Clinical Features

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PsA is characterized by varied clinical patterns (Glad-man and Rahman 2001) with varying degrees of involvement of joints (both peripheral and spinal), ent-hesium, and skin (Gladman and Rahman 2001; Glad-man et al. 2005; Helliwell and Wright 2000). Psoriasis usually develops before joint involvement by many years, although occasionally arthritis may precede the psoriasis. Nail lesions, which occur in 87% of patients with PsA (Gladman et al. 1986), help distinguish PsA from RA (Eastmond and Wright 1979).

10.5 Clinical Features 99

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Fig. 10.2. a PIP and DIP synovitis. b DIP synovitis and psoriatic nail changes.

Fig. 10.1. Psoriasis plaque

Skin involvement usually occurs as plaque psoriasis, the most common form of psoriasis (Fig. 10.1). This is characterized by thickened, erythematous, hyperkera-totic skin lesions. These scaly patches usually occur over extensor surfaces, such as the elbow and/or knees, and may coalesce to cover large parts of the body. Other forms of psoriasis, such as guttate, pustular, and ery-throdermic, are less common (Langley et al. 2005; Men-ter 2004). The severity of the psoriasis is not predictive of the severity of PsA, but recent studies show there maybe a correlation between psoriasis severity and the occurrence of PsA (Gelfand et al. 2005; Gladman 1998).

Joint involvement often is asymmetric, with frequent inflammation of distal interphalangeal (DIP) as well as other joints. Other characteristic features include enthesitis, dactylitis, and spine inflammation, particularly in the sacroiliac joints. About 40% have spine involvement (Gladman et al. 2005). Enthesitis involves inflammation at sites where tendons, ligaments, and joint capsule fibers insert into bone, such as the insertions of the Achilles tendon and plantar fascia, as well as ligaments around the rib cage and pelvis. Dactylitis, swelling of a whole digit, includes both joint synovitis as well as enthesitis of tendon and ligament attachments in the digit. Another less frequent clinical feature is iritis (Gladman et al. 2005; Gladman and Rahman 2001; Helliwell and Wright 2000).

Serum tests for rheumatoid factor (RF) usually are negative in PsA, but may occasionally be mildly elevated, which is also true for antibody to cyclic citrullinated protein (CCP) (Taylor et al. 2005). Elevations in levels of acute phase reactants, such as erythrocyte sedimen-

Fig. 10.2. a PIP and DIP synovitis. b DIP synovitis and psoriatic nail changes.

tation rate (ESR) or C reactive protein (CRP), are variable. Radiographic features include: (1) joint space narrowing and erosions; (2) lytic changes (such as the pen-cil-in-cup change) that reflects gross bone and cartilage lysis; and (3) evidence of new bone formation, such as complete ankylosis of joints and juxta-articular osteitis (Gladman and Rahman 2001; Helliwell and Wright 2000; Ory et al. 2005; van der Heijde et al. 2005). Several of these features help distinguish PsA from RA. A significant proportion of patients with PsA experience functional impairment and reduced quality of life (Gladman et al. 2005; Mease 2003; Mease et al. 2005b, Mease and Menter 2006, Husted et al. 2001, Gladman and Mease 2006).

Fig. 10.2. c Dactylitis and psoriatic nail changes. d Iritis

Fig. 10.3a-d. Radiographic features. a X-ray of distal interpha-langeal joint in PsA shows classic pencil-in-cup change due to severe erosion of bone on both sides of joint. b Joint shows joint space narrowing and erosions, whilst along the shaft of the bone in a juxta-articular location there is periostitis. c Pelvis X-ray shows asymmetric involvement of the sacroiliac joints wherein the right SI joint (viewer's left) is spared and the left SI joint shows significant narrowing, erosion, and periar-ticular sclerosis.

Fig. 10.2. c Dactylitis and psoriatic nail changes. d Iritis

Fig. 10.3a-d. Radiographic features. a X-ray of distal interpha-langeal joint in PsA shows classic pencil-in-cup change due to severe erosion of bone on both sides of joint. b Joint shows joint space narrowing and erosions, whilst along the shaft of the bone in a juxta-articular location there is periostitis. c Pelvis X-ray shows asymmetric involvement of the sacroiliac joints wherein the right SI joint (viewer's left) is spared and the left SI joint shows significant narrowing, erosion, and periar-ticular sclerosis.

Fig. 10.3. d Lateral view of the spine in PsA patient with intervertebral ligament calcification and exuberant syndesmophy-tes

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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