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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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