Asymmetric Oligoarthritis Research Articles

Correlation Between the Type of Psoriasis and the Pattern of Arthritis Among Patients with Psoriatic Arthritis: A Single-center Cross-sectional Study

Background: Psoriatic arthritis (PsA) is an inflammatory condition linked to psoriasis. According to studies, there is little correlation between arthritic patterns and PsA. Objective: To find relationships between psoriasis symptoms and PsA arthritis patterns. Methods: 100 PsA patients were enrolled in a cross-sectional study at Baghdad Teaching Hospital from December 2021 to June 2022, using CASPAR criteria. We gathered thorough demographic and clinical information, examined arthritis patterns, classified them into five kinds, and evaluated eight types and sites of psoriasis. Disease activity was measured using clinical and psoriasis indicators. Results: a weak negative connection among 100 individuals with psoriatic arthritis, plaque psoriasis, and distal interphalangeal (DIP) arthropathy. Erythrodermic psoriasis and spondylitis (with or without sacroiliitis) showed a slight positive connection. There was also a slight positive association between scalp psoriasis and DIP arthropathy. A comparable positive and weak relationship was found between polyarthritis and age, as well as polyarthritis and psoriatic arthritis disease activity. In contrast, asymmetrical oligoarthritis and PsA disease activity had a modest negative connection. Furthermore, enthesitis and DIP arthritis showed a weak negative connection. Body mass index and spondylitis (with or without sacroiliitis) showed a positive and weak correlation. The most significant finding was a modestly favorable relationship between skin psoriasis and psoriatic arthritis disease activity. Conclusions: There are weak but significant associations between particular psoriasis types and locales and arthritis patterns in PsA patients. These findings point to the possibility of developing individualized therapeutic regimens for PsA that take into account both dermatological and rheumatological signs.

Relapsing polychondritis

Relapsing polychondritis (RP) is a rare multisystemic disease predominantly involving the extracellular matrix. Typical manifestations are chondritis of the ears, nose and trachea as well as an asymmetrical oligoarthritis or polyarthritis of small and also larger joints. Various other involvements have also been described. The treatment of RP is individually dependent on a variety of factors, e.g., organ manifestations. Glucocorticoids, immunosuppressants and targeted treatment are implemented. In the case of seronegative rheumatoid arthritis or vasculitis with an atypical course the symptoms of RP should be taken into consideration.

Correlation Between Insulin Resistance and Psoriatic Arthritis Disease Activity: A Cross-Sectional Study.

Most psoriatic arthritis (PsA) research and studies focus solely on the skin and joint manifestations, but there is also an increased risk of metabolic disorders, including insulin resistance (IR). This study aims to discover the relationship between IR and disease activity (DA) in PsA and its phenotype. Patients with PsA classified using the CASPAR criteria with the disease activity was measured using the DAPSA score, and IR was identified as an elevated HOMA-IR of >2.5. The disease phenotype was determined with Moll and Wright's classification of the PsA subtype. The Pearson correlation test examined the relationship between DA and IR. The descriptive analysis was conducted to determine the relationship between the DAPSA score and HOMA-IR value in each PsA phenotype. All tests were two-tailed, analysed with GraphPad Prism 9, and a P-value of less than .05 was considered statistically significant. From thirty-one patients, there was a strong and positive relationship between DA and IR (r = .768, P = .000). We also observed variations in DAPSA score and HOMA-IR value across different phenotypes, with symmetrical polyarthritis exhibiting the highest DAPSA score (21.55 ± 3.50) and HOMA-IR value (2.913 ± .5392) despite asymmetrical oligoarthritis that being the most frequent phenotype. Our study revealed a significant association between disease activity and insulin resistance in PsA patients, with the symmetrical polyarthritis phenotype demonstrating the highest levels of DAPSA score and IR value. This finding allowed rheumatologists to behold this manifestation and could improve PsA patients' long-term outlook.

A rupioid rash.

A 72-year-old man presented for a thick hyperkeratotic skin rash on the shins that had erupted 7 months earlier after minimal local trauma (Fig. 1A, B). Topical treatments with glucocorticoids and antibiotics were ineffective, although a slight improvement was noted during summer. Additionally, low-grade fevers and an asymmetric oligoarthritis of the upper and lower limbs and dactylitis of the thumb and fourth toe on the left appeared over the last weeks. Mild non-specific onychodystrophy of the toes was found, whereas no inflammatory back pain or enthesitis was present. Plain radiographs did not reveal disease-specific deformities, erosions or osteo-proliferative lesions. Laboratory tests showed raised inflammatory markers (CRP: 17.7 mg/dl, ESR: 107 mm/h), leukopoenia (2.580/μL) and anaemia (haemoglobin: 10.3 g/dl). Differential diagnosis of the rash included crusted scabies, secondary syphilis, neutrophilic dermatoses, histoplasmosis and a hyperkeratotic psoriasis variant [1]. Skin biopsy revealed psoriasiform acanthosis, thick parakeratosis, dense neutrophilic infiltration and microabscess formation (Fig. 1C). Based on the type of musculoskeletal involvement and the skin histopathology, the patient was diagnosed with psoriatic arthritis with rupioid psoriasis. Treatment with medium-to-low dose systemic glucocorticoids and infliximab led to arthritis remission, skin (Fig. 1D) and laboratory improvement. Rupioid psoriasis (derived from the Greek word ρύπος = dirt) is a rare hyperkeratotic variant of psoriasis characterized by well-demarcated plaques with thick, dirty-appearing adherent crusts. It is associated with local treatment failure [2], psoriatic arthritis and male sex and it may present challenges in the diagnosis of patients with arthritis and systemic inflammation. Written informed consent has been obtained from the patient.

Reactive arthritis

Reactive arthritis Abstract. Reactive Arthritis is a sterile, inflammatory arthritis that is typically preceded by a bacterial gastrointestinal or urogenital infection occurring one to four weeks previously. The typical pattern is an asymmetric oligoarthritis most common affecting the lower extremities. Similar to other spondyloarthropathies, enthesitis, dactylitis, and sacroiliitis can occur as well as extra-articular manifestations, such as conjunctivitis, anterior uveitis, oral ulcers, circinate balanitis, and keratoderma blennorrhagicum. The treatment of "triggering" infection with antibiotics is the first therapeutic goal, especially for Chlamydia trachomatis. For arthritis NSAIDs are the treatment of first choice, followed by intraarticular or oral glucocorticosteroids. DMARDs (Sulfasalzine, TNF-alpha inhibitors) are reserved for refractory cases. Over 50% of the patients have a self-limited course lasting two to six months, 30% have recurrent episodes, and 10-20% have a chronic course requiring immunosuppressive therapy.

Does post-COVID reactive arthritis exist? Experience of a tertiary care centre with a review of the literature

BackgroundRheumatological manifestations following COVID-19 are various, including Reactive Arthritis (ReA), which is a form of asymmetric oligoarthritis mainly involving the lower limbs, with or without extra-articular features. The current case series describes the clinical profile and treatment outcome of 23 patients with post-COVID-19 ReA. MethodsA retrospective, observational study of patients with post-COVID-19 arthritis over one year was conducted at a tertiary care centre in India. Patients (n=23) with either a positive polymerase chain reaction test for SARS-CoV2 or an anti-COVID-19 antibody test were included. Available demographic details, musculoskeletal symptoms, inflammatory markers, and treatment given were documented. ResultsSixteen out of 23 patients were female. The mean age of the patients was 42.8 years. Nineteen patients had had symptomatic COVID-19 infection in the past. The duration between onset of COVID-19 symptoms and arthritis ranged from 5 to 52 days with a mean of 25.9 days. The knee was the most involved joint (16 out of 23 cases). Seven patients had inflammatory lower back pain and nine had enthesitis. Most patients were treated with non-steroidal anti-inflammatory drugs (NSAIDs) and steroids – either depot injection or a short oral course. Three patients required treatment with hydroxychloroquine and methotrexate which were eventually stopped. No relapse was reported in any of the patients. ConclusionOn combining our data with 21 other case reports of ReA, a lower limb predominant, oligoarticular, asymmetric pattern of arthritis was seen with a female preponderance. The mean number of joints involved was 2.8. Axial symptoms and enthesitis were often coexistent. Treatment with NSAIDs and intra-articular steroids was effective. However, whether COVID-19 was the definitive aetiology of the arthritis is yet to be proven.

Streptobacillaire rattenbeetziekte: casus en literatuurbespreking

Streptobacillary rat-bite fever: case report and literature review Streptobacillary rat-bite fever (RBF) is a rare multisystem infectious disease caused by Streptobacillus moniliformis and is transmitted by rat bites or through direct contact with rat excretions. Symptoms can include fever, polyarthralgia or polyarthritis and a polymorphic rash. A 48-year-old woman with fibromyalgia was admitted to the hospital with a 3-week history of fever and asymmetric oligoarthritis. S. moniliformis was isolated from blood cultures and the diagnosis of RBF was confirmed by a targeted anamnesis, which revealed a rat bite. After 7 days in hospital with benzylpenicillin treatment (IV), she was discharged to complete a 5-week course of oral amoxicillin at home. Her symptoms almost completely resolved. This case illustrates the diagnostic and clinical difficulties microbiologists and clinicians face in a case of RBF. A thorough history-taking by clinicians and extensive microbiological investigations can be helpful for an early diagnosis and a correct treatment of streptobacillary RBF, preventing morbidity and mortality.

TREATMENT IN PSORIATIC ARTHRITIS: CHOICE AND DETERMINANTS OF RESPONSE

Psoriatic arthritis (PsA) is the second most common inflammatory arthropathy after rheumatoid arthritis in early arthritis clinics. PsA presents as a symmetrical polyarthritis, like rheumatoid arthritis or an asymmetrical oligo-arthritis, with a predilection for the distal interphalangeal joints. Spinal involvement is like ankylosing spondylitis. Joint damage occurs early in up to 50% of PsA patients and has an 11% annual erosion rate in the first 2 years of the disease. There have been significant advances in understanding of PsA pathogenesis in recent years in the areas of genetics and molecular biology implicating both innate and adaptive immune systems. This has led to the introduction of evidence-based targeted therapy, primarily with tumour necrosis factor inhibitor (TNFi) agents. Therapy with disease-modifying anti-rheumatic drugs, such as methotrexate and leflunomide, remains the first-choice therapeutic intervention, even though there are few randomized controlled trials with these agents. In contrast, several successful studies of TNFi agents demonstrate excellent efficacy, in combination with methotrexate, and several novel agents are currently in development for the treatment of PsA. Before the introduction of targeted biologic medications, such as TNF inhibitors, the capacity to control disease activity was limited, with only modest effects noted in most patients with traditional oral medications such as methotrexate and sulfasalazine. Pak J Physiol 2022;18(4):31–4

Does post-COVID reactive arthritis exist? Experience of a tertiary care centre with a review of the literature.

BackgroundRheumatological manifestations following COVID-19 are various, including Reactive Arthritis (ReA), which is a form of asymmetric oligoarthritis mainly involving the lower limbs, with or without extra-articular features. The current case series describes the clinical profile and treatment outcome of 23 patients with post-COVID-19 ReA.MethodsA retrospective, observational study of patients with post-COVID-19 arthritis over one year was conducted at a tertiary care centre in India. Patients (n = 23) with either a positive polymerase chain reaction test for SARS-CoV2 or an anti-COVID-19 antibody test were included. Available demographic details, musculoskeletal symptoms, inflammatory markers, and treatment given were documented.ResultsSixteen out of 23 patients were female. The mean age of the patients was 42.8 years. Nineteen patients had had symptomatic COVID-19 infection in the past. The duration between onset of COVID-19 symptoms and arthritis ranged from 5 to 52 days with a mean of 25.9 days. The knee was the most involved joint (16 out of 23 cases). Seven patients had inflammatory lower back pain and nine had enthesitis. Most patients were treated with non-steroidal anti-inflammatory drugs (NSAIDs) and steroids – either depot injection or a short oral course. Three patients required treatment with hydroxychloroquine and methotrexate which were eventually stopped. No relapse was reported in any of the patients.ConclusionOn combining our data with 21 other case reports of ReA, a lower limb predominant, oligoarticular, asymmetric pattern of arthritis was seen with a female preponderance. The mean number of joints involved was 2.8. Axial symptoms and enthesitis were often coexistent. Treatment with NSAIDs and intra-articular steroids was effective. However, whether COVID-19 was the definitive aetiology of the arthritis is yet to be proven.

Juvenile spondyloartropathies.

Juvenile spondyloarthropathies (JSpA) are defined as a heterogeneous group of diseases that start before the age of 16, which is associated with peripheral joint (especially large joints of the lower limbs) and axial skeletal (spine and sacroiliac joint) involvement, enthesitis, and human leukocyte antigen (HLA) B27 positivity. Juvenile spondyloarthropathies mainly cover juvenile ankylosing spondylitis (JAS), psoriatic arthritis, reactive arthritis, inflammatory bowel disease-associated arthritis, seronegative enthesopathy, arthropathy syndrome (SEA), and enthesitis-associated arthritis. Symptoms associated with spondyloarthropathies are enthesitis, inflammatory low back pain, dactylitis, nail changes, psoriasis, acute anterior uveitis, and inflammatory bowel disease-related symptoms. In JSpA, axial involvement is rarely seen in the early stages of the disease, in contrast to adult patients with ankylosing spondylitis (AS). The disease usually begins as asymmetric oligoarthritis of lower extremities in children, and axial skeletal involvement can occur in the course of the disease. Although the debate on the classification of juvenile spondyloarthropathies continues due to its initial nonspecific findings and the heterogeneity of the disease phenotype, the International League of Associations Rheumatology (ILAR) classification criteria are the most commonly used pediatric criteria. In that set of criteria, patients with JSpA are mainly classified under enthesitis-related arthritis or psoriatic arthritis group. Since juvenile spondyloarthropathies can cause severe loss of function and long-term sequelae, the main goal in treatment should be suppression of inflammation as early as possible and prevent sequelae.

Knowledge and Perceptions of Reactive Arthritis Diagnosis and Management Among Healthcare Workers During the COVID-19 Pandemic: Online Survey.

Reactive arthritis (ReA) is an often neglected disease that received some attention during the coronavirus disease 2019 (COVID-19) pandemic. There is some evidence that infection with severe acute respiratory syndrome coronavirus 2 can lead to "reactive" arthritis. However, this does not follow the classical definition of ReA that limits the organisms leading to this condition. Also, there is no recommendation by any international society on the management of ReA during the current pandemic. Thus, a survey was conducted to gather information about how modern clinicians across the world approach ReA. An e-survey was carried out based on convenient sampling via social media platforms. Twenty questions were validated on the pathogenesis, clinical presentation, and management of ReA. These also included information on post-COVID-19 arthritis. Duplicate entries were prevented and standard guidelines were followed for reporting internet-based surveys. There were 193 respondents from 24 countries. Around one-fifth knew the classical definition of ReA. Nearly half considered the triad of conjunctivitis, urethritis and asymmetric oligoarthritis a "must" for diagnosis of ReA. Other common manifestations reported include enthesitis, dermatitis, dactylitis, uveitis, and oral or genital ulcers. Three-fourths opined that no test was specific for ReA. Drugs for ReA were non-steroidal anti-inflammatory drugs, intra-articular injections, and conventional disease-modifying agents with less than 10% supporting biological use. The survey brought out the gap in existing concepts of ReA. The current definition needs to be updated. There is an unmet need for consensus recommendations for the management of ReA, including the use of biologicals.

O006. Clinical features of paediatric HIV arthropathy

Abstract Background Advanced HIV infection is associated with an inflammatory arthritis, however few reports have described this disorder in children. This study aimed to describe the clinical features of HIV arthropathy in a case series of children in South Africa and compare these with features of JIA. Methods Retrospective data were collected from HIV-infected children with HIV arthropathy enrolled in a Paediatric Rheumatology clinic in Cape Town, South Africa. Data from a recently described, published cohort of children with JIA enrolled in the same clinic were included for comparison. Ethical approval was granted by the Human Research Ethics Committee of the University of Cape Town, with a waiver for consent. Results Eleven cases of HIV arthropathy were identified. Cases predominantly affected boys (8/11), and the median age of onset was 10.3 years (IQR 6.9–11.6). Most cases presented in the setting of advanced immunosuppression, with a median absolute CD4+ count of 389 cells/uL (IQR 322–449) and median CD4+ proportion of 19.5% (IQR 14.8–25.0) at presentation. The clinical presentation was variable, with both oligoarthritis (6/11) and polyarthritis (5/11) being prevalent. All cases exhibited large joint involvement, which was usually asymmetrical. In addition, four children had asymmetrical small joint involvement. Associated features included enthesitis (4/11) and dactylitis (1/11). The most consistent laboratory feature was elevated acute phase reactants, and typical ultrasonographic findings were joint effusions and synovial hypertrophy. JIA and HIV arthropathy presented at a similar age, with median age at HIV arthritis onset of 10.3 years (IQR 6.9–11.6) versus 9.25 years (IQR 4.5–12.3) at arthritis onset in the JIA subgroup. HIV arthropathy cases were predominantly male (M/F ratio 3.0), whereas JIA cases had an equal sex distribution (M/F ratio 0.9). Oligo-articular disease was more frequently described in children with HIV arthropathy (55%), compared to those with JIA (38%). Conclusion In this series, most cases of HIV arthropathy exhibited asymmetrical large joint oligoarthritis or polyarthritis, and presented in older boys with advanced immunosuppression. HIV arthropathy appears to present at a similar age to JIA, with a comparable pattern of joint involvement to oligo-articular and poly-articular JIA subtypes.

Reactive arthritis: a clinical review.

Reactive arthritis (ReA) is a form of inflammatory arthritis triggered by a remote antecedent infection, usually in the genitourinary or gastrointestinal tract. It is part of the spondyloarthropathy (SpA) spectrum, an umbrella term for a group of distinct conditions with shared clinical features. Typically, it presents with an asymmetric oligoarthritis of the lower limb joints, and patients may also have sacroiliitis, enthesitis and dactylitis. Other features often seen include anterior uveitis, urethritis and skin manifestations such as pustular lesions on the plantar areas. Although ReA was characterised initially as a sterile arthritis, the detection of metabolically active Chlamydia species in the joint fluid of some affected patients has generated further questions on the pathophysiology of this condition. There are no formal diagnostic criteria, and the diagnosis is mainly clinical. HLA-B27 can support the diagnosis in the correct clinical context, and serves as a prognostic indicator. The majority of patients have a self-limiting course, but some develop chronic SpA and require immunomodulatory therapy.

Relationship between smoking, clinical, inflammatory, and radiographic parameters in patients with ankylosing spondylitis

BackgroundAnkylosing spondylitis (AS) is an autoimmune multisystemic disease that attacks the spine, sacroiliacs, and often causes asymmetrical peripheral oligoarthritis. It results from the interaction between the genetic factors mainly Human Leukocyte Antigen B27 (HLA B27) and environmental factors. Current smoking has been reported to be a major risk factor for the incidence and progression of ankylosing spondylitis. So, we aim to explore the relationship between smoking and each of the clinical, inflammatory markers, functional limitation, and radiographic progression in ankylosing spondylitis patients.ResultsFifty ankylosing spondylitis patients were included in this study. Comparisons of clinical data, radiographic, and inflammatory markers among smokers and nonsmokers revealed that AS current smokers showed a statistically significant decrease in chest expansion, increase in the occiput to wall distance (p < 0.001**), higher inflammatory marker, higher disease activity indices (Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Disease Activity Index), higher Bath Ankylosing Spondylitis functional index, and modified Stoke Ankylosing Spondylitis Spine Score than nonsmokers (P < 0.001**). The smoking index was positively correlated with BASFI, ASDAS, (mSASSS) (r = 0.584, p = 0.005*) and negatively correlated with chest expansion.ConclusionsCurrent smoking in ankylosing spondylitis patients is associated with higher disease activity, inflammatory markers, functional disability, and radiological progression. This may add to the disease burden and thus interferes with the personal daily activities, physical mobility, life quality, and the response to TNFi therapy. So, stopping smoking is a mandatory step in controlling the disease activity and having favorable outcome.

Synovitis due to Histoplasma capsulatum: a case series and literature review.

Musculoskeletal manifestations of Histoplasma capsulatum infection are uncommon but can mimic inflammatory arthritis. Early diagnosis of this complication is of critical importance in the era of potent immunosuppression for rheumatologic diseases. We conducted a retrospective chart review for patients with histoplasmosis and tenosynovitis, synovitis, or arthritis, diagnosed and treated at our institution between January 1, 2000, and December 31, 2019. We also reviewed the relevant literature. Four patients with biopsy-proven, culture-proven histoplasma tenosynovitis were identified at our institution. All four patients had wrist or hand involvement in an asymmetric pattern, and one patient had lower extremity involvement as well. Two patients were not immunocompromised at baseline. One patient underwent a lengthy evaluation and received immunosuppression for 4years without improvement prior to the diagnosis of histoplasmosis. Histoplasma serologic tests varied among patients with localized infection. Pathologic findings revealed non-caseating granulomatous inflammation. Three patients recovered after 6-12months of antifungal treatment. One patient still had recurrent infection despite 20months of treatment. Histoplasma tenosynovitis and synovitis are rare causes of inflammatory arthritis. Infectious causes should be considered and carefully evaluated when patients present with asymmetric oligoarthritis. Early recognition is crucial for successful treatment, especially in patients with concomitant rheumatologic diseases receiving immunosuppressive treatment.

Prevalence of psoriatic arthritis among patients with plaque psoriasis: a Brazilian retrospective study.

Psoriatic arthritis is the most frequent and impactful comorbidity among psoriatic patients and appears in most cases after skin disease. Dermatologists play a key role in its early diagnosis and treatment. To determine the prevalence of psoriatic arthritis and associated variables among patients with plaque psoriasis seen at a reference center for treating psoriasis. Retrospective cross-sectional study conducted among 300 patients at an outpatient clinic in a university center in Juiz de Fora, MG, Brazil. Standardized records of 300 patients with plaque psoriasis were examined. Demographic data and medical variables relating to psoriasis (Psoriasis Area and Severity Index (PASI), family history, age at onset and disease progression) and psoriasis arthritis (CASPAR criteria) were evaluated. Laboratory and radiographic tests in the medical records were reviewed. Seventy-three (24.3%) of these 300 patients with plaque psoriasis had psoriatic arthritis. Asymmetric oligoarthritis (58.9%) was the most common clinical form, followed by polyarthritis (20.5%), distal interphalangeal arthritis (15.2%) and spondyloarthritis (5.4%). Dactylitis was present in 21.9% and enthesitis in 35.6% of patients. Compared with patients without arthritis, patients with arthritis had higher average age, higher frequency of positive family history of psoriasis, longer duration of evolution and higher PASI rates. Psoriatic arthritis is often underdiagnosed. Since dermatologists perform the initial approach, these professionals need to be trained to diagnose this comorbidity and treat it, together with rheumatologists.

Clinical and laboratory characteristics of psoriatic arthritis in a cohort of Egyptian patients

Aim of the workTo detect the clinical and laboratory characteristics of psoriatic arthritis (PsA) in sample of Egyptian population. Patients and methods100 PsA patients were subjected to full medical history, full clinical, musculoskeletal and dermatological examination, routine laboratory investigations and assessment of disease severity. ResultsAmong 100 PsA patients, 79 females and 21 males. The mean age was 44.4 ± 12.9 years. 21% of patients had hypertension, 11% had diabetes and 4% hepatitis C-virus. 14% had family history of other rheumatologic disease. 66% of patients experienced psoriasis onset with mean latency; 11.6 ± 8.2 years, 20% had dual onset of both diseases and 10% experienced PsA first with mean latency 3.6 ± 3.5 years. 86% of the patients had enthesitis, 41% had dactylitis, 39% had axial affection and 18% of patients had uveitis. 90% of patients had current psoriasis and 89% of them had current nail lesion. The most common drug was methotrexate. 38% of patients had axial spondyloarthritis, 33% had symmetric polyarthritis,26% had asymmetric oligoarthritis, and 3% had predominant distal inter-phalangeal (DIP) involvement. The mean value for serum hemoglobin was 12.1 ± 8.21.6 g/dl, platelets; 278.4 ± 90.3 x103/mm3, the white blood cells 7.2 ± 2.2 x103/mm3, C-reactive protein was 10.9 ± 10.1 mg/dl and erythrocyte sedimentation rate was 49.3 ± 27.5 mm/1st hr. 92% of patients were negative for rheumatoid factor. ConclusionAmong the cohort of Egyptian patients, most had axial spondyloarthritis, followed by symmetric polyarthritis and asymmetric oligoarthritis. The least frequent was predominant DIP involvement. The onset of psoriasis precedes arthritis and methotrexate was the most common therapy.

Clinical Features of Psoriatic Arthritis in Children

Psoriasis is one of the most common childhood skin disorders, the second after atopic dermatitis. Psoriatic Arthritis (PsA) is a chronic inflammatory disorder of the joints, spine and enthesis, usually associated with psoriasis. In children, PsA belongs to the group of juvenile idiopathic arthritis (according to the classification of the International League of Associations for Rheumatology, ILAR). The paper reviews the current scientific literature data on PsA peculiarities in childhood, the highest incidence in children, distribution by gender, as well as the predominant forms of joint syndrome. Results: Juvenile PsA is characterized by the pronounced clinical heterogeneity. The disease is twice as common in the girls. Two peaks of incidence are distinguished among 6-7 years and 14-18 years. Skin events precede the development of arthritis in 30% of children. The predominant form of the disease in children is asymmetric oligoarthritis.

Chronic seronegative spondyloarthropathy following acute Mycoplasma pneumoniae infection in a human leukocyte antigen B27-positive patient: a case report

BackgroundWe report a case of a 30-year-old patient who presented with acute Mycoplasma pneumoniae infection that was complicated by reactive arthritis and asymmetric proximal myopathy and progressed to chronic spondyloarthropathy. Reactive arthritis and sacroiliitis are unusual extrapulmonary manifestations of M. pneumoniae infection, which is a common condition.Case presentationA 30-year-old Greek previously healthy man presented to our emergency department with fever, progressively worsening bilateral lower limb weakness, and asymmetric oligoarthritis. Our diagnosis was based on a positive polymerase chain reaction test for M. pneumoniae using blood and cerebrospinal fluid and magnetic resonance imaging findings that suggested sacroiliitis. Our patient was also found to be human leukocyte antigen B27 positive. His infection was successfully treated with a 14-day course of doxycycline; the arthritis was treated with naproxen and corticosteroids. His arthritis, which restricted his mobility, improved progressively, and he was discharged without any neurological symptoms.ConclusionsIn our case, an acute M. pneumoniae infection eventually progressed to chronic spondyloarthropathy. In our patient, M. pneumoniae infection may represent a random event, or it might be a necessary factor for the development of reactive arthritis, asymmetric proximal myopathy, and sacroiliitis, always in combination with the appropriate genetic background. Extrapulmonary manifestations of M. pneumoniae may occur even in the complete absence of respiratory symptoms, and the diagnosis of unusual complications, such as reactive arthritis, requires high clinical suspicion and extensive investigation.

Comment on: The conundrum of juvenile spondyloarthritis classification: Many names for a single disease? Lesson learned from an instructive clinical case

Dear Editor, We read with great interest the paper titled “The conundrum of juvenile spondyloarthritis classification: Many names for a single disease? Lesson learned from an instructive clinical case” by Maniscalco et al1 which emphasizes the complexity of the clinical phenotypes of juvenile spondyloarthropathies (JSpA). All pediatric rheumatologists face these evolving phenotypes of these groups of diseases in their daily practice. To handle these classificational dilemmas, several classification criteria have been proposed for JSpA.2-4 The most recent one, International League of Associations for Rheumatology (ILAR) classification criteria for juvenile idiopathic arthritis (JIA), does not mentioned JSpA as a discrete subgroup and classifies these groups of diseases under three main groups: enthesitis-related arthritis, psoriatic arthritis and undifferentiated arthritis.2 The main concerns about these criteria are: the certain phenotypes of JSpA like inflammatory bowel disease-related arthritis, reactive arthritis were not included in these criteria, and some of the patients are classified as undifferentiated arthritis because of patients fulfilling two subtypes of JIA. It is obvious that these classification criteria are insufficient to reflect all phenotypes of JSpA and there is apparently a need for new sets of criteria.5 The nomenclature for juvenile spondyloarthropathies is not well-defined and still remains enigmatic. This term mainly encompasses enthesitis-related arthritis, psoriatic arthritis, juvenile ankylosing spondylitis, inflammatory bowel disease-related arthritis and reactive arthritis.6, 7 Contrary to adult SpA, JSpA rarely involves the axial skeleton in the early stages of the disease and it usually presents with asymmetric oligoarthritis of lower extremity joints and enthesitis. Therefore, enthesitis-related arthritis can be seen as an early presentation of JSpA. In addition to mentioned diseases, it is also shown that clinical features of JSpA can be seen in the course of familial Mediterranean fever (FMF) and Mediterranean fever gene mutation may be a susceptibility factor for enthesitis-related arthritis especially in regions endemic for FMF.8 In our cohort of patients with FMF, 10.2% of children also fulfilled classification criteria for JSpA.8 Moreover, chronic recurrent multifocal osteomyelitis (CRMO) was suggested to be an unusual form of SpA by several authors and Vittecoq et al9 showed that some of the patients with CRMO developed SpA. The insightful report by Maniscalco et al1 also supports this perspective. In adult patients, rheumatoid arthritis which is the most common cause of adult chronic arthritis and ankylosing spondylitis are well-defined as two distinct phenotypes and both of them have highly accepted classification criteria. In contrast, JSpA is considered under the JIA umbrella in ILAR classification criteria. Yet, this classification criteria obviously are not sufficient to cover this broad spectrum of JSpA (the reasons mentioned above). It is difficult to distinguish between oligoarticular JIA and JSpA especially in the early stages of disease and pediatric rheumatology societies should focus on establishing clearer definitions for JIA and JSpA and developing the new classification criteria which cover all frameworks of JSpA as a distinct disease. We think this approach will not only provide expanded covering but also, better understanding between pediatric and adult rheumatologists. No author of this paper has a conflict of interest, including specific financial interests, relationships and/or affiliations relevant to the subject matter or materials included.