Recommendations for the management of comorbidity in hidradenitis suppurativa.

BACKGROUND: The association between hidradenitis suppurativa (HS) and some diseases is becoming relevant in recent years. Providing appropriate management of HS from an early stage requires to include prompt diagnosis and treatment of concomitant diseases and to prevent any potential comorbidity. This approach should consider the adverse events of the drugs used to treat HS potentially related to the onset of a comorbidity. OBJECTIVE: To provide the dermatologist with an accurate, easily used tool that will inform the diagnosis of HS comorbidity, and to facilitate decision-making regarding the referral and treatment of patient with HS-associated comorbidity. METHODS: These recommendations have been developed by a working group composed of seven experts (three dermatologists, a cardiovascular specialist internist, a rheumatologist expert in spondyloarthritis, a gastroenterologist and a psychiatrist) and a team of three methodologist researchers. The expert group selected the HS comorbidities considered in these recommendations through a literature review. The recommendations on diagnostic criteria are based on the relevant clinical practice guidelines for each of the comorbidities and on the recommendations of the experts. The information regarding the repercussion of HS medical treatments on associated comorbid diseases was obtained from the summary of product characteristics of each drug. RESULTS: The comorbidities considered in this guide are as follows: cardiovascular risk factors (diabetes, dyslipidaemia, obesity, hypertension and metabolic syndrome), inflammatory bowel disease, inflammatory joint disorders and psychological disorders (anxiety and depression). In addition, the association between HS and the consumption of alcohol and tobacco is included. The tables and figures are a precise, easy-to-use tool to systematize the diagnosis of comorbidity in patients with HS and facilitate the decision-making process regarding referral and treatment of patients with an associated disease. CONCLUSION: The application of these recommendations will facilitate the dermatologist practice and benefit HS patients' health and quality of life.

Association of IL1Β (-511 A/C) and IL6 (-174 G > C) polymorphisms with higher disease activity and clinical pattern of psoriatic arthritis.

The objective of this study is to analyze whether IL1ß (-511G > A) and IL6 (-174 G > C) polymorphisms are associated with inflammatory activity, radiographic damage or clinical pattern of psoriatic arthritis (PsA). One hundred twenty-five patients classified as PsA according to the Classification of Psoriatic Arthritis (CASPAR) criteria were included. Patients were stratified according to their clinical pattern at inclusion as peripheral, axial, or mixed involvement. Disease activity in peripheral or mixed forms was measured using the number of swollen and tender joints, pain analog visual scale, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and disease activity score 28 (DAS28). Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was used for axial and mixed forms, as were pain visual analog scale, ESR and CRP. Radiographic damage was evaluated using a modified Sharp score and modified stoke ankylosing spondylitis spinal score (SASSSm). The polymorphisms for the promoter region of IL1ß (-511 G/A) and IL-6 (-174 G/C) were analyzed. The G allele of IL1B (-511G/A) polymorphism was associated with higher peripheral joint disease activity (OR 3.13; p < 0.0004; CI 95 % 1.43-6.82, p (corrected) <0.008), while the G allele of the IL6 (174G > C) polymorphism presented a strong trend to be associated with peripheral forms (70.86 %) (OR 1.89; p < 0.03; CI 95 % 1.06-3.39, p-corrected 0.05). In addition, this allele showed a lower association with HLA-B27 (15.78 %) compared with C allele (28.57 %) (OR 0.469; p = 0.02; CI 95 % 0.238-0.923, p-corrected 0.03). This study suggests that the G allele polymorphism of IL1B (-511 A/C) is associated with higher peripheral joint disease activity. On the other hand, the IL6 (-174 G/C) polymorphism showed a strong trend to be associated with the peripheral pattern of PsA.

Common and rare CARD14 gene variants affect the antitumour necrosis factor response among patients with psoriasis.

BACKGROUND: The CARD14 gene encodes a protein that enhances nuclear factor (NF)-κB activation and the upregulation of proinflammatory pathway genes. CARD14 is upregulated in psoriatic vs. normal skin, and rare and common CARD14 variants have been associated with the risk of developing psoriasis. Our hypothesis was that CARD14 variants could also influence the response to antitumour necrosis factor (anti-TNF) therapies among patients with psoriasis. OBJECTIVES: To determine whether CARD14 gene variants were linked to a significant positive anti-TNF response in patients with psoriasis. METHODS: DNA from 116 patients with psoriasis was subjected to next-generation sequencing of the CARD14 gene. All of the patients were nonresponders or had contraindications to conventional systemic treatments. RESULTS: A reduction of at least 75% in Psoriasis Area and Severity Index (PASI 75) at week 24 was considered a positive response to treatment. In total 116 patients (79 responders and 37 nonresponders) were next-generation sequenced, and we identified five nucleotide variants that would result in missense amino acid changes. These variants were determined in all of the patients, and allele and genotype frequencies were compared between the two groups. We found a significantly higher frequency of rs11652075 CC (p.Arg820Trp) among the group with a positive response (P = 0.01, odds ratio 3.71, 95% confidence interval 1.30-10.51). Furthermore, among responders, six patients were heterozygous carriers of the rare p.Glu422Lys variant, and two patients were heterozygous for p.Arg682Trp (P = 0.04). CONCLUSIONS: The common CARD14 p.Arg820Trp variant might have a significant effect on the response to anti-TNF therapies among patients with psoriasis. In addition, rare CARD14 missense variants could also predispose to a better response.

Erosive discovertebral lesion (Andersson lesion) as the first sign of disease in axial psoriatic arthritis.

OBJECTIVES: To present two cases of Andersson lesion (AL) as the form of onset of psoriatic arthritis (PsA), to review the form of onset of axial disease in PsA in our area, and to study the prevalence of AL in this series. PATIENTS AND METHODS: Two patients with psoriasis and recent-onset inflammatory back pain (IBP) with no known arthritis are presented. A final diagnosis of AL based on magnetic resonance imaging (MRI) findings was made. The medical records of 120 consecutive patients with axial PsA were reviewed and the most relevant features at disease onset analysed. RESULTS: Including the two cases presented, an AL prevalence of 5.7% was found in this series. The most common onset forms of axial PsA were: oligoarthritis (30%), IBP (21.7%), enthesitis (17.5%), polyarthritis (16%), gluteal pain (8.3%), dactylitis (3.3%), and distal interphalangeal (DIP) involvement (3.3%). Compared to women, men more frequently showed enthesitis (25% vs. 9%, p = 0.03) and IBP (31% vs. 10.7%, p = 0.007) as onset forms whereas a polyarticular onset was predominant in women (25% vs. 8%, p = 0.01). The polyarticular onset was predictive of radiological damage in the cervical column during follow-up [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.82-6.83, p = 0.01]. Enthesitis (23.6% vs. 8.3%, p = 0.02) and IBP (29.7% vs. 10.4%) were the predominant onset forms in patients with age at disease onset ≤ 40 years and polyarthritis (27% vs. 8.3%, p = 0.009) was predominant in those with disease onset > 40 years. CONCLUSIONS: AL is an uncommon finding in axial PsA and its appearance at disease onset is exceptional. MRI is a key tool in its early recognition.

Synovitis-acne-pustulosis-hyperostosis-osteitis syndrome and psoriatic arthritis exhibit a different immunogenetic profile.

BACKGROUND AND OBJECTIVES: Patients with psoriatic arthritis (PsA) as well as those with synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome share some common features, and in fact, for many authors the SAPHO concept fits well into the broader concept of PsA. However, some clinical features are unique to the SAPHO syndrome, and in the other hand, these patients do not show the known association between the HLA-B27 antigen and the spondyloarthropathies. To date, there are no studies comparing the immunogenetic profile of these two conditions, so the main objective of the present report was to analyse whether or not both entities may share the same genetic basis. PATIENTS AND METHODS: All patients with SAPHO syndrome (n=25) seen in a single university hospital from 1985 to 2005 were recruited and followed up in standardised manner in order to study their main characteristics and HLA profile. The HLA-Cw6, DR and B27 antigen distribution of these cases was compared to that of 50 patients with psoriasis vulgaris, 120 with PsA, and 170 healthy blood donors. PsA patients were classified in accordance with their predominant pattern observed in the last 5 years of disease evolution. Odds ratios (OR) values were calculated to measure the strength of the association between HLA antigens and disease, while the statistical significance of the association was assessed with a two-tailed Fisher's exact test. P<0.05 values were considered significant. RESULTS: No association was found between HLA-Cw6, B27, or DR antigens, and SAPHO syndrome. HLA-Cw6 was strongly associated with psoriasis, OR 12 (95% CI: 5.6-26, p<0.0001) and PsA, OR 10 (95% CI: 5.4-19.5, p<0.0001), however this antigen was equally distributed among the three articular categories of PsA. HLA-DR4 was found under-represented in PsA patients compared to controls, OR 0.4 (95% CI: 0.2-0.7, p=0.002). HLA-DR7 correlated well with psoriatic oligoarthritis, OR 9.6 (95% CI: 2.9-28, p<0.0001), HLA-DR8 was found associated with polyarthritis, OR 6.7 (95% CI: 2-25, p=0.002), while HLA-B27 was over-represented in psoriatic spondylitis, OR 10 (95% CI: 3.3-25, p<0.0001). CONCLUSIONS: Psoriasis/PsA and SAP-HO syndrome show a different immunogenetic background, however the genetic basis of SAPHO syndrome remains unknown.

Haematogenous vertebral osteomyelitis in the elderly.

The aim of our study was to analyse the characteristics of haematogenous vertebral osteomyelitis (HVO) in the elderly. A retrospective comparative analysis of the medical records of 72 patients (38 younger than 63 years, group 1, and 34 aged 63 years and over, group 2) with haematogenous vertebral osteomyelitis of confirmed aetiology was carried out. Intravenous drug addiction and infection with the human immunodeficiency virus were seen in 4/38 (10%) and 5/38 (13%) patients from group 1 and 0/34 patients (0%) from group 2 (P = 0.05 and 0.035, respectively). Seven of 34 elderly (20%) and 0/38 (0%) young individuals had recently had surgery (P = 0.0036). Escherichia coli was isolated in 7/34 elderly (20%) and 0/38 (0%) young patients (P = 0.0036). The remaining studied data did not reach statistical significance. Recent surgery is a risk factor for developing HVO in the elderly, the urinary tract being the source of the pathogen in a large number of elderly patients with spinal infection.

Vertebral osteomyelitis in northern Spain. Report of 62 cases.

OBJECTIVE: The records of 62 patients with clinical and radiographic evidence of vertebral osteomyelitis and positive bacteriological diagnosis, seen between 1979 and 1996, were reviewed in order to gather data on the epidemiology and the clinical pattern displayed by patients with this condition in northern Spain. RESULTS: Staphylococcus aureus (15 cases), Mycobacterium tuberculosis (15 cases) and Brucella melitensis (13 cases) were the microorganisms most frequently found in our patient series. After improvement of the sanitary and hygienic control of food products, the role of Brucella melitensis is decreasing as a causative agent (only 3 cases in the last 6 years). Staphylococcus epidermidis, present in 4 cases (6.6%), should be suspected in elderly patients with previous intravenous cannulations (3 of 4 cases). The most frequent risk factors were alcoholism (7 cases), chronic hepatic disease (7 cases), diabetes (6 cases) and previous surgery (6 cases). Delay in diagnosis was high (the mean number of days between the onset of symptoms and diagnosis was 125). The lumbar region was the most commonly affected site. Neurologic involvement was present in 10 patients on admission (16%). ESR was > 50 mm/hr in a high number of cases. Blood cultures were found to be the most valuable routine test. Plain x-rays were normal in 10 patients (16%); in 6 of them Staphylococcus aureus was the responsible organism. Other imaging modalities showed a high sensitivity. Surgical drainage was necessary in 12 individuals (in 7 due to Mycobacterium tuberculosis). Outcome was good in the majority of cases: only 2 patients with associated endocarditis died. Neurologic sequelae were present in another 3 patients. CONCLUSION: Vertebral osteomyelitis can be caused by a variety of pathogens. Therefore, bacteriological studies are necessary to establish the etiologic diagnosis and determine the specific antimicrobial treatment required.