Clinical, radiographic and HLA associations as markers for different patterns of psoriatic arthritis.

OBJECTIVE: The aim of this study was to examine whether the five clinical forms of psoriatic arthritis (PsA) identified by Moll and Wright (Semin Arthritis Rheum 1973;3:55-78) could be clearly distinguished, especially as the disease evolved over time, to analyse whether radiographic features or HLA associations could define subsets with greater precision and to identify predictors of disease outcome. METHODS: Seventy-three patients (37 males and 36 females) were followed for a median time of 8 yr (range 1-16 yr). A standard clinical protocol was used to assess patients at each visit and two clinical scores. based on the joint areas involved, were defined to evaluate the mode of onset and the evolution of arthritis. X-ray films of the hands, feet and sacroiliac joints were taken and the patients were divided into two categories according to the presence or absence of erosions and an X-ray erosion score was also used. Three classification methods were used to define the different clinical subsets. HLA-A, B and DR antigens were tested by standard microlymphocytotoxicity assays. A multiple linear regression model was used in the statistical analysis. RESULTS: The five classical clinical subsets defined by Moll and Wright did not remain since distinct peripheral arthritis patterns tended to evolve over time. Only two discrete groups were identified, axial disease (AD) (sacroilitis with or without peripheral arthritis) in 29% of cases and peripheral disease (PD) without sacroilitis in 71%. AD was positively associated with the duration of arthritis (P < 0.04), presence of mutilation (P < 0.02) and the joint area score over disease evolution (JASE) (P < 0.02). There were erosions in 71% of the patients. Erosions correlated with the presence of mutilation (P < 0.007) and with the JASE (P < 0.0005). HLA-B27 was found in 43% of patients with AD, but only in 11% of PD patients (P < 0.01). No other clear HLA correlations were found. CONCLUSIONS: Despite the relatively small number of patients, this longitudinal study suggests that only two clinical subsets can be clearly defined in PsA, AD and PD; these are primarily determined on clinical grounds although HLA-B27 is strongly associated with AD. The evolution of PD pattern with time means that narrower peripheral arthritis subsets are of little clinical use.

Traumatic spinal cord injury complicating ankylosing spondylitis.

The aim of this paper is to review the incidence and characteristics found in traumatic spinal cord injury (SCI) occurring in patients with long-standing ankylosing spondylitis (AS). The incidence of patients with traumatic SCI admitted to our unit from January 1984 to February 1996 was 2% (15 out of 893). They were all men with a mean age of 56 years. Most frequently the etiology of the lesion was a motor vehicle accident and the injury was mainly due to a hyperextension mechanism. Acute spinal fracture occurred in 13 patients, all involving the cervical region. No fracture was observed in two patients with thoracic neurological level. Three patients presented with an interval free period of neurological symptoms in whom a spinal epidural hematoma was visualized with magnetic resonance imaging. On admission eight patients were diagnosed as having complete SCI and the other seven an incomplete SCI. In the acute phase, respiratory complications were most frequent, causing six patients to die. Treatment was conservative in 14 patients. Multidisciplinary management of these patients should be implemented in an institution equipped with both a Spinal Injury Unit and an Intensive Care Unit.

Reactive arthritis with a severe lesion of the cervical spine.

Reactive arthritis, or Reiter's disease, characteristically affects the joints of the lower limbs in an asymmetrical pattern. Usually it does not affect the cervical spine, and atlantoaxial subluxations are the exception. This paper describes the case of an HLA-B27-positive female patient with a sexually acquired reactive arthritis where a non-reducible atlantoaxial subluxation was present. The patient was followed from age 27 to 41. By the age of 38, an anterior decompression of the cervico-medullary junction was performed by a transoral approach; in a second stage, the patient underwent an occipito-cervical posterior fusion. The pathological study revealed a non-specific and chronic inflammatory infiltrate.

Pigmented villonodular synovitis of the knee in a patient with Paget's disease of the adjacent femoral bone.

A 49-year-old male patient, diagnosed as having Paget's disease involving the lumbar vertebrae and both femora, felt persistent pain and swelling in the left knee after trauma. A synovectomy was performed. Clinical and histological findings led to the diagnosis of pigmented villonodular synovitis of the knee joint. Only one previous case of this association has been reported. A common aetiology for both diseases is discussed, and traumatic factors should be considered in the aetiology of the association.

[Evaluation and significance of circulating immunocomplexes and their correlation with other immunologic parameters in connective tissue diseases]. / Estudio y significado de los inmunocomplejos circulantes y su correlación con otros parámetros inmunológicos en enfermedades del tejido conjuntivo.

The presence of circulating immunocomplexes (CIC) was evaluated in several collagen diseases and in a control group of 100 healthy individuals. Three methods were used for their detection: binding to C1q in solid phase, binding to conglutinin in solid phase, and measurement of the serum capacity to solubilize an experimental immunocomplex. In the group of patients with systemic lupus erythematosus (SLE) significant differences were found for the three techniques (p less than 0.001) and also for activity (p less than 0.001). The most sensitive method was binding to C1q. The sensitivity of the three techniques for CIC was very low in the group of patients with systemic sclerosis, and the highest rate of positive results was found with binding to C1q (10%). In the group with hypersensitivity vasculitis and polyarteritis nodosa CIC were found in 71% of cases, more than one method being positive in 50%. The highest sensitivity was obtained with the conglutinin method (48%). In patients with temporal arteritis, significant differences were only found for conglutinin binding method (p less than 0.001), with low rates of positivity.

Arthritis mutilans, tumoral calcinosis, Raynaud's phenomenon and Sjögren's syndrome.

We report a female patient who over 25 years developed a progressive deforming arthropathy involving both hands without anatomical or functional abnormalities of other joints. Raynaud's phenomenon, lung fibrosis and Sjögren's syndrome. She had multiple soft tissue and periarticular calcification particularly evident in the lower extremities, shoulders, hands, fingers and back.