a 40-year-old gentleman and is a dedicated long distance runner. He had a 1-year history of right ankle arthralgias and a 2-month history of right knee arthralgias. Then, during a meeting he was attending in the U.S., he developed right thigh, calf & foot swelling, and a right knee effusion. Evaluation yielded the following: Laboratory findings - ESR 40 mm/hr - normal CBC, differential & uric acid Right leg venous Doppler – negative for DVT Right knee MRI - positive for a ruptured Bakers cyst Subsequent evaluation included: Orthopedics consultation x 4 Rheumatology consultation x 1 Emergency Department evaluation x 1 These evaluations revealed the following: Laboratory findings – normal comprehensive metabolic profile, ESR, urinalysis, and Lyme ELISA & Western blot Arthrocentesis x 3 (representative values): WBC – 10,683/mm3 Differential – 79% neutrophils and 21% mononuclear cells Crystals – none Bacterial culture – negative Right leg venous Doppler - positive for a Bakers cyst Abdomino-pelvic CT scan – normal Pharmacologic interventions: Celecoxib, indomethacin & nabumetone Tramadol Hydrocodone/APAP Doxycycline Intra-articular corticosteroids Presentation to Johns Hopkins Rheumatology Clinic He had persistent right leg swelling but the effusion in his right knee had resolved. He had a new effusion in his left knee and had developed arthalgias in the left ankle. Past Medical History, Family History & Social History – unremarkable Review of Systems: Rash or psoriasis – none Ocular inflammation – none Cough or dyspnea – none Cramping, diarrhea, hematochezia or mucous stool – none Dysuria or genital lesions – none Low back pain - present Low back stiffness – none Tick exposure – none Physical Examination Cutaneous: Right 4th and 5th fingernails - isolated “pitting” Psoriatic plaques – none Oral mucosa – no lesions Eyes – no inflammation Chest – clear Gastrointestinal: Abdomen – benign Stool Hemoccult - positive Peripheral articular: Right knee synovitis – none Left knee synovitis - present Left ankle synovitis – none Axial articular: Sacro-iliac joint tenderness – none Schober test – 4 cm lumbar distraction Differential Diagnosis [ ] Trauma [ ] Microcrystalline arthritis [ ] Septic/viral arthritis [ ] Lyme disease [ ] Rheumatoid arthritis [ ] Sarcoidosis [ ] Sero-negative spondyloarthropathy Additional Diagnostic Studies CBC & differential – normal Rheumatoid factor – negative Lyme serology – negative Parvovirus serology – negative Chest x-ray – normal Sacro-iliac joint x-ray – normal This narrowed the differential diagnosis to a sero-negative spondyloarthropathy. Possiblities included: Ankylosing spondylitis Inflammatory bowel disease Psoriatic arthritis Reiters syndrome Further evaluation revealed: History - “Dandruff” x 3 months Examination -Scaling plaque right occiput -Dactylitis right 3rd toe EGD & colonoscopy with biopsy – normal Dermatology consult with biopsy - Psoriasis Subsequent Course These pharmacologic interventions were initiated sequentially, in combination with physical therapy: NSAIDs Intra-articular corticosteroid injection Methotrexate (7.5 mg-15 mg weekly) x 5 months Etanercept (25 mg SQ b.i.w.) He had a dramatic clinical response in all respects except for persistent and diffuse right leg swelling. Discussion Five percent of patients with psoriasis are affected by an inflammatory arthritis in some form. Men and women are affected with equal frequency. Psoriatic skin disease may pre-date the onset of arthritis (70% of cases), present coincident with arthritis (15% of cases), or follow the onset of arthritis (15% of cases). Characteristic, but not necessarily pathognomonic, features of psoriatic arthritis include nail involvement (pitting, separation from the nail bed known as “onycholysis”, and yellow discoloration known as the “oil drop” sign); dactylitis (“sausage digits”); inflammation at the sites of ligamentous and tendonous insertion (“enthesopathy”); and absence of rheumatoid factor. There are five clinical patterns of psoriatic arthritis, which may evolve and are not necessarily mutually exclusive: Symmetrical polyarticular (30-50% of cases) Asymmetrical oligoarticular (30-50% of cases) Distal interphalangeal joint involvement (25% of cases) Arthritis mutilans (characterized by resorption of the phalangeal bones) (5% of cases) Axial arthritis (includes both sacro-iliitis which may be asymmetric & spondylitis) Extra-articular manifestations are uncommon but may include uveitis, aortic insufficiency, and pulmonary fibrosis. Radiographically, psoriatic arthritis is a unique blend of bone destruction & proliferation. Manifestations may include erosive arthritis giving rise to the classic “pencil-in-cup” deformity in the phalanges, osteolysis, sacro-iliitis, ankylosis, spondylitis, enthesopathy, and periostitis. Our understanding of the etiology and pathophysiology of psoriatic arthritis remains incomplete. However, what is known can be summarized as follows. Genetic factors play an important role as evidenced by the 70% concordance for psoriasis in monozygotic twins; 50-fold increased risk of developing psoriatic arthritis in 1st degree relatives of patients with the disease; and epidemiologic association with the expression of both class I and class II HLA alleles including -B13, -B17, -B27, -B38, -B39, -Cw6, -DR4, and -DR7. Environmental factors have also been implicated including infectious agents (streptococci & staphylococci) and trauma (“Koebner phenomenon”) that may precipitate the onset or a flare of disease activity. T-cells have been demonstrated to play a role in both initiation and perpetuation of disease activity. Interestingly, peripheral joint activity in psoriatic arthritis parallels cutaneous activity in 1/3 of cases. Treatment options include NSAIDs, intra-articular or low-dose systemic corticosteroids, and a variety of “disease-modifying” agents including anti-malarials, gold, methotrexate, sulfasalazine, azathioprine, and cyclosporin A. The TNF inhibitor, etanercept (Enbrel®) is also an approved therapy for patients with psoriatic arthritis. Factors which portend a worse prognosis include a strong family history of psoriasis, disease onset
Posted on: Fri, 14 Mar 2014 07:32:51 +0000
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