Journal of Clinical and Cellular Immunology

Journal of Clinical and Cellular Immunology
Open Access

ISSN: 2155-9899

+44 1223 790975

Case Report - (2014) Volume 5, Issue 3

Successful Treatment of Severe Psoriatic Arthritis and Psoriasis with Double Filtration Plasmapheresis

Xiaoxia Yu1*, Lei Zhang2 and Peng Zhang1
1Department of Rheumatology and Immunology, Traditional Chinese Medicine-Western Medicine Hospital of Cangzhou of Hebei, China
2Medical Unit, 66019 Troops of Chinese people's Liberation Army, Beijing, China
*Corresponding Author: Xiaoxia Yu, Department of Rheumatology and Immunology, Traditional Chinese Medicine-Western Medicine Hospital of Cangzhou of Hebei, No.31 Yellow River West Road, Cangzhou 061001, Hebei, People’s Republic of China, Tel: 13513276959, Fax: 86-0317-2025774 Email:

Abstract

Psoriatic arthritis (PsA) is a chronic, progressive, inflammatory arthropathy associated with psoriasis. Traditional disease modifying anti-rheumatic drugs (DMARDs) have shown inconsistent and unsatisfactory results. Treatment with biological agents has shown different results. Despite the evident efficacy of biologic agents for psoriasis and psoriatic arthritis, there is an increase in psoriasis following biologic agents’ therapies. Psoriasis has no permanent cure and represents a lifelong burden for affected patients. We report herein a successful therapeutic approach for PsA with widespread psoriasis using double filtration plasmapheresis (DFPP) in a 25-year-old female patient. Two months after the first DFPP treatment, a remarkable normalization of the clinical appearance was achieved. During the 3 years follow-up, the patient has had no detectable disease, and a sustained clinical remission has been maintained for 2 years after the interruption of therapy. DFPP therapy led to the complete regression of the severe disease. Therefore, we consider the therapy as promising for treatment of PsA.

Keywords: Double filtration plasmapheresis, Psoriatic arthritis, Psoriasis

Introduction

PsA is progressive, erosive, and destructive, resulting in marked impairment of the activities of daily living and poor quality of life. Patients with PsA are usually affected with psoriasis before signs of joint disease have developed. Although not life-threatening, psoriasis substantially affects health-related quality of life and has negative psychological and social implications. A comparative study reported reduction in physical functioning and mental functioning comparable with these seen in cancer [1]. Traditional disease modifying anti-rheumatic drugs, have shown inconsistent and unsatisfactory results. Treatment with biological agents has shown different results. Despite the evident efficacy of biologic agents for psoriatic arthritis [2,3] and psoriasis [4], there is an increase in psoriasis following biologic agents therapies [5-8]. Psoriasis has no permanent cure and represents a lifelong burden for affected patients. We report herein the first case of a successful treatment of PsA with widespread psoriasis using DFPP, its major mode of action is rapid depletion of specific disease-associated plasma factors [9].

Case Report

The patient, a 25-year-old woman, had a 4-year history of psoriasis and a 2-year history of tender and swelling joints. She was taking methotrexate and leflunomide for treatment. The therapy did not result in sufficient relief of joint pain and lesions. Her daily living activities were severely affected by the dual burden of widespread psoriatic skin lesions and joint involvement.

On admission, her body temperature was 36.2, heart rate 75/min, blood pressure 110/80 mmHg. Her knee joints and left ankle joint showed marked swelling and tenderness and her great toe of the left foot showed a sausage-shaped swelling, but no sign of muscular weakness. Her arms, trunk and legs showed large areas of raised, well-demarcated, erythematous plaques with adherent silvery scales, and pustules was developed on erythematous areas on the legs (Figure 1A). There was also mild limitation in the patient’s scalp. Examination of the chest and abdomen was unremarkable.

cellular-immunology-One-month

Figure 1: (A) Psoriasis before treatment with double filtration plasmapheresis (DFPP). Severe widespread psoriasis on patient’ arms, trunk and legs (left to right). (B) One month after the first DFPP, the patient showed significant improvement in the skin lesions. (C) Two months after the first DFPP, showing complete remission of psoriasis.

Laboratory findings were as follows: CRP was 102 mg/l (normal range 0-8 mg/l), ESR 61 mm/h (normal range 0-20 mm/h), HLA–B27 and rheumatoid factor were negative. Based on these findings, the patient was diagnosed as having psoriatic arthritis combined with psoriasis. In this study, the DLQI score was 30, the PASI score was 55, and the HAQ score was 1. These represented severe disease. 12-month treatment with MTX and LEF did not result in sufficient relief of joint pain and lesions. Therefore, we decided to treat the patient with DFPP. DFPP was performed once a week for 2 sessions. For long-term treatment, patients continued to take the same doses of medications: LEF 10 mg, two times daily, plus MTX 15 mg orally once weekly. Most interestingly, the patient showed significant improvement in tender joints and swollen joints 1 day after the first DFPP, CRP 58 mg/l, ESR 3 mm/h. Two days after the second DFPP, the patient experienced complete relief of joint pain and swelling, and HAQ score was 0. The level of CRP was 9. The patient showed significant improvement in the skin lesions at month 1 (Figure 1). After 2 months, a remarkable normalization of the skin was achieved (Figure 1), DLQI score and PASI score were 0. The patient didn’t take any medicine after a 1-year MTX - LEF therapy period. During the 3 years follow-up, the patient has had no detectable disease, and a sustained clinical remission has been maintained for 2 years after the interruption of therapy (Figure 2).

cellular-immunology-psoriatic-arthritis

Figure 2: Responses to double filtration plasmapheresis therapy in the patient with severe psoriatic arthritis and psoriasis: improvement in PASI, DLQI, HAQ, CRP and ESR at different time points.

Discussion

By definition, all patients with PsA have psoriasis. Skin involvement can occur anywhere on the body. Manifestations of PsA contribute to reduced physical and psychosocial health-related quality of life. The health-related quality of life was assessed with the dermatology life quality index (DLQI) questionnaire. The DLQI is a self-reported questionnaire to measure how much a skin problem has affected the life of the patient, covering symptoms and feelings, daily activities, leisure, work/school, personal relationships and treatment. A DLQI score of 21-30 is considered as extremely large effect [10]. The severity of psoriasis was assessed with the psoriasis area and severity index (PASI) [11]. The severity of psoriasis according to the PASI was defined as mild (PASI<7), moderate (PASI 7-12), and severe (PASI>12). The health assessment questionnaire (HAQ) is commonly used to assess physical function in PsA.

PsA is thought to be an immune-mediated disease with a complex pathophysiology and a strong genetic background [12-14]. A variety of cytokines, autoantibodies and immunoglobulins have been implicated in the pathogenesis of PsA and psoriasis [14-16]. A biologic agent could target only a single inflammatory mediator and may show unsatisfactory results [17,18]. Double filtration plasmapheresis selectively removes high-molecular-weight substances, such as immunoglobulins, autoantibodies, immune complexes, acute-phase reactant proteins and cytokines [9,19-21]. Double filtration plasmapheresis (DFPP) was conducted by application of a double-filtration technique with a membrane plasmapheresis apparatus (Plasauto iQ, Asahi Medical Co., Tokyo, Japan). OP-08W and EC-30W were used as plasma separator and plasma fractionator. In DFPP, a first filter was used to separate plasma from blood (plasma separator) and a second to filter larger molecules from the plasma (plasma fractionator). Disease activity of the patients with autoimmune diseases could be controlled completely following the rapid depletion of specific disease-associated plasma factors [20-27].

To our knowledge, treatment of PsA with a DFPP therapy has not previously been reported. In the present case report, in addition to the effect on widespread skin lesions after 2 months, the complete resolution of swollen and tender joints 9 days after initiation of DFPP therapy is remarkable. Of particular note, a sustained clinical remission has been maintained for 2 years after the interruption of therapy. DFPP therapy led to the complete regression of the severe disease.

A good initial response and a sustained response to DFPP therapy were all observed. We consider a DFPP therapy to be promising in PsA.

References

  1. Rapp SR, Feldman SR, Exum ML, Fleischer AB Jr, Reboussin DM (1999) Psoriasis causes as much disability as other major medical diseases. J Am Acad Dermatol 41: 401-407.
  2. Mease P (2004) TNFalpha therapy in psoriatic arthritis and psoriasis. Ann Rheum Dis 63: 755-758.
  3. Kyle S, Chandler D, Griffiths CE, Helliwell P, Lewis J, et al. (2005) Guideline for anti-TNF-alpha therapy in psoriatic arthritis. Rheumatology (Oxford) 44: 390-397.
  4. Gottlieb AB, Evans R, Li S, Dooley LT, Guzzo CA, et al. (2004) Infliximab induction therapy for patients with severe plaque-type psoriasis: a randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol 51: 534-542.
  5. Harrison MJ, Dixon WG, Watson KD, King Y, Groves R, et al. (2009) Rates of new-onset psoriasis in patients with rheumatoid arthritis receiving anti-tumour necrosis factor a therapy: results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis 68: 209-215.
  6. Sfikakis PP, Iliopoulos A, Elezoglou A, Kittas C, Stratigos A (2005) Psoriasis induced by anti-tumor necrosis factor therapy: a paradoxical adverse reaction. Arthritis Rheum 52: 2513-2518.
  7. Sari I, Akar S, Birlik M, Sis B, Onen F, et al. (2006) Anti-tumor necrosis factor-alpha-induced psoriasis. J Rheumatol 33: 1411-1414.
  8. Tichy M Jr, Tichy M, Kopova R, Sternbersky J, Ditrichova D (2012) Psoriasis and psoriatic arthritis induced in a patient treated with infliximab for Crohn's disease. J Dermatolog Treat 23: 208-211.
  9. Ismail N, Neyra R, Hakim RM (2001) Plasmapheresis. In: Daugirdas JT, Blake PG, Ing TS (eds) Handbook of dialysis. (3rdedn) Lippincott Williams Wilkins, Philadelphia, pp: 231-262.
  10. Hongbo Y, Thomas CL, Harrison MA, Salek MS, Finlay AY (2005) Translating the science of quality of life into practice: What do dermatology life quality index scores mean? J Invest Dermatol 125: 659-664.
  11. Feldman SR, Krueger GG (2005) Psoriasis assessment tools in clinical trials. Ann Rheum Dis 64 Suppl 2: ii65-68.
  12. Liu Y, Krueger JG, Bowcock AM (2007) Psoriasis: genetic associations and immune system changes. Genes Immun 8: 1-12.
  13. Nickoloff BJ, Qin JZ, Nestle FO (2007) Immunopathogenesis of psoriasis. Clin Rev Allergy Immunol 33: 45-56.
  14. Hueber AJ, McInnes IB (2007) Immune regulation in psoriasis and psoriatic arthritis--recent developments. Immunol Lett 114: 59-65.
  15. Toichi E, Torres G, McCormick TS, Chang T, Mascelli MA, et al. (2006) An anti-IL-12p40 antibody down-regulates type 1 cytokines, chemokines, and IL-12/IL-23 in psoriasis. J Immunol 177: 4917-4926.
  16. Fitch E, Harper E, Skorcheva I, Kurtz SE, Blauvelt A (2007) Pathophysiology of psoriasis: recent advances on IL-23 and Th17 cytokines. Curr Rheumatol Rep 9: 461-467.
  17. Collamer AN, Battafarano DF (2010) Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: clinical features and possible immunopathogenesis. Semin Arthritis Rheum 40: 233-240.
  18. Ma HL, Napierata L, Stedman N, Benoit S, Collins M, et al. (2010) Tumor necrosis factor alpha blockade exacerbates murine psoriasis-like disease by enhancing Th17 function and decreasing expansion of Treg cells. Arthritis Rheum 62: 430-440.
  19. Yeh JH, Chen WH, Chiu HC, Bai CH (2006) Clearance studies during subsequent sessions of double filtration plasmapheresis. Artif Organs 30: 111-114.
  20. Yu X, Ma J, Tian J, Jiang S, Xu P, et al. (2007) A controlled study of double filtration plasmapheresis in the treatment of active rheumatoid arthritis. J Clin Rheumatol 13: 193-198.
  21. Hatano Y, Katagiri K, Arakawa S, Umeki T, Takayasu S, et al. (2003) Successful treatment by double-filtration plasmapheresis of a patient with bullous pemphigoid: Effects in vivo on transcripts of several genes for chemokines and cytokines in peripheral blood mononuclear cells. Br J Dermatol 148: 573-579.
  22. Thalgahagoda S, Webb NJ, Roberts D, Birch A, Milford DV, et al. (2014) Successful ABO incompatible renal transplantation following rituximab and DFPP after failed immunoadsorption. Pediatr Transplant 18: E74-76.
  23. Kim JY, Park JS, Park JC, Kim ME, Nahm DH (2013) Double-filtration plasmapheresis for the treatment of patients with recalcitrant atopic dermatitis. Ther Apher Dial 17: 631-637.
  24. Yu XX, Wang LX, Xu P, Lu WW, Lan GB, et al. (2012) Effects of Double Filtration Plasmapheresis, Leflunomide, and Methotrexate on Inflammatory Changes Found Through Magnetic Resonance Imaging in Early Rheumatoid Arthritis. J Rheumatol 39: 1171-1178.
  25. Yu XX, Wang LX, Zhang XW, Sun FY, Lu WW, et al. (2010) Magnetic resonance imaging outcomes of double filtration plasmapheresis combined with immunosuppressive agents in patients with high active rheumatoid arthritis. Chin J Rheumatol 14: 473-476.
  26. Chiu HC, Yeh JH, Chen WH (2003) Pulmonary function study of myasthenia-gravis patients treated with double-filtration plasmapheresis. J Clin Apher 18: 125-128.
  27. Otsubo S, Tanabe K, Shinmura H, Ishikawa N, Tokumoto T, et al. (2004) Effect of post-transplant double filtration plasmapheresis on recurrent focal and segmental glomerulosclerosis in renal transplant recipients. Ther Apher Dial 8: 299-304.
Citation: Yu X, Zhang L, Zhang P (2014) Successful Treatment of Severe Psoriatic Arthritis and Psoriasis with Double Filtration Plasmapheresis. J Clin Cell Immunol 5:222.

Copyright: © 2014 Yu X, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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