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					The many faces of


   Psoriasis
           Contents
Psoriasis and arthritis
Reiter`s syndrome
Clinical cases
Reiter`s and Psoriasis:a disease
continuum ?
HIV associated arthropathy
       Psoriatic arthritis
Psoriasis is very common          Expression based on:
Physicians,dermatologists,rhue-
matologists
Prevalence 1 – 2 %                genetic influences
Severity varies
                                  environmental factors
Cause remains unknown
Hyperproliferation results in a   associated diseases
germination layer 2 X thicker     immunological status
than normal.Cell cycle
shortened 311hrs to 36hrs and
epidermal turnover time
accelerated from 27ds to 4ds.
                                  Cyclosporin blocks IL2
Where does arthritis fit in ?

 Moll and Wright classification
 a)asymmetric oligoarthritis.dactylitis
 common.
 b)symmetric polyarthritis
 c)involvement of only DIP joints
 d)Arthritis mutilans
 e)Ankylosing spondylitis type
         Reiter’s syndrome
Reactive arthropathy occuring in
genetically susceptible hosts in
response to infection of the lower genito
urinary and gastrointestinal tract.
Classical form – triad of urethritis,conjunctivitis and
arthritis in association with keratoderma
blennorhagica and circinate balanitis.
General population: young men          0.04 – 0.06 %
      Reiter’s versus Psa
 Differences               Similarities
 - widespread skin         - keratoderma
 lesions of psoriasis      impossible to distiguish
- absence of muco-         from pustular psoriasis
 cutaneous & genito-       - subset of Psa develop
 urnary Dx in Ps.            an explosive onset
- nail pitting             - HIV – distinctions lost
- onset of illness         - HIV – pustular Ps and
- pattern of Jnt invlmnt   Reiter’s merge into one
            Mr . S
 presented:
6/12 rash (arms,legs,feet)
3/12 painfull,swollen jnts
(knees,ankles)
Also c/o discharge
Background: +ve ETOH,+ve cannabis
   On examination:
Wasted,oral candida,
generalised keratotic plaques
No eye signs, no AI
MSS:bedbound,soft tissue        Investigations:
  contractures of knees &       Hb 7.4 nB12 nfolate
  elbows.                       abn Fe studies
  synovitis of ankles/wrists/   wcc 9.1
  elbows.                       CRP 170
                                urethral swab:Klebs. Pn
                                              Proteus mirabilis
                                              Staph. Aureus

                                HIV +ve CD4 572
                                VDRL +ve
    MANAGEMENT
ORAL ANTIBIOTICS
AMPHOTERECIN B LOZENGES
NSAIDS
RETINOIDS (acitretin)
LOTIONS
PHYSIOTHERAPY
SKIN TRACTION
                MR B
 PRESENTED:
   5/7 HISTORY OF
 eruptive skin rash spread upwards
 from feet to groin.
 arthralgia – shoulders and right knee
 painless penile ulcer
 dark coloured urine
   On examination:
temp. 38,1 C
Crusty,pustular lesions over
Dorsum of feet & groin area

Nil systemically
                                   Investigations:
MSS:dactylitis                     Hb 11,2 wcc 11,2 plts 697
      R knee synovitis +effusion   Urea 10.0 Cr 150 CRP 145
      L SA bursitis                Bld culture –ve
      R acj arthritis              ASOT –ve antiDNASE b 1280
Urine dipstix:num rbc’s and        HIV+ve CD4 66 vdrl-ve
    granular casts.
                                   Jnt aspirate –org’s - crystals
                                   Skin Bx: confirmed Reiter’s
                                   Renal Bx: FSGN
                                   Opthalmology : no intra-oc.
                                      Path.
       Managemaent
IVI antibiotics
Rehydration
Pulsed with medrol (renal fxn deterior.)
Iai’s
Lasix/thiamine
Acitretin/salicylic acid
SSZ
                      Mrs T
  Presented:
  2/12 history:rash affecting legs and soles of feet
             arthralgia – knees/wrists/elbows
             discharge
Background: came to CT in 1994
            psoriasis of R leg diagnosed since
            coming to CT.
  On examination:
No candida,L red eye
Psoriatic plaques L leg
Papulosquamous lesions
Of trunk and legs.
                            Investgations:
                          Hb 8 wcc 5.4 mcv 87 CRP 182
Keratod. Blen. Of soles
                          HIV +ve CD4 180
No nail changes.
                          Knee aspirate:830wcc’s/mm3
Systems N
                                         -orgs/-AFB’s
MSS:synovitis R wrist/
  ankle and bilateral     Vaginal swab: C. Albicans
  effusions of knees.     Opthalmology:L ant.uveitis
                          Gynae: Grade 1 PID
                          Infetious Dx’s:mantoux -ve
        Management
Iai’s
ANALGESIA AND NSAIDS
SSZ
ACITRETIN
PREDNISONE FORTE EYE DROPS
NYSTATIN PESSARY
PHYSIOTHERAPY
HIV associated joint Dx.
CDC : OVER 60 MILLION PEOPLE INFECTED

WHOLE SPECTRUM OF RHEUMATIC DISEASES

RhA AND SLE APPEAR TO IMPROVE

SPONDYLOARTHROPATHIES ARE NOT BENEFICIALLY AFFECTED
HIV associated arthralgia
Reported with many viral infections
Prevalence as high as 45%
Cause -?circulating viral:host IC’s
Uncommon for polyarthralgia to
progress to inflammatory jnt disease.
Rx: analgesia and reassurance
Painful articular syndrome
Self-limited syndrome characterised by
extremely painful bone and jnt. Pain
Intense pain usually lasts less than
24hrs and exam reveals no synovitis.
Aetiology remains unknown.
      HIV ASSOCIATED ARTRITIS
SERONEGATIVE ARTHRITIS
CLINICAL FEATURES:
oligoarticular,lower extremities
self-limited course,lasting<6 weeks
Aetiology:no assoc. with HLA-B27
           synovial fluid leucocyte
           count < reactive arthritis
    Reiter’s syndrome
First described (HIV) in 1987
HLA-B27 found in 80-90% in
Caucasians but majority of Africans
are –ve
Course: more severe,progressive
         and refractory to Rx than
         in HIV –VE patients.
      Psoriatic arthritis
Initially reported in 1985

Psa and reactive arthritis tend to occur
late in the course of HIV infection.

Psa improves with antiretroviral Rx.
     Undifferentiated
   spondyloarthropathy
Patients may present with signs of
reactive arthritis or Psa who do not
develop full-blown disease eg:
enthesopathy.
        Septic Athritis
Bone and joint infection due to usual
agents do not happen more
frequently in patients with HIV infxn.
HIV infection alone is a poor
yardstick with which to gauge
outcome.
Atypical mycobacterial infections
rarely occur except in advanced
HIV infection:CD4 T-lymphocytes<100/uL
In contrast:MTB occurs at any stage
Along with std. Anti-TB Rx ,
clarithromycin may be effective.
CD4 <100 assoc. with fungal
infections,namely C.albicans and
sporotrichosis schenkii.
Fungal infections can respond to intra-
articular amphotericin B.
             Conclusion
                        HIV pt’s encounter unique Dx’s
 Psa versus Reiter’s
                        Reiter’s and Psa more severe
MANY                    RhA and SLE improve

  OVERLAPPING           New antiretroviral agents are
                         changing presentation and
        FEATURES         treatment of Rh Dxs in HIV
                        Need to evaluate which Rx is
                         best without further
                         compromising immunity eg:
                         MTX:PCP        CQ decreases
                         viral load and viral replication
                         SSZ – increases CD4 in some
                         etritinate – very good in RS

				
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posted:11/30/2009
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