Psoriatic Arthritis Mutilans: Case Series and Literature Review

To the Editor: Psoriatic arthritis (PsA) is a seronegative spondyloarthropathy that develops in 1% to 39% of patients with psoriasis1. It may present clinically in different forms, including distal interphalangeal joint arthritis, asymmetrical oligoarthritis, symmetrical polyarthritis, spondylitis, and arthritis mutilans (AM)2. Although AM accounts for less than 5% of all PsA, it undeniably represents the most severe and disabling form. Therefore, AM requires timely diagnosis and therapy aiming to prevent or block the irreversible destruction of small joints, mainly involving distal interphalanges of digits and toes. However, data on patients with such arthritis have been published as anecdotal reports or as very small series, so that the available information is sparse. We describe a series of patients with delayed diagnosis of AM, and a systematic review of studies published in the last decade. A 77-year-old woman, with a 37-year history of psoriasis, was diagnosed with PsA at age 55 years when a symmetric polyarthritis involving both hands and feet occurred. She received longterm therapy with different nonsteroidal antiinflammatory drugs (NSAID) without significant improvement of arthritis, because she was intolerant to disease-modifying antirheumatic drugs (DMARD). She refused biological therapy. When significant deformity in phalanges of the left hand developed, she was referred to our ambulatory service. Biochemical tests revealed erythrocyte sedimentation rate (ESR) 50 mm/h, C-reactive protein (CRP) 5.84 g/l; clinical assessment showed pain score 70 on 100-cm visual analog scale (VAS), Health Assessment Questionnaire (HAQ) score 1.75, swollen joint count (SJC) = 6, tender joint count (TJC) = 5, and DJC = 5. Figure 1A illustrates AM involving the hands. We suggested biologic therapy with an anti-tumor necrosis factor-α (anti-TNF-α) agent, but she declined treatment. Figure 1. Destructive involvement of distal interphalangeal (DIP) joints and subluxation of the metacarpophalangeal joints (A). Mutilation of fourth and fifth digits of … Address correspondence to Dr. Bruzzese; E-mail: vinbruzzese{at}tiscali.it

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