CC BY
55
UDC 616.72-002:616.517-056.52
PECULIARITIES OF CLINICAL PICTURE IN PATIENTS WITH PSORIATIC ARTHRITIS WITH LIPID STORAGE DISEASE
Irkutsk State Medical University, Irkutsk A.I. Yakubovich, L.S. Saldamayeva
The clinical features of joint and skin syndromes in 120 patients with psoriatic arthritis with lipid storage disease were studied. The clinical forms of psoriasis were prevalent in patients with vulgar (50%) and exudative psoriasis (33.3%). The clinical forms of PA were dominated by the distal form and oligoarthritis, respectively, 38.3% and 39.3% of patients. Patients with a prescription of psoriasis for (more than 10 years (53.3%)), with a prescription of articular syndrome from 1 to 5 years (36.7%) prevailed. There were established specific features of the clinical picture and course of psoriatic arthritis against a background of lipid storage disease characterized by the predominance of the distal and oligoartritic variants of the joint syndrome, with the duration of arthritis from 5 to 10 years, with a minimum and average degree of activity. Key words: psoriasis, psoriatic arthritis, articular syndrome, skin syndrome, dyslipidemia.
The etiology and pathogenesis of psoriasis and psoriatic arthritis (PA) has been the focus of numerous clinic-epidemiological studies over the whole period of dermatology development and, in recent years, of molecular genetic researches [3, 6, 8, 9, 10]. The majority of patients with psoriatic arthritis are characterized by the association of dyslipidemia with high inflammatory activity of arthritis, which causes subclinical manifestations of atherosclerosis [2]. Considering that in patients with psoriatic arthritis there is observed high frequency of metabolic disorders, consequently, there grows the risk of cardio-vascular complications, the search of means of increasing the efficiency of pathogenetically reasonable methods of psoriatic arthritis treatment with due account for metabolic disorders is quite topical. In this regard, the study of clinical peculiarities of articular and dermal syn-
dromes in patients with psoriatic arthritis with lip-id storage disease presents scientific interest.
Research objective: the study of clinical peculiarities of articular and dermal syndromes in patients with psoriatic arthritis with lipid storage disease.
Materials and methods
The studied sample included 120 patients with psoriatic arthritis at the age from 21 to 66 years, 66 men and 54 women. The average age of patients constituted 48 years. 41,7% - patients at the age from 41 to 50, 27,5% - patients at the age from 51 to 60, 15% - patients at the age from 31 to 40, 10% - patients at the age over 60 and 5,8% - patients at the age from 21 to 30. The distribution of patients according to age and sex is presented in Table 1.
Table 1
Distribution of patients with psoriatic arthritis according to age and sex
(n=120)
Age group N (number) %
Men Women
21-30 years 4 3 5,8
31-40 years 10 8 15,0
41-50 years 28 22 41,7
51-60 years 16 17 27,5
Over 60 years 8 4 10,0
Total 66 54 100
PA was diagnosed by rheumatologist on the basis of complaints, clinical examination, clinic-anatomical variant of articular syndrome, degree of activity of articular process, x-ray examination of joints and spine considering international criteria of diagnosis according to CASPAR, 2006 [4, 12]. The dermal syndrome was estimated by means of PASI index (Psoriasis Area and Severity Index) [5]. The intensity
of symptoms (erythema, infiltration, peeling) was evaluated in points from 0 (lack of symptom) to 4 (highly expressed) and summed; the damage area of every body part (head, body, upper and lower limbs) was multiplied by the corresponding index. The minimal index value constituted 0 points, maximum - 72 points.
All patients underwent complex examination (general blood analysis, common urine analysis, biochemical blood analysis, chest X-ray examination, joint and spine X-ray examination, consultation of rheumatologist and therapist). The lipid exchange was measured after 12-hour starvation by determining total cholesterol in blood serum and plasm, triglycerids, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol calculated by computational method according to Friedewald formula.
Dyslipidemia criteria were assessed with due account for Russia recommendations elaborated by the committee of expert of the Russian Society of Cardiology in 2009 [1].
The statistical data processing of clinical and laboratory research implied standard methods of descriptive and variation statistics using
simple and multiple linear analysis determining an arithmetic mean (M), average error mean (m), validity coefficient (P) by means of Student test (t) for parametric values. The results were presented in the form of M±c, where M - sample mean, c -sample standard deviation. The statistical processing was conducted on the basis of analysis of random variable distribution characterizing the state of patients and distribution parameters. Differences were considered significant by P <0,05.
Results and discussion
The duration of articular syndrome in patients with psoriatic arthritis constituted from 1 to 25 years. In 22,5% of patients articular syndrome had been observed for more than 6 years, in 20,8% of patients - for more than 10 years (Table 2).
Table 2
Distribution of patients with psoriatic arthritis according to the prescription of articular syndrome (n=120)
Prescription of articular syndrome N (number) %
up to 1 year 24 20,0
from 1 to 5 years 44 36,7
from 6 to 10 years 27 22,5
over 10 years 25 20,8
Total 120 100
The duration of dermal syndrome varied within the broad range from 1 to 30 years. In 53,3% of pa-
tients the disease prescription constituted over 10 years (Table 3).
Table 3
Distribution of patients with psoriatic arthritis according to the prescription of psoriasis (n=120)
Prescription of psoriasis N (number) %
up to 1 year 4 3,3
from 1 to 5 years 20 16,7
from 6 to 10 years 32 26,7
over 10 years 64 53,3
Total 120 100
It was stated that the formation of articular syndrome in 70% of patients occurred on the background of existing dermal manifestations of psoriasis, in 30% of cases it was the cause of such manifestations. the articular process in the majority of patients (78%) was represented by the distal
form of arthritis and oligoarthritis. respectively, 46 (38,3%) patients and 47 (39,3%) patients, polyarthritis - 7 (5,8%) patients, spondylarthritis - 10 patients (8,3%), combination was registered in 10 patients (8,3%) (Table 4).
Table 4
Distribution of patients with psoriatic arthritis according to the clinical form of arthritis (n=120)
Clinical form of PA N (number) %
distal form 46 38,3
oligoarthritis 47 39,3
polyarthritis 7 5,8
spondylarthritis 10 8,3
combination 10 8,3
Total 120 100
95,1% of patients were characterized by seronegative arthritis, average and low degrees of activity were registered more often, respectively, 55,6% and 30,3%, high degree of PA activity was diagnosed in 14,1% of patients. In 60 (50%) patients the damage of joints started from pains and inflammatory changes in minor joints of hands and feet, including distal interphalangeal joints. Clinical manifestations of the inflammatory process in damaged joints in 70% of patients were characterized by edema, hyperemia. In 65% of patients inflammatory joint changes were asymmetric. In 35% of patients they localized only in the area of great toes. The change of joint configuration was revealed in 80% of patients. Dactylitis was observed in 20% of patients. According to the type of articular syndrome development, 75% of patients were characterized by low progressive PA course.
In such patients, the disease for a long time proceeded without expressed pains and morning stiffness, without joint deformity and expressed muscle hypotrophy and restraint of movement. High progressive course of the disease was registered in 25% of patients. This group of patients was characterized by the appearance of steady inflammatory changes of joints in 1-2 years after the disease onset. The aggravation of articular process was registered 1-2 times a year and correlated with dermal syndrome exacerbation.
Clinical manifestations of psoriasis were characterized by a considerable abundance of eruption. The average PASI index (n=120) constituted 36,5. The distribution of PA patients depending on the clinical form of psoriasis is presented in Table 5.
Table 5
Distribution of patients depending on the clinical form of psoriasis
(n=120)
Clinical form of psoriasis Absolute number %
Vulgar 60 50,0
Exudative 40 33,3
Pustulous 12 10,0
Erythroderma 8 6,7
Total 120 100
According to the present data, 60 (50%) patients were diagnosed with psoriasis vulgaris. 8 patients (6,7%) had the form of psoriatic erythro-derma. In 40 patients (33,3%) there was diagnosed psoriasis exudative. The pathological process in such patients was characterized by papules and plaques cover with grew-yellow scaly-barks, and the disease, as a rule, had an extensive nature. In 91 patients (75,8%) the psoriatic process was progressive.
The study of anamnesis showed that psoriasis was seasonal, 81 patients (67,5%) had autumn-winter type of disease, 23 patients (19.2%) - spring-summer type, 16 patients (13,3%) - undif-ferentiated type, by which the patients could not associate the aggravation of the disease with particular type of the year.
The progressive stage was diagnosed in 91 patients (75,8%), stationary stage - in 29 patients (24,2%). According to the duration of recurrence there were observed 2 variants: in 75 patients (62,5%) the disease recurrence was registered up to 2 months, in 45 patients (37,5%) - from 2 to 6 months.
The predisposing factors of the disease onset were the following: intensive psychoemotional loads and stress situations in 50 (41,7%) patients, cold-related diseases (ARVI, influenza) and hypo-
thermia in 40 patients (33,3%), systemic alcohol consumption was observed in 18 patients (15%), solar insolation effect - in 5 (4,2%), administration of different medications - in 5 patients (4,2%). In 4 patients (3,3%) the occurrence of first symptoms of the disease and its exacerbation were not connected with trigger factors.
The study of influence of hereditary factors showed that the presence of psoriasis was revealed in close relatives of 34 PA patients (28,3%), 20 men and 14 women.
Genetic predisposition to psoriasis (GP) was observed in three lines and two levels of relation: maternally, paternally and both lines of relation, there were also determined the first and the second levels of relation.
Maternally inherited predisposition to psoriasis was registered in 14 people (41,2% of PA patients with GP), paternally inherited - in 13 people (38,2%), both lines - 7 (20,6%).
GP to psoriasis was most frequently observed in men on mother's side of the first level of relation.
There were stated peculiarities of clinical picture and PA course on the background of lipid storage disease characterized by prevalence of distal and oligo- arthritic variants of articular syndrome with arthritic prescription from 5 to 10 years and minimal and average activity.
PA on the background of lipid storage disease is characterized by the following peculiarities: by atherogenic dyslipidemia of 2b type the number of patients with polyarthritic and spondiloarthritic variants of articular syndrome with disease prescription over 10 years with severe forms of psoriasis (exudative, pustulous and erythroderma) of average and high intensity increased; by the 4th type of dyslipidemia and hypercholesterolemia there were more often observed distal and oligo- arthritic variants of articular syndrome with arthritic prescription from 5 to 10 years with psoriasis vulgaris and minimal intensity. The analysis of dyslipidemia incidence depending on the age of patients revealed the correlation with the age of patients - increase of incidence in the age group over 51 years.
Thus, in the studied sample, the correlation of men and women constituted - 1,2:1, the average age of PA patients - 48 years. The major part (62,5%) of patients were at the age from 21 to 50 years.
The articular process in the majority of patients (77,6%) was presented by distal from and oligoarthritis, according to the literature, such variants are registered in 75% [11].
According to the literature data, rheumatic factor is observed in 12% of patients, in the current study - in 5% [1].
Average and low degrees of intensity were registered more often, 55,6% and 30,3% respectively, while the high degree of PA activity was diagnosed in 14,1% of patients. According to the character of articular syndrome development, 75% of patients were characterized by low progressive PA course, when the disease for a long time proceeded without expressed pains and morning stiffness, without joint deformity and expressed muscle hypotrophy and restraint of movement which corresponds to the data of literature [12]. High progressive course of the disease was registered in 25% of patients, was characterized by the development of steady inflammatory changes of joints in 1-2 years after the disease onset. The aggravation of articular process was registered 1-2 times a year and correlated with dermal syndrome exacerbation. In 22,5% the prescription of articular syndrome constituted over 6 years, in 20,8% - over 10 years.
Clinical forms of psoriasis were prevailed by vulgar (50%) and exudative psoriasis (33,3%). Amon clinical anatomic variants of articular process there prevailed distal and distal and oligoartritic variants, 38,3% and 39,3% of patients, respectively. The average PASI index = 36,5. The onset of psoriasis is more often observed at the age of 21-30 years (58,3%). There prevailed patients with psoriasis prescription over 10 years (53,3%), articular syndrome prescription from 1 to 5 years 936,7%). 81 patients (67,5%) were characterized by autumn-winter type of the disease. Among possible causes of psoriasis
aggravation the majority of patients (41,7%) stated psychoemotional stress and cold-related diseases (33,3%). The evaluation of clinical course in terms of psoriasis aggravation frequency showed that in the majority of patients psoriasis exacerbation happened in 76 (63,3%) twice a year. The progressive stage was diagnosed in the overwhelming majority of patients - 91 (75,8%), stationary stage - in 29 (24,2%). The recurrence of dermal syndrome lasted up to 2 months in 75 patients (62,5%).
The highest rate among concomitant diseases accounted for cardio-vascular diseases - 42 (35%).
Psoriatic arthritis on the background of lipid storage disease is characterized by the following peculiarities: by atherogenic dyslipidemia of 2b type the number of patients with polyarthritic and spon-diloarthritic variants of articular syndrome with disease prescription over 10 years with severe forms of psoriasis (exudative, pustulous and erythroderma) of average and high intensity increased; by the 4th type of dyslipidemia and hypercholesterolemia there were more often observed distal and oligo- arthritic variants of articular syndrome with arthritic prescription from 5 to 10 years with psoriasis vulgaris and minimal intensity. The analysis of dyslipidemia incidence depending on the age of patients revealed the correlation with the age of patients - increase of incidence in the age group over 51 years.
References
1. Diagnosis and correction of lipid storage disease aimed at prevention and treatment of atherosclerosis. Russian recommendations (IV revision). Cardiovascular Therapy and Prevention. 2009; 6: 10-12.
2. Yanysheva A.V. Psoriatic arthritis and the risk of cardiovascular pathology. Siberian medical journal (Irkutsk). 2008; 6: 8-13.
3. Bergboer J. G. Paediatric Onset Psoriasis is Associated with ERAP1 and IL23R loci, LCE3C LCE3B deletion and HLA - C*06. Br. J. Dermatol. 2012; 18: 1365-2133.
4. Chandran V., Schentag C.T., Gladman D. Sensitivity of the classification of psoriatic arthritis criteria in early psoriatic arthritis. Arthr. Rheum. 2007; 57: 1560-1563.
5. Fredriksson T., Petterson U. Severe psoriasis -oral therapy with a new retinoid. Dermatologica. 1978; 4 (157): 238-244.
6. Giulia T. Cutting Edge: A Critical Functional Role for IL-23 in Psoriasis. J. Immunol. 2010; 185: 5688-5691.
7. Gladman D.D., Shuckett R., Russel M.I. Psoriatic arthritis (PSA) - an analysis of 220 patients. Q. J. Med. 1987; 62: 127-141.
8. Laws P. M. Ustekinumab for the treatment of psoriasis. Expert. Rev. Clin. Jmmunol. 2011; 2 (7): 155-164.
9. Lima X. T. Psoriasis prevalence among the 2009 AAD National Melanoma. Skin Cancer
Screen Program participants. J. Eur. Acad. Dermatol. Venereal 2013; 27(6): 680-685.
10. Ludwig R. J. Psoriasis: a possible risk factor for development of coronary artery calcification. Br. J. Dermatol. 2007; 156: 271-276.
11. Moll J.M.H., Wright V. Psoriatic arthritis. Semin. Arthr. Reum. 1973; 3: 55-78.
12. Taylor W., Gladman D., Helliwell P. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthr. Reum. Dis. 2002; 54: 2665-2673.
13. Young M.S. The ACCEPT study: usteki-numab versus etanercept in moderate - tos-
evere psoriasis patients. Clin. J Immunol. 2011; 1(7): 9-13.
Contacts:
Corresponding author - Yakubovich Andrei Igor-evich, Doctor of Medical Sciences, Head of the Department of Dermatovenerology with the course of esthetic medicine of Irkutsk State Medical University, Irkutsk.
664025, Irkutsk, Rossiiskaya Ulitsa, 16. Tel.: (3952) 242239. Email: [email protected]
