Psoriatic Arthritis Mutilans: Case Series and Literature Review
Bibliographic record
Abstract
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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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.005 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.001 |
| Bibliometrics | 0.008 | 0.008 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.002 | 0.003 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.003 | 0.002 |
| Insufficient payload (model declined to judge) | 0.005 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".