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from previous page of note and no axial symptoms.
Further history reveals a family history of psoriasis – his father was affected with mild disease of the scalp requiring topical therapy.
On examination there is a moderate effusion of the left knee with some quadriceps wasting. Examination of the feet reveals a swollen but non-painful right second toe. On questioning, Matt had noted the swelling several months ago but assumed he had injured it at sport. As it was not particularly painful, he had not sought advice.
An examination of his nails showed pitting of several nails, and a small patch of psoriasis was detected in the natal cleft.
Blood investigations show ESR 2, CRP < 4, HLA B27 detected, urate 0.30.
He is referred to a rheumatologist who confirms psoriatic arthritis. Matt is treated with aspiration and injection of Depo-Medrol 80mg IA on two further occasions, with the knee effusion settling. Matt begins to resume normal function, the swelling involving the toe resolves slowly and he starts a rehabilitation physiotherapy program.
Within three months he is running again and his symptoms have completely resolved. He decides not to return to rugby union that season but subsequently plays for the next two seasons.
Matt presents again aged 30 with new onset joint symptoms of four weeks’ duration. He has
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developed large effusions affecting both knees, dactylitis of the left, third toe( painful and swollen), morning joint stiffness in his shoulders, knees and wrists of 45 minutes duration and Achilles tendonitis of the right ankle.
His psoriasis has remained stable and has not required treatment. Apart from increased external stressors at his place of work, there is no obvious preceding event. He has no associated fever or systemic symptoms and is taking diclofenac 50mg daily( OTC) to help him manage during the day.
Bloods show ESR 14, CRP 5.1(< 5mg / L), FBC normal, UEC, LFT normal. Recognising psoriatic arthritis, his GP secures an urgent appointment with Matt’ s treating rheumatologist.
He is treated initially with lowdose steroids at 7.5mg daily with cessation of diclofenac, and methotrexate is added at 10mg weekly initially, titrated to 25mg weekly over a four-week period. Unfortunately, after three months of treatment at maximum dose with his prednisone reduced to 5mg daily, he develops ongoing, large knee effusions. Despite ultrasound guided injections to the tendon sheath of the left third toe, there is no relief.
At this point, leflunomide 20mg daily is added and dual combination therapy is continued for a further three months.
At the end of this course of therapy, Matt still has very active disease. He requires prednisone up
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to 10mg daily to control his symptoms, which include dactylitis, Achilles tendonitis and knee effusions, limiting his mobility. His psoriasis remains quiescent, and ESR and CRP remain normal( on prednisone).
Therapy with a TNF inhibitor is discussed and he is started on adalimumab 40mg fortnightly in combination with methotrexate. Leflunomide is ceased.
Matt begins to respond after four weeks of therapy. Knee effusions reduce considerably during this initial period and the tenosynovitis and tendonitis begin to resolve. He is referred for a physical therapy program as part of his recovery, prednisone is weaned by 1mg every two weeks initially and eventually stopped by week 10 of therapy.
By week 24, his tendonitis and dactylitis have resolved, knee effusions are small and continuing to improve and the large joint stiffness has resolved. Morning joint stiffness has resolved and fatigue is markedly improved.
The case illustrates the fluctuating nature of symptoms, the different possible presentations in the same patient over time, the importance of history clues in the initial diagnostic period, and the need to continue to treat until inflammation has resolved.
Although this patient required a biologic agent, a substantial proportion of patients will reach remission with conventional synthetic DMARD therapy.
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Source: Roland Tanglao http:// bit. ly / 2BI6rzR
Conclusion THE management of psoriatic arthritis continues to evolve as new cytokine pathways are identified and treatment options increase.
The most important part of management is initial diagnosis – many patients with this condition remain undiagnosed because of the fluctuating nature of symptoms, the disparate nature of clinical manifestations and the lack of elevation of inflammatory parameters.
Without diagnosis, patients are at risk of considerable morbidity from the disease.
Patient questionnaires to detect psoriatic arthritis are sensitive and a useful adjunct for clinical assessment in primary care.
In the future, biomarkers and pharmacogenetics may allow individualised therapy, facilitating tailoring of therapy to increase efficacy and reduce adverse effects.
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Key points
• Suspect psoriatic arthritis in patients presenting with unexplained monoarthritis, dactylitis or refractory enthesitis
• Psoriasis may be mild and undiagnosed
• Use symptom screening tests to assist in diagnosis
• Normal ESR and CRP does not exclude the diagnosis
• Treatment dramatically alters outcome for patients with moderate to severe symptoms
Online resources
Online symptom checker www. doublewhammy. com. au
References
Available on request from howtotreat @ adg. com. au
Pustular psoriasis.
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1. Which THREE are shared features of the spondyloarthropathies? a) Axial skeleton involvement. b) Cervical spine disease. c) Enthesitis. d) Uveitis.
2. Which TWO statements regarding psoriatic arthritis are correct? a) The severity of psoriasis does not correlate with onset of joint symptoms b) Joint manifestations precede psoriasis in the majority of cases. c) Psoriatic arthritis can begin in childhood. d) The severity of psoriasis is directly proportional to the joint symptoms
3. Which ONE feature is the most pathognomonic joint manifestation in psoriatic arthritis? a) Axial disease. b) DIP involvement. c) Dactylitis. d) Enthesitis.
4. Which THREE clinical features best
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describe the oligoarticular subtype of psoriatic arthritis? a) Severe destruction of digits. b) Four or fewer joints involved. c) Asymmetrical. d) Small and large joint involvement.
5. Which THREE comorbidities are associated with psoriasis and psoriatic arthritis? a) Coronary artery disease. b) Type 2 diabetes. c) Metabolic syndrome. d) Hypertension.
6. Which TWO statements regarding the diagnosis of psoriatic arthritis are correct? a) Psoriatic arthritis is likely if the score is above four on the Classification Criteria for Psoriatic Arthritis. b) The diagnosis of psoriatic arthritis is based upon the recognition of clinical and imaging features. c) The absence of psoriasis excludes a diagnosis of psoriatic arthritis. d) A score of three or more on the EARP questionnaire indicates possible psoriatic
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arthritis and referral is recommended.
7. Which THREE statements regarding the investigation of psoriatic arthritis are correct? a) Normal radiographs do not exclude the diagnosis. b) Power Doppler can assist in differentiating inflammatory from non-inflammatory causes in patients with entheseal involvement. c) ESR and CRP are always elevated in patients with psoriatic arthritis. d) The most important lesion to note on MRI in the sacroiliac joints is osteitis.
8. Which condition is best described as asymmetric, mono – or oligoarticular, and without sacroiliitis and erythema accompanying joint swelling? a) Psoriatic arthritis. b) Rheumatoid arthritis. c) Osteoarthritis. d) Gout.
9. Which THREE statements regarding the management of psoriatic arthritis are
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correct? a) Management includes treating joint symptoms, skin and nail disease and comorbidities. b) Low-dose prednisone can be used to control symptoms long-term. c) Despite the lack of clinical trial evidence, conventional synthetic DMARDs are commonly used in patients with psoriatic arthritis. d) About 30-50 % of patients fail to achieve disease remission with available conventional synthetic DMARDs.
10. Which TWO statements regarding the management of psoriatic arthritis are correct? a) Anti-tumour necrosis factor therapy is particularly effective for joint symptoms, skin disease, dactylitis, enthesitis and axial disease. b) Adverse effects associated with TNF inhibitors are common and thus limit their use in many patients. c) The risk of oropharyngeal candidiasis is increased in patients taking secukinumab. d) Ustekinumab has excellent data to support the management of psoriatic arthritis.
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