Elsevier

Joint Bone Spine

Volume 75, Issue 5, October 2008, Pages 544-547
Joint Bone Spine

Original article
Clinical expression, but not disease outcome, may vary according to age at disease onset in psoriatic spondylitis

https://doi.org/10.1016/j.jbspin.2007.11.005Get rights and content

Abstract

Objectives

To investigate whether the clinical expression and disease outcome in psoriatic spondylitis (PsS) may vary according to age at disease onset.

Methods

This study included 70 patients from a unique outpatient spondylitis clinic followed on a regular basis with a standard protocol. Patients were diagnosed with PsS according to ESSG criteria plus radiographic sacroiliitis (SI). Outcome parameters included: disease activity, functional evaluation, radiological damage, mobility restriction, and enthesitis score. Patients were divided into those with disease onset before 40 years (young-onset PsS) and those with onset over this age (late-onset PsS). Clinical features and outcome parameters were compared between groups.

Results

There were 44 men and 26 women. Thirty-nine (M:F ratio 1.8) patients had disease onset before 40 years and 31 (M:F ratio 1.6) over this age. HLA-B27 correlated with PsS susceptibility (34% vs 7%, RR 6.4, p < 0.0004), but it was found over-represented in young-onset PsS compared to late-onset cases (51% vs 13%, p = 0.001). Young-onset cases tended to have a higher frequency of family history (26% vs 13%), bilateral SI (62% vs 29%, p = 0.013), isolated axial pattern (31% vs 13%), and enthesitis (54% vs 29%, p = 0.09). In late-onset PsS there was a higher frequency of unilateral SI (71% vs 38%, p = 0.013), polyarthritis (45% vs 23%, p = 0.022), and silent axial disease (32% vs 10%, p = 0.022). Outcome parameters were similar between groups.

Conclusions

Clinical picture but not outcome parameters, varies according to age at disease onset in PsS. The correlation between HLA-B27 and young-onset PsS supports the notion that disease susceptibility and disease expression are not driven by the same gene in this entity.

Introduction

The spondyloarthropathies comprise at least five diseases, all of which can be differentiated on a clinical basis: ankylosing spondylitis (AS), reactive arthritis (ReA), psoriatic arthritis (PsA), arthritis of chronic inflammatory bowel disease (AIBD) and undifferentiated spondyloarthropathy (USpA) [1]. Spondyloarthropathies are generally observed in young patients but can be observed later in life or in persons older than 50 years of age. All the spondyloarthropathy subgroups are represented in the elderly with some features particular to this age group [2]. In the case of PsA, some few reports suggest that it is more severe in the elderly with worse outcomes than in younger patients [3], [4]. Immunological changes associated with aging, such as higher concentrations of IL-1β and IL-6 in the synovial fluid of elderly onset PsA, may explain these differences [3].

The distinction between elderly versus younger onset PsA might be arbitrarily established in the cut off point of 60 years of age, probably as an extrapolation coming from the field of rheumatoid arthritis (RA). However, RA and PsA are different conditions, and most cases of PsA are diagnosed between the third and fourth decade of life [5]. Therefore it is surprising to observe that no report has been published to date comparing the clinical picture of the disease between patients older and younger than this group of age.

In the present study we have compared the clinical profile of a group of patients with psoriatic spondylitis (PsS) with respect to age at disease onset. Given that most spondylitic patients are diagnosed before 40 years of age, we chose this cut off point for the purposes of the present study.

Section snippets

Methods

This retrospective cohort study included 70 patients diagnosed with PsS on the basis of radiological and clinical criteria plus psoriasis, who were recruited from the Spondylitis Clinic at the Rheumatology Department of Asturias University Central Hospital in northern Spain. These patients are followed on a regular basis in accordance with the standard protocol of the spondylitis outpatient clinic. To be included in the category of PsS, apart of psoriasis, the presence of clear radiographic

Results

Of the 70 patients with PsS (mean age 50 ± 12 years), 44 were men and 26 women (male to female ratio: 1.7). Mean duration of psoriasis was 19 ± 9 years, and the duration of spondylitis was 14 ± 7 years. The average age at onset of psoriasis was 28 ± 14 years, and of arthritis 35 ± 12 years. The mean latency period between the onset of psoriasis and the onset of arthritis was 7 ± 7 years. A positive family history of PsA was recorded in 20% of this series. Psoriasis preceded arthritis onset in 74% of the subjects.

Discussion

PsA is classified with the spondyloarthropathies because of the presence of spondylitis in up to 40% of patients, the occurrence of extra-articular features common to the spondyloarthropathy group, and association with HLA-B27 [5]. PsA may be distinguished from the other spondyloarthropathies by the presence of psoriasis, peripheral arthritis, asymmetrical distribution of the spinal involvement, and lower level of pain and limitation of movement in axial skeleton [5]. Most cases of PsA are

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