Clinical features of late onset psoriatic arthritis

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Abstract

The aim of this work is to compare the clinical and radiological manifestations of patients presenting late onset psoriatic arthritis (PsA) with early onset PsA. An overall of 96 consecutive PsA patients were studied over an 8-month-period. Clinical, laboratory and radiographic signs were assessed. Of the 96 patients studied, 84 had their earliest symptoms before the age of 60 (Group I) and 12 after it (Group II). In Group II the mean age was 65.7 years (range 60–73), the sex ratio (male/female) was 9/3. All patients were HLA-B27 negative; the clinical forms observed were: polyarticular (6 patients; 50%), oligoarticular (4 patients; 33%) and spondyloarthropathy (SpA) (2 patients; 17%). Only two patients had asymmetric sacroiliitis and three had history of dactylitis episodes. In conclusion, we found distinct clinical manifestations in late onset PsA. Peripheral affection was found predominant. The male/female ratio was higher than other age groups.

Introduction

Although the association between psoriasis and arthritis has been known for long, it was not until the 1960s that it was acknowledged as an entity different from, and independent of, rheumatoid arthritis (RA). However, a number of questions regarding its characterisation and classification remain unanswered. Thus, patients with psoriasis may coincidentally develop RA or some type of spondyloarthropathy (SpA); also, some key features of the entity are still highly controversial (Patel et al., 2001). Most researchers endorse its definition as an inflammatory arthritis with psoriasis, which is usually negative for the rheumatoid factor (Moll and Wright, 1973). The pathogenesis of psoriatic arthritis (PsA) involves the interplay of genetic, immunological, and environmental factors (Gladman, 1992, Barton et al., 2001).

The gradual aging of the population in developed countries has shown up the influence of age on the clinical expression of various rheumatic diseases. Thus, some diseases such as rheumatic polymialgia (with or without temporal arteritis) are exclusive in elderly patients, while of others such as ankylosing spondylitis, RA and systemic erytematous lupus exhibit clinical characteristics that are of an earlier onset (Bjelle, 1994, McGann, 2000). The differences between both clinical entities can be partly due to age-associated changes in the immune system; such changes are known collectively as immunosenescence. Aging decreases the efficiency of the immune system, basically via T-cells, but also via B-cells and other immune cells (Yung, 2000, Grubeck-Loebenstein, 1997, Malaguarnera et al., 2001) involved in the pathogeny of inflammatory rheumatic diseases.

The influence of age on PsA has only occasionally been considered and almost invariable in studies where other spondyloarthropathies are also included (Olivieri et al., 1995, Caplanne et al., 1997). In fact, few authors have examined it separately. This has possibly been due to the result of the disease that is rarely emerging after 60 years of age.

The aim of this work is to examine the clinical manifestations of late onset PsA and compare them with those in patients with an earlier onset of the disease. For this sake, we studied patients where the earliest clinical manifestations had appeared after the age of 60.

Section snippets

Patients and methods

An overall of 96 consecutive patients diagnosed with PsA according to the criteria of Wright and Moll (1976) were studied over an 8-month-period. Eighty-four had their earliest symptoms before the age of 60 and 12 after it.

On their first visit, patients were clinically assessed for axial affection (inflammatory spinal pain), peripheral arthritis, onycopathy, dactylitis and extra-articular signs. The presence or absence of a family history of skin psoriasis or PsA was also recorded.

Results

Of the 96 patients studied, 84 had their earliest symptoms before the age of 60 (Group I) and 12 after it (Group II). The features of both groups are summarised in Table 1.

Mean age of patients with late onset PsA was 65.7 years (range 60–73). All patients were both HLA-B27 and rheumatoid factor negative; only one of them was ANA positive at a 1/80 titre. Forty of the 84 patients in Group I and nine in Group II were men. Spondyloarthropathy was most frequent in Group I and polyarticular disease

Discussion

The results of this study suggest that those patients with late onset PsA (≥60 years) exhibit differential clinical and biological manifestations with respect to patients with early onset of the disease. The 60-year-threshold coincides with that commonly used in RA investigations and with that employed by Punzi et al. in their study on late onset PsA (Punzi et al., 1999).

Peripheral affection (particularly symmetric polyarticular forms) was found to predominate. The male to female ratio, 3:1,

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1

Servicio de Anestesia, Reanimación y Terapia del Dolor, Hospital San Juan de Dios de Córdoba.

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