银屑病与银屑病关节炎患者下肢附着点病变的超声对比研究

Comparison of ultrasonic image of enthesopathy in lower limbs of patients with psoriasis and psoriatic arthritis

目的观察银屑病和PsA患者下肢附着点病变的超声表现与异同，探讨银屑病出现PsA的危险因素。方法收集就诊于解放军总医院皮肤科和风湿科门诊的性别、年龄匹配的银屑病、PsA患者和健康对照组的资料，采用GE Logiqe R6超声检查系统，探头频率（4-12）MHz Button高频线阵探头分别对其下肢附着点（股四头肌腱、髌腱起点、髌腱止点、跟腱、跖底筋膜）行超声检查，并比较各组下肢附着点超声表现的异同。定量资料采用方差分析或秩和检验，定性资料采用χ^2检验或Fisher确切概率法。结果共纳入银屑病、PsA患者和健康对照各45例，在每组450处附着点检查部位中，银屑病、PsA和健康对照组分别发现230处（51.1%）、233处（51.8%）和114处异常（25.3%），3组间异常率差异有统计学意义（χ^2=83.6，P〈0.01）。PsA组的跟骨骨侵蚀、跟腱骨赘和跟腱滑囊处能量多普勒信号显著多于银屑病组[（9（2.0%）和1（0.2%），52（11.6%）和35（7.8%），12（2.7%）和1（0.2%），χ^2=4.96，3.68，9.44；P〈0.05]，但银屑病面积和严重度指数（PASI）明显小于银屑病组（2.40和3.60，Z=-2.59，P〈0.01）。Logistic回归分析结果显示银屑病长病程与PsA发病有关（回归系数为0.121，OR=1.13，P〈0.01）。同时，银屑病、PsA组的格拉斯哥附着点炎评分系统（GUESS）评分较健康对照组明显升高（7.0、15.0和2.0，Z=-6.10、-5.56，P〈0.01），但2组间GUESS评分差异无统计学意义（Z=-1.29，P=0.196）。有指/趾甲病变的银屑病/PsA患者与指/趾甲正常的银屑病/PsA患者附着点病变发生率亦差异无统计学意义（χ^2=0.10，0.09；P=0.125，0.10）。结论跟骨骨侵蚀、跟腱骨赘和跟腱滑膜处PD信号是PsA患者区别于银屑病患者的主要超声表现。银屑病长病程可能是PsA发病的危险因素。

Objective To investigate the characteristics and differences of enthesopathy of ultrasonic imaging in the lower limbs in patients with psoriasis（Ps） and psoriatic arthritis（PsA）, and to explore the risk factors of Ps developing to PsA in the future.Methods Sex- and age-matched patients with Ps, PsA and HC who visited the dermatological and rheumatic outpatient of the PLA General Hospital were enrolled. Ultrasound of the lower limbs entheses （quadriceps insertions, patellar tendon origins and insertions, Achilles and plantar fascia insertion） were performed using a Logiqe R6 machine, both with a linear probe at 4-12 MHz. And then the ultrasonic imaging of the lower limbs entheses between the 3 groups were compared. T test, χ^2 text and Fisher exact probability methods were used.Results Forty-five Ps, 45 PsA cases and 45 HC were conse-cutively recruited into the study. Two hundred and thirty of 450 enthesal sites were abnormal in the Ps group, compared with 233 and 114 abnormal sites in PsA and HC group respectively （χ^2=83.6, P〈0.01）. The presence of osteophyte, erosion and power Doppler （PD） signals in the Achilles tendon were significantly higher in the PsA group than that in the Ps group [9（2.0%） vs 1（0.2%）, 52（11.6%） vs 35（7.8%）, 12（2.7%） vs 1（0.2%）,χ^2=4.96, 3.68, 9.44; P〈0.05], but the Psoriasis Area and the Severity Index （PASI） was less than the Ps group （2.40 vs 3.60, Z=-2.59, P=0.01）. Logistic regression results showed a longer course of psoriasis was the risk factor of developing into PsA （regression coefficient was 0.121, OR=1.13, P〈0.01）. The Glasgow Ultrasound Enthesitis Scoring System（GUESS） score was significantly higher in patients with Ps and PsA than that in HC （7.0 vs 15.0 vs 2.0, Z=-6.10, -5.56, P〈0.01）. However, there were no differences in GUESS score between the two groups （t=1.172, P=0.245）. Meanwhile, no differences were found in the presence of enthesopathy between the Ps/PsA with or without nail disease （χ^2=0.10、0.09, P=0.125, 0.10）.Conclusion Osteophyte, erosion and PD signal in Achilles tendon were the main features of ultrasonic imaging that could distinguish between patients with psoriasis and PsA. A longer course of psoriasis may be the predictive signal of developing into PsA in the future.