Short Case Rheumatoid Arthritis versus Psoriatic arthritis

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Case diagnosed as Rheumatoid Arthritis then turned to be Psoriatic Arthritis and the skin lesions

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Short Case:

Short Case Ahmed EL-Belasy MSc Rheumatology Alexandria University Egypt

Personal History:

Personal History 27 years old , housewife. complaining of Pain and swelling of right wrist and small joints of both hands of 5 month duration .

Present History:

Present History Condition started 5 month ago by gradual onset of pain , swelling of small joints of both hands and right wrist. She had medical treatment ( NSAIDs ) with no improvement.

Present History:

Present History 3 month later the condition progressed to include pain and swelling of both wrist joints , MCPs , PIPs of both hands and bilateral ankle joint pain . She has morning stiffness lasting for ½ hour. There was no fever. No ocular manifestations. No chest or cardiac complains.

Drug History:

Drug History Diclofenac 150mg MR Tab once/day orally Past History No Hypertension No DM

Family History :

Family History Parents : negative consanguinity. Irrelevant family history.

Examination:

Examination General condition is good Vital signs : Pulse : 78 / min regular equal on both sides B.P : 120/ 80 mmhg Temp : 36.8 C R.R : 18/ min

Examination:

Examination Head and neck: Clinically free Chest examination: Clinically Free. Heart : Clinically Free. Abdomen: Clinically Free. Neurologically : clinically Free Skin lesions: Clinically free

Joints Examination:

Joints Examination Tender swollen joints. Tender joints. Tenderness of : Bilateral Wrist joints.( swelling ) Bilateral MCP joints. Bilateral PIP joints. Bilateral ankle joints. ROM is limited due to pain.

Laboratory Investigations::

Laboratory Investigations: Routine Investigations Hb : 11.2 gm WBC: 5,300 PLT: 279.000 S.Creatinine: 0.8 mg/dl (N. 0.5-1.2) SGPT: 49 U/L (N. up to 65 ) SGOT : 31 U/L (N. up to 37 )

Laboratory Investigations::

Laboratory Investigations: Serum Uric acid : 4.0 mg/dl( normal 2-6 mg/l) C – Reactive protein (CRP): 20 mg/l ( normal : 6 mg/l) ESR: 60 - 97 mm/hr Rheumatoid factor (Latex): Negative 8 ( normal : 16 units/l )

Laboratory Investigations::

Laboratory Investigations: ANA (ELISA) : Positive 45 ( normal 25 unit/ml ) ACPA (Anti CCP) : Negative 12 ( normal : 20 unit/ml )

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Sero -Negative Rheumatoid Arthritis Diagnosis

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Methotrexate injection 20 mg / week S.C Folic acid 1 mg in the form of 2 tablets 500 ug /day Leflunomide 20mg tablet once daily orally Diclofenac 150 mg MR Tablet once daily orally

3 Month Later ….:

3 Month Later ….

Follow up visit:

Follow up visit Joint complain improved. She started complaining about her nails and asked if it is related to the medications?

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Her nails affection was suspected as a psoriatic lesion . She was referred to a Dermatologist.

Psoriatic Arthritis:

Psoriatic Arthritis

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Can we as Rheumatologists diagnose Psoriatic skin lesions ?

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Clinical presentations of Psoriatic skin lesions

Common sites affected by psoriasis:

Common sites affected by psoriasis Can affect any part of the body – typically scalp , elbow , knees and sacrum 1. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004.

Psoriasis:

Well-defined and sharply demarcated Round/oval -shaped lesions Usually symmetrical Erythematous , raised plaques Covered by white, silvery scales 1. Schon MP et al . N Engl J Med 2005; 352 (18): 1899–912. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology . 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al . Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. Psoriasis Classic

Types of psoriasis:

Types of psoriasis Chronic plaque Guttate Flexural Erythrodermic Pustular Localised and generalised Local forms Palmoplantar Scalp Nail (psoriatic onychodystrophy ) 1. van de Kerkhof P, ed . Textbook of psoriasis . 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Rossi S, ed . Australian medicines handbook . Adelaide: AMH, 2010.

Chronic plaque psoriasis:

Chronic plaque psoriasis Most common type – affects approximately 85% Features pink, well-defined plaques with silvery scale Lesions may be single or numerous Classically affects elbows, knees, buttocks and scalp 1. Menter A et al . Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology . Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology . 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

Chronic plaque psoriasis:

Chronic plaque psoriasis

Chronic plaque psoriasis:

Chronic plaque psoriasis

Chronic plaque psoriasis:

Chronic plaque psoriasis

Guttate psoriasis:

Guttate psoriasis Numerous and small lesions – 1 cm diameter Pink with less scale than plaque psoriasis Commonly found on trunk and proximal limbs 1. Dermatology Expert Group. Therapeutic guidelines: dermatology . Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al . Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R, ed . MJA practice essentials – dermatology . 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 4. Menter A et al . J Am Acad Dermatol 2008; 58 (5): 826–50.

Flexural psoriasis:

Flexural psoriasis Lesions in skin folds Particularly groin, gluteal cleft, axillae and submammary regions. Often minimal or absent scaling 1. Dermatology Expert Group. Therapeutic guidelines: dermatology . Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Schon MP et al. N Engl J Med 2005; 352 (18): 1899–912.

Erythrodermic psoriasis:

Erythrodermic psoriasis Generalized erythema covering entire skin surface May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon Relatively uncommon 1. Dermatology Expert Group. Therapeutic guidelines: dermatology . Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology . 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. J Am Acad Dermatol 2008; 58 (5): 826–50.

Pustular psoriasis:

Pustular psoriasis Two forms: Localized form More common multiple small pustules on palms and soles Generalized form Uncommon widespread pustules across inflamed body surface 1. Buxton P et al. ABC of dermatology . 5th ed. UK: Wiley-Blackwell, 2009. 2. Griffiths CEM et al. Psoriasis. In: Burns T et al., eds . Rook’s textbook of dermatology . 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Menter A et al. J Am Acad Dermatol 2008; 58 (5): 826–50.

Palmoplantar psoriasis:

Palmoplantar psoriasis Can be hyperkeratotic or pustular Possibly aggravated by trauma 1. Dermatology Expert Group . Therapeutic guidelines: dermatology . Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

Scalp psoriasis:

Scalp psoriasis Varies from minor scaling with erythema to thick hyperkeratotic plaques May extend beyond hairline Patient scratching may produce asymmetric plaques 1. Dermatology Expert Group . Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004.

Nail psoriasis:

Nail psoriasis Can take several forms : Pitting: discrete, well-circumscribed depressions on nail surface. Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate. Onycholysis : nail separates from nail bed at free edge. ‘Oil-drop sign’: pink/red color change on nail surface.

Nail psoriasis:

Nail psoriasis

Nail psoriasis :

Nail psoriasis

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No need for a Dermatologist then ?

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You will always need my knowledge & I will prove it t o you

Localised patches/plaques:

Localised patches/plaques 1. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. Tinea corporis Psoriasis

Localised patches/plaques:

Localised patches/plaques 1. Menter A et al . Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. Discoid eczema Psoriasis

Localised patches/plaques:

Localised patches/plaques Superficial basal cell carcinoma/Bowen’s disease 1. van de Kerkhof P, ed . Textbook of psoriasis . 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al . Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. Bowen’s disease Psoriasis

Localised patches/plaques:

Localised patches/plaques Seborrhoeic dermatitis 1. Marks R et al. Dermatology within the pharmacy . Australia: Department of Dermatology, St Vincent’s Hospital, 1998. 2. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. Dermatitis Psoriasis

Localised patches/plaques:

Localised patches/plaques 1. Fry L. An atlas of psoriasis . Spain: Taylor & Francis, 2004. 2. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. Mycosis fungoides Psoriasis

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Want more ?

Guttate psoriasis:

Guttate psoriasis 50 1. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. < Psoriasis ^ Pityriasis rosea

Guttate psoriasis:

Guttate psoriasis 51 1. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. 2. Van de Kerkhof P, ed. Textbook of psoriasis . 2nd ed. Melbourne: Blackwell Publishing, 2003. < Psoriasis ^ Secondary syphilis

Flexural psoriasis:

Flexural psoriasis 52 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Fischer, G. How to treat: atopic dermatitis. Australian Doctor . 16 April 2010: 29–36. < Psoriasis ^ Atopic eczema

Palmoplantar psoriasis:

Palmoplantar psoriasis 53 Tinea manum 1. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. Tinea corporis Psoriasis

Palmoplantar psoriasis:

Palmoplantar psoriasis 54 Hand and foot eczema 1. Menter A et al. Fast facts: psoriasis . 2nd ed. Oxford: Health Press, 2004. 2. van de Kerkhof P, ed. Textbook of psoriasis . 2nd ed. Melbourne: Blackwell Publishing, 2003. Eczema Psoriasis

Take Home Message:

Diagnosis can change with new clinical findings along the course of the disease. We need to know different types of psoriatic skin lesions. Referral to a Dermatologist is an essential step for accurate diagnosis . Take Home Message

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