical history and physical examination, especially in the hidden parts of the skin damage, such as scalp hair, navel, perineum and groin and other skin lesions are easily overlooked, Pay attention to distinguishing from other skin diseases.
Differential diagnosis
1. Reed syndrome both skin lesions, nail changes are quite similar, but Reiter syndrome has urethritis and conjunctivitis, male patients have prostatitis, in the joints, although both are asymmetric Arthritis, but Reiter syndrome involves the lower extremity major joints, and this disease involves the distal or proximal interphalangeal joints. Reiter syndrome often has a history of diarrhea or urinary tract infection about 2 weeks before onset, silver Scab arthritis has a history of skin psoriasis.
2. Rheumatoid arthritis not only has similar clinical manifestations, but also can coexist. It should be noted that if serum rheumatoid factor is positive, and the titer is high or there are subcutaneous nodules, mostly rheumatoid arthritis, if there is skin first Damage, each subsequent joint symptom onset is associated with the appearance of skin lesions, that is, psoriatic arthritis should be considered.
3. Patients with gout psoriasis active blood uric acid often increase, if the arthritis manifests as acute single joint or less joint synovitis, and hyperuricemia, it is easy to be misdiagnosed as gout, but gout has a typical history of gout Before the onset, the patient often has excessive fatigue, overeating, alcoholism and other incentives, and is effective in the treatment of colchicine. Chronic recurrent episodes often have tophi.
4. Asymmetric osteoarthritis distal knuckle damage should be differentiated from osteoarthritis with Heberden nodules. Osteoarthritis is characterized by hyperosteogeny, no skin lesions, normal erythrocyte sedimentation rate, and psoriatic arthritis There is a bone-dissolving lesion at the fingertips, accompanied by skin lesions. The X-ray is a typical "pen-like" change, and the erythrocyte sedimentation rate is normal.
