Akira Watarai

Evaluation of nail disease in psoriatic arthritis by using a modified nail psoriasis severity score index

Background  The Classification of Psoriatic Arthritis Study Group published new criteria for classifying psoriatic arthritis (PsA) which included nail psoriasis. Our aim was to clarify the clinical importance of nail disease in PsA patients.

Antibodies against cyclic citrullinated peptide in Japanese psoriatic arthritis patients

Anti‐cyclic citrullinated peptide antibodies (anti‐CCP) are highly considered to indicate disease severity and be predictive markers in rheumatoid arthritis (RA). RA patients who are positive for anti‐CCP tend to progress more frequently to joint deformity and functionally deteriorate more than negative patients. A study concerning the presence of anti‐CCP in Japanese patients with psoriatic arthritis (PsA) has been published. Our aim was to clarify that anti‐CCP could be a potentially useful marker in PsA patients. We herein describe a PsA patient with presence of anti‐CCP. We examined anti‐CCP in 15 patients with PsA, and compared with 18 controls who had other types of psoriasis. Three PsA patients were positive for anti‐CCP, but no controls showed positive. The anti‐CCP‐positive patients had higher counts of radiographic erosion, higher prevalence rates of polyarticular disease, use of disease‐modifying anti‐rheumatic drugs, and the human leukocyte antigen DRB1*04 shared epitope than negative patients. Our study demonstrated that anti‐CCP was potentially both predictive and a severity marker of joint involvement in PsA, the same as in RA.

Expression of bleomycin hydrolase in keratinization disorders

A neutral cysteine protease, bleomycin hydrolase (BH), is widely expressed in mammalian tissues, with the skin seeming to contain the highest level. Our previous study revealed that BH transcription is modulated both during differentiation and by cytokines. However, BH involvement in keratinization disorder is not well known. In the present study, we performed immunohistochemical studies of BH and other serine/cysteine proteases in human normal skin and lesional skin with keratinization disorders. BH-positive cells were detected in granular layers of orthokeratotic and hyperkeratotic skin diseases, such as erythrokeratoderma and lichen planus. In parakeratotic skin diseases with porokeratosis, pityriasis rubra pilaris and psoriasis, BH staining was decreased in lesional skins compared to that in normal skin. Similar results were obtained for cysteine proteases, caspase-14 and calpain I. On the other hand, cells positive for serine proteases kallikrein 5 and 7 were increased in parakeratotic and inflammatory skin diseases, such as psoriasis. Semi-quantification analysis revealed that BH- and caspase-14-positive staining had higher intensity than those of the other proteases in normal epidermis. As BH is the major citrulline aminopeptidase in normal granular layer, the alternation would have a significant effect on terminal differentiation processes, such as aberrant processing of deiminated peptides. Therefore, BH may play an important role during the late stage of epidermal differentiation.

Nestin expression is increased in the suprabasal epidermal layer in psoriasis vulgaris.

We investigated the expression of both epidermal fatty acid-binding protein (FABP5), a marker of transit amplifying cells, and nestin, a putative marker of epidermal stem cells, in psoriatic epidermis and in normal human cultured keratinocytes. In lesional psoriatic epidermis, immunostaining showed that the suprabasal layer was positive for nestin, with some cells co-expressing FABP5. Flow cytometric analysis revealed that the expression of both nestin and FABP5 were increased in keratinocytes cultured in a low concentration of calcium relative to those cultured in a high concentration of calcium. These results suggest that nestin and FABP5 are expressed in actively proliferating keratinocytes in vitro and in the suprabasal layer in lesional psoriatic epidermis, and that double-positive cells may identify transit amplifying cells in the epidermis.

Analysis of clinical, radiological and laboratory variables in psoriatic arthritis with 25 Japanese patients

Psoriatic arthritis (PsA) has many clinical and radiological manifestations but lacks a specific laboratory marker. The aim of the present study was to identify noteworthy features in PsA patients on routine clinical examinations. The subjects were 25 PsA patients who were classified based on the Classification of Psoriatic Arthritis (CASPAR) criteria. The clinical and radiological findings and laboratory parameters were analyzed by retrospective chart review. On clinical examination, dactylitis was present in 13 (52%) of 25 patients, swollen and/or tender Achilles tendons were present in nine (36%), and sacroiliitis was present in eight (32%). Of the radiological features, juxta‐articular new bone formation (JANF) was seen in 12 (48%), extra‐articular new bone formation was seen in nine (36%) and sacroiliitis was seen in six (24%). Dactylitis and JANF had the highest prevalence rates. The Psoriasis Area and Severity Index score, swollen and/or tender joint count, erythrocyte sedimentation rate, C‐reactive protein, and matrix metalloproteinase‐3 were higher in patients with sacroiliitis than in those without sacroiliitis (P < 0.05). Dactylitis, JANF and sacroiliitis may be noteworthy manifestations in Japanese patients with PsA.

Cutaneous myeloid sarcoma presenting as grey pigmented macules.

According to previous reports, cutaneous myeloid sar-coma often manifests as a red nodule on the skin. We report here a patient with cutaneous myeloid sarcoma presenting with a unique skin lesion. A 71-year-old man presented with pigmented macules of one month duration. Physical examination showed multiple grey pigmented macules, 10–30 mm in diameter , on the face and trunk (Fig. 1a). His white blood cell count was 2.3 × 10 9 /l, with 8.5% blast cells, 1.0% myeloid cells, 3.5% stab cells, 23.0% segmented neu-trophils, 56.0% lymphocytes, 6.5% monocytes, 0.5% eosinophils, and 0.5% basophils. His platelet count was 7.2 × 10 9 /l, red blood cell count 3.75 × 10 12 /l, and haemoglobin level 10.3 g/dl. Other routine biochemical tests and urinalysis were normal. Microscopic examination showed sheets of cells with abundant eosinophilic cytoplasm, enlarged, frequently reniform, nuclei, and numerous mitotic figures (Fig. 1b). Immunohistoche-mical studies were positive for CD43, CD45, myelo-peroxidase, and lysozyme, and negative for CD3, CD4, CD8, CD20, and CD56, confirming the diagnosis of myeloid sarcoma. When examined at the department of haematology at our request, the patient was diagnosed as having acute myeloid leukaemia with the 7;21 trans-location. On the basis of this diagnosis, the patient was administered induction chemotherapy with intravenous enocitabine and aclarubicin hydrochloride. The macu-les promptly disappeared with this treatment. After 3 courses of chemotherapy, the patient was in complete clinical remission and remained disease-free during a follow-up period of 18 months. DISCUSSION The cutaneous manifestations of leukaemia can be non-specific (containing no leukemic cells), e.g. panni-culitis and generalized pruritus; or specific (leukaemia cutis). Non-specific lesions are found in up to 30% of leukaemia patients (1), but leukaemia cutis is much less common. Skin involvement is usually a late occurrence, and leukaemia cutis preceding marrow or peripheral blood abnormality is extremely rare (2). The clinical manifestations of leukaemia cutis are variable, including macules, nodules, purpura, and erythroderma, and the condition often resembles cutaneous lymphoma. Myeloid sarcoma is an extramedullary tumour of immature cells of granulocytic series, generally occurring in approximately 2% of patients with acute myeloid leukaemia (3). Myeloid sarcoma occurs mostly in adults aged 45–55 years, and it has a predilection for the bone, soft tissue, and skin (4), but they have been found in many other organs, including the abdominal organs, testis, and lacrimal gland. The skin lesions most commonly occur on the trunk, scalp and face. In general, they …

Adverse effects of methotrexate in three psoriatic arthritis patients

Methotrexate, a folic acid analogue with anti-proliferative and anti-inflammatory effects, is commonly used to treat patients with severe destructive psoriatic arthritis and has considerable efficacy. Combined anti-tumor necrosis factor and MTX therapy result in less treatment discontinuation due to adverse events. Despite its efficacy, MTX may result in adverse effects including hepatic, pulmonary, and renal toxicity as well as lymphoproliferative disorders and predisposition to infection. We herein report rare adverse effects of MTX treatment, specifically asymptomatic pulmonary tuberculosis, renal cell carcinoma, and lateral uveitis, in three psoriatic arthritis patients treated with MTX. MTX is an important drug for the treatment for psoriatic arthritis patient, but an awareness of the possible adverse effects is needed.

A psoriasiform drug eruption induced by polyethylene glycol interferon-alpha-2b, successfully treated by narrow band ultraviolet B therapy.

ejd.2011.1596 Auteur(s) : Shinji Kuwabara kaijiyamato@yahoo.co.jp, Hideki Maejima, Akira Watarai, Yuko Hamada, Kensei Katsuoka Department of Dermatology, Kitasato University School of Medicine, 1-15-1 Kitasato Sagamihara, Kanagawa 228-8555, Japan Polyethylene glycol interferon-alpha-2b (PEG-IFN-α-2b), a cytokine with pleiotropic activities, is a useful agent for treating several chronic viral and malignant diseases [1]. Common side-effects include fatigue, fever, nausea, marrow suppression, vomiting, [...]

Japanese version of the early psoriatic arthritis screening questionnaire (EARP)

The early psoriatic arthritis screening questionnaire (EARP) is a simple and fast method for the identification of arthritis in patients with psoriasis. We established the Japanese version of the EARP (J‐EARP) questionnaire, which includes 10 items with two choices for each. This study aimed to evaluate the utility of the J‐EARP questionnaire. A total of 90 psoriasis patients, 19 psoriatic arthritis (PsA) patients and 71 psoriasis patients without joint involvement, were administered the J‐EARP questionnaire. The diagnostic accuracy of the J‐EARP questionnaire for the diagnosis of PsA and early‐stage PsA was compared by receiver–operator curve (ROC) analysis. The J‐EARP questionnaire showed similar ROC characteristics to those of the original version of the EARP (specificity 97.2% and 91.6% and sensitivity 97.2% and 85.2%, respectively) in PsA patients using the cut‐off value of 3 for the J‐EARP questionnaire, which was the same as that used for the original EARP questionnaire. The scores of the J‐EARP questionnaire in early‐stage PsA patients (<1 year from onset) were significantly higher than in those of psoriasis patients, but not lower than in those of later stage (≥1 year from onset) PsA patients. The J‐EARP questionnaire is simple and fast to administer and has been proven to be robust for the identification of PsA. The J‐EARP questionnaire is a useful diagnostic tool for early‐stage PsA patients.

Onset of psoriatic arthritis at the hip joint without spondylitis.

Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis that may have an indolent or progressive course. Several factors can contribute to delay in diagnosis of PsA, including insidious onset, lack of symptoms, and absence of a specific diagnostic biomarker (1). The diagnosis of PsA is based on clinical evaluation and imaging, and may be difficult in patients with coexisting osteoarthritis, even for rheumatologists (2). We describe here a rare case of PsA with hip joint involvement at onset. Inflammatory hip joint disease occurs in less than 10% of PsA patients, and involvement of the hip joint at onset is rare (3). In this case, inflammatory disease of the hip joints developed at a relatively young age with radiological evidence of erosion and ankylosis, requiring bilateral hip arthroplasty. Despite oral methotrexate treatment after left hip arthroplasty, computerized tomography revealed asymptomatic sacroiliitis. We suggest that psoriatic hip arthropathy may require early treatment with methotrexate or leflunomide along with intra-articular steroid injections, following anti-tumour necrosis factor alpha (anti-TNFα) therapy.