Purpura and serum mixed cryoglobulinemia in psoriatic arthritis.

We here firstly describe the case of a psoriatic arthritis associated with cutaneous purpura and lower limbs weakness. The presence of type III mixed cryoglobulinemia in serum was the only possible detected cause. Discrepancies with the hepatitis C virus-related mixed cryoglobulinemia picture are discussed.

Pharmacological management of undifferentiated spondyloarthropathies.

Among undifferentiated spondyloarthropathies (uSpA) are included incomplete forms or early phases of definite seronegative spondyloarthritides and cases of spondyloarthritides that remain undifferentiated. The treatment of all spondyloarthritides is more conditioned by the disease localisation, number of involved districts and severity of inflammation rather than by the subtype of the spondyloarthritides itself. Specific studies focused on the pharmacological approach to uSpA are scarce. As a consequence, many drugs are used on the basis of the experiences that have been gained in the treatment of other spondyloarthritides. At present, non-steroidal anti-inflammatory drugs/COX-2 inhibitors and disease-modifying antirheumatic drugs are the main therapeutic agents for the involvement of peripheral joints in uSpA. In those cases in which severe symptoms persist despite these treatments or when there is a severe axial involvement, antitumour necrosis factor agents represent an effective choice. In these patients, antitumour necrosis factor treatment raises the important possibility of blocking a shift from uSpA to differentiated severe forms of spondyloarthritides such as ankylosing spondylitis. Local administration of corticosteroids is useful when a small number of joints are involved, as is also the case for the extra-articular localisations of soft tissues.

Hepatitis C virus infection in psoriatic arthritis.

OBJECTIVE: To evaluate the prevalence of hepatitis C virus (HCV) infection in patients with psoriatic arthritis (PsA), compared with patients affected by non HCV-related rheumatic degenerative disorders. METHODS: One-hundred consecutive subjects with PsA, and a statistically comparable group of 100 consecutive patients with peripheral osteoarthritis (OA) or sciatica due to L4-L5 or L5-S1 herniated disc were tested for HCV infection with a third-generation microparticle enzyme immunoassay (MEIA). Positive cases were submitted to a third-generation recombinant immunoblot assay (RIBA) confirmatory test. Comparison between the HCV prevalence obtained in the 2 enrolled groups was performed using Fisher's exact test. RESULTS: Anti-HCV antibodies were found with the MEIA method, in 1 patient with PsA, and in 4 patients with OA or sciatica. The RIBA method confirmed MEIA results in all positive patients. The difference in HCV prevalence detected in the PsA group and in the control group was not statistically significant (P = 0.68). Furthermore, HCV prevalence in PsA patients was lower than the ones reported in different geographic areas of Italy. CONCLUSION: Our present report does not confirm previous data that indicated an increased prevalence of HCV in PsA patients, and as a consequence, does not sustain a possible trigger role of HCV in cases of PsA. The absence of clinical or instrumental resources that consent a definite differential diagnosis between PsA and HCV-related arthritis was outlined and analyzed.

Management of hepatitis C virus-related arthritis.

In recent years, hepatitis C virus-related arthritis (HCVrA) has been recognised as an autonomous rheumatic disorder. Two subsets of the disease have been identified: a polyarthritis involving small joints that resembles rheumatoid arthritis, but is usually milder, and a mono-oligoarthritis that shows an intermittent course and is frequently associated with the presence of cryo-globulins in serum. Few data about HCVrA treatment are reported in the literature. As a consequence, the therapeutic approach for this disorder is still largely empirical. Hydroxychloroquine, low doses of corticosteroids and NSAIDs are frequently administered to patients with HCVrA, but some authors describe an incomplete relief of symptoms, especially in the rheumatoid-like subset. Intake of low doses of corticosteroids and NSAIDs is more effective in subjects belonging to the mono-oligoarthritis group. Use of antiviral drugs (IFN plus ribavirin) shows good results, but IFN can induce or worsen autoimmune disorders. For this reason, in our opinion, this approach should be prescribed only when required by the coexistent liver disease. On the basis of the poor available data, the administration of anti-TNF-alpha agents seems safe in HCV patients, but the usually non-aggressive course of HCVrA does not justify their use as a current therapy.

Effects of combined antiviral therapy on asymptomatic mixed cryoglobulinemia in naive patients with chronic hepatitis C virus infection: a preliminary study.

The clinical spectrum of mixed cryoglobulinemia embraces several manifestations: recurrent vascular purpura, weakness, arthralgia/arthritis, glomerulonephritis, peripheral neuropathies, and Raynaud's phenomenon. Mixed cryoglobulinemia is currently treated with steroids, low-antigen content diet, immunosuppressors, plasma exchange, and antiviral therapy, namely, alpha -interferon alone or, more recently, in association with ribavirin. In the present research, we verified the effectiveness of combined therapy with interferon and ribavirin on asymptomatic mixed cryoglobulinemia in naïve (never treated before) patients with chronic hepatitis C. We enrolled 50 consecutive patients, 31 males and 19 females, with chronic hepatitis C who showed a sustained response to combined antiviral therapy (interferon and ribavirin). Before treatment, cryoglobulins were detected in 25 subjects (50%). Only 1 of the 25 patients with asymptomatic mixed cryoglobulinemia had persistence of cryoglobulins at the end of the follow-up period. Unexpectedly, in 7 of 25 subjects without mixed cryoglobulinemia before treatment, cryoglobulins became detectable after antiviral therapy. Our present study first reports the onset of asymptomatic mixed cryoglobulinemia in hepatitis C virus patients after clearance of the virus from blood obtained with a combined antiviral treatment. Possible explanations are discussed. Our data also suggest that the appearance of a clinically evident mixed cryoglobulinemia cannot be excluded in this kind of subject.

Management of reactive arthritis.

Reactive arthritis (ReA) is an aseptic form of articular inflammation induced by infections mainly localised in the gastrointestinal (enteroarthritis) or urogenital (uroarthritis) tracts. The bacteria principally involved as causative agents are Chlamydia, Salmonella, Shigella, Campylobacter and Yersinia. The clinical picture is usually characterised by a mono-oligoarthritis of the lower limbs. Axial involvement is possible and extra-articular manifestations such as enthesitis, tenosynovitis, bursitis and dactylitis are frequent. NSAIDs and sulfasalazine are still the drugs most commonly used in the treatment of ReA. Steroids are administered when inflammatory symptoms are resistant to NSAIDs. Experiences with other DMARDs (disease modifying antirheumatic drugs) such as azathioprine, methotrexate and cyclosporin, have been sporadically reported and they can be employed in patients that are unresponsive to the more usual medicaments. The intake of antibacterials (tetracyclines) may be useful in uroarthritis but have not been so successful in enteroarthrits. In more aggressive cases, or when ReA evolves towards ankylosing spondylitis, TNF-alpha blockers could represent an effective choice.