Download Reactive Arthritis

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U.S. 28 year old male, catholic, married, born
on May 6, 1981, works as a tricycle driver since
2001, residing in Caloocan City with wife.
Chief Complaint:
7 Yrs
PTA
2 Yrs
PTA
1 Yr PTA
•White scales of the scalp resembled dandruff when
scratched (no consult)
• Few mos. later: pustules and papules that later coalesced
to erythematous plaques topped with scales spread all
over his body affecting his back, trunk, upper and lower
extremities and his face  consult at UST Dermatology
OPD; punch biopsy: Psoriasis – medications: PUVA
therapy (once in 2002), Methotrexate 1 tab BID for 1 wk,
Dermovate with Petroleum Jelly and LCD, Hydroxizine
(Iterax) for pruritus 3x/day prn  resolution of Symptoms
• Reappearance of lesions
• Painful swelling of distal and proximal joints of the fingers
of right and left hands and feet (self-medication: Naproxen
 temporary relief)
• Gradual limitation of in the movement of digits
• Consult to Rheumatologist, prescribed with Celebrex and
requested for further lab work-ups; but patient lost to
follow-up
• Pain and swelling in both knees, noted to be limping, and
pain when walking down the stairs
• Relieved by rest or sitting down
1 month
PTA
• Swelling of both knees with increasing severity of pain (no
consult)
1 week
PTA
• Pain in the hips extending down to his ankles
• More difficulty in ambulating
5 days PTA
4 days
PTA
• Consulted an Orthopedic Surgeon in Marikina; was told to
have excess fluid in knee joints & advised arthrocentesis (pt.
opted not to)
•Fever [undocumented] (self-medication: Paracetamol 
temporary lysis of fever)
• Persistence of pain and fever  consult at FEU Hospital
(X-Ray of leg: soft tissue swelling); advised admission but
refused due to financial constraints; referred to USTH for
further evaluation & management
ADMISSION
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(-) DM
(-) HPN
(-) Joint surgery
(-) history of trauma
(-) Allergy
Diagnosed with dengue fever (2nd year high
school)
Excision of cyst at the back (2007)
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(+) Myocardial Infarction – father
(+) DM – father
(-) HPN
(-) stroke
(-) Psoriasis
(-) Cancer
(-) Arthrides
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Smoker: 16-22 y/o (1-2 sticks per day)
Occasional Alcoholic Beverage Drinker
Denies Illicit Drug Use
3 past sexual partners, all protected
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No wt. loss, no loss of appetite
No hearing loss, no nasal congestion, no cough
No dyspnea, orthopnea, cyanosis
No chest pain, palpitations
No abdominal pain, diarrhea, constipation
No dysuria, frequency, change in character of
urine
General Survey
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Conscious, coherent, oriented as to time, place and
person, not in cardio-respiratory distress
Vital Signs
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BP 120/70 mmHg, PR 83 bpm, RR 20 cpm, T 36.6
°C
Skin
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Warm moist skin, (+) erythematous plaques
topped with scales all over the body, (+)
hyperpigmented patches over the extremitie, (+)
oil spots, (+) nail pitting, (+) onychodystrophy
HEENT
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Pink palpebral conjunctivae, anicteric sclerae, no
naso-aural discharge, no tragal tenderness, moist
buccal mucosa, nonhyperemic PPW, tonsils not
enlarged
Neck
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Supple neck, trachea midline, no palpable cervical
lymph nodes, thyroid gland not enlarged
Cardiovascular
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Adynamic precordium, AB at 5th LICS, MCL; no
murmurs
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All pulses full and equal
Respiratory
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Symmetric chest expansion, no retractions, clear
breath sounds on all lung fields, no crackles, no
wheezes
Abdomen
• Flat abdomen, NABS, soft, nontender, no
masses
Musculoskeletal
• (+) sausage-shaped 4th digit of the right hand
• (+) swelling and tenderness, both knees, DIP 4th
R digit of the hand, R ankle
• (+) flexed 5th left digit and the 4th R digit of the
hand
• Cannot flex the PIP and DIP of the right 2nd
digit of the hand
Neurological
• Conscious, oriented to person, place and time,
can follow commands
• GCS 15 E4V5M6; pupils 2-3 mm, isocoric ERTL,
V1,V2,V3 intact; intact hearing, can swallow,
(+) gag reflex, can shrug shoulders, tongue
midline on protrusion
• Motor: MMT 5/5 on both UE; 4/5 on both LE,
no atrophy
• Cerebellum: no deficits, can do FTNT, APST,
HTST
• Sensory: no sensory deficits
• DTRs: 2+ on the UE, LE not assessed
• (-) Babinski; no nuchal rigidity
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History of Psoriasis
Painful swelling of distal and proximal joints of
the fingers of right and left hands and feet
Gradual limitation of in the movement of digits
Pain and swelling in both knees (increasing
severity of pain), limping, and pain when
walking down the stairs (difficulty in
ambulating); Relieved by rest or sitting down
Pain in the hips extending down to ankle
excess fluid in knee joints
Persistence of pain and fever
X-ray of leg: soft tissue swelling
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(+) erythematous plaques topped with scales
all over the body, (+) hyperpigmented patches
over the extremitie, (+) oil spots, (+) nail
pitting, (+) onychodystrophy
(+) sausage-shaped 4th digit of the right hand
(+) swelling and tenderness, both knees, DIP 4th
R digit of the hand, R ankle
(+) flexed 5th left digit and the 4th R digit of the
hand
Cannot flex the PIP and DIP of the right 2nd
digit of the hand
Differential diagnosis
 Gout
 Osteoarthritis
 Reactive Arthritis
 Rheumatoid Arthritis
 Septic Arthritis
Gout
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a common disorder of uric acid metabolism
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can lead to deposition of monosodium urate (MSU)
crystals in soft tissue and recurrent episodes of
debilitating joint inflammation
if untreated - joint destruction and renal
damage
definitively diagnosed based on the
demonstration of urate crystals in aspirated
synovial fluid
Gout
Physical examination findings:
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During an acute gout attack, examine all joints to determine if
the patient's arthritis is monoarticular or polyarticular
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Involved joints have all the signs of inflammation: swelling,
warmth, erythema, and tenderness
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The erythema over the joint may resemble cellulitis; the skin
may desquamate as the attack subsides
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The joint capsule becomes quickly swollen, resulting in a loss
of range of motion of the involved joint
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During an acute gout attack, patients may be febrile,
particularly if it is an attack of polyarticular gout
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Look for sites of infection that may have seeded the joint and
caused an infectious arthritis that can resemble or coexist with
acute gouty arthritis
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The presence of tophi suggests long-standing hyperuricemia
Osteoarthritis
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Predominantly involves the weight-bearing
joints, including the knees, hips, cervical and
lumbosacral spine, and feet
Other commonly affected joints - the distal
interphalangeal (DIP) and proximal
interphalangeal (PIP) joints of the hands
Cartilage is grossly affected
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Focal ulcerations eventually lead to cartilage loss
and eburnation
Subchondral bone formation also occurs, with
development of bony osteophytes
Osteoarthritis
Physical examination findings:
• Mostly limited to the affected joints
• Malalignment with a bony enlargement
(depending on the disease severity) may occur
• Most cases of osteoarthritis do not involve
erythema or warmth over the affected joint(s)
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however, an effusion may be present
Limitation of joint motion or muscle atrophy
around a more severely affected joint may
occur
Reactive Arthritis
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Also known as Reiter syndrome, is an autoimmune condition that develops in
response to an infection
Usually develops 2-4 weeks after a genitourinary or gastrointestinal infection
– recent evidence indicates that a preceding respiratory infection with
Chlamydia pneumoniae may also trigger the disease
– about 10% of patients do not have a preceding symptomatic infection.
Both postvenereal and postenteric forms of reactive arthritis may manifest
initially as nongonococcal urethritis
Mild dysuria, mucopurulent discharge, prostatitis and epididymitis in men,
and vaginal discharge and/or cervicitis in women are other possible
manifestations
Onset - usually acute and characterized by malaise, fatigue, and fever
An asymmetrical, predominately lower-extremity, oligoarthritis - the major
presenting symptom
Low-back pain occurs in 50% of patients
Heel pain is common because of enthesopathies at the Achilles or plantar
aponeurosis insertion on the calcaneus
The complete Reiter triad of urethritis, conjunctivitis, and arthritis may occur
Reactive Arthritis
Physical examination findings:
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Joints, axial skeleton, entheses
– Peripheral joint involvement associated - typically asymmetric and usually
affects the weight-bearing joints (ie. knees, ankles, hips), but the shoulders,
wrists, and elbows may also be affected
– More chronic and severe cases - the small joints of the hands and feet may also
be involved; as in other spondyloarthropathies, dactylitis (ie, sausage digits)
may develop.
– While 50% of patients with reactive arthritis may develop low-back pain, most
physical examination findings in patients with acute disease - minimal except
for decreased lumbar flexion; patients with more chronic and severe axial
disease may develop physical findings similar to ankylosing spondylitis
– As with other spondyloarthropathies, the enthesopathy of reactive arthritis
may be associated with findings of inflammation (ie. pain, tenderness, swelling)
at the Achilles insertion; other sites include the plantar fascial insertion on the
calcaneus, ischial tuberosities, iliac crests, tibial tuberosities, and ribs
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Skin and nails
– Keratoderma blennorrhagica on the palms and soles is indistinguishable from
pustular psoriasis - highly suggestive of chronic reactive arthritis
– Erythema nodosum may develop but uncommon
– Nails can become thickened and crumble, resembling mycotic infection or
psoriatic onychodystrophy, but nail pitting is not observed
– Circinate balanitis may also develop
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Other mucosal signs and symptoms: Painless shiny patches in the palate, tongue,
and mucosa of the cheeks and lips have been described
Reactive Arthritis
Physical examination findings:
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Ocular findings
– Conjunctivitis - part of the classic triad of Reiter syndrome and can
occur before or at the onset of arthritis
– Other ocular lesions include acute uveitis (20% of patients),
episcleritis, keratitis, and corneal ulcerations; the lesions tend to recur
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Enteric infections
– May trigger reactive arthritis; pathogens include Salmonella, Shigella,
Yersinia, and Campylobacter species; the frequency of reactive arthritis
after these enteric infections - about 1-4%
– Some patients continue with intermittent bouts of diarrhea and
abdominal pain; lesions resembling ulcerative colitis or Crohn disease
have been described when ileocolonoscopy is performed in patients
with established reactive arthritis
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Other manifestations
– Mild renal pathology with proteinuria and microhematuria
– In severe chronic cases, amyloid deposits and immunoglobulin A
(IgA) nephropathy have been reported
– Cardiac conduction abnormalities may develop, and aortitis with
aortic regurgitation occurs in 1-2%
Rheumatoid Arthritis
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A chronic systemic inflammatory disease of unknown cause that
primarily affects the peripheral joints in a symmetric pattern
Constitutional symptoms, including fatigue, malaise, and morning
stiffness are common
Extra-articular involvement of organs such as the skin, heart,
lungs, and eyes can be significant
Causes joint destruction and thus often leads to considerable
morbidity and mortality
Has a significant genetic component, and the shared epitope of the
HLA-DR4/DR1 cluster is present in up to 90% of patients with
RA, although it is also present in more than 40% of controls
Synovial cell hyperplasia and endothelial cell activation are early
events in the pathologic process that progresses to uncontrolled
inflammation and consequent cartilage and bone destruction
Genetic factors and immune system abnormalities contribute to
disease propagation
Rheumatoid Arthritis
Physical examination findings:
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Joint involvement - the characteristic feature
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In general, the small joints of the hands and feet are affected in a relatively symmetric
distribution
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The most commonly affected joints, in decreasing frequency, include the MCP, wrist,
PIP, knee, MTP, shoulder, ankle, cervical spine, hip, elbow, and temporomandibular
joints
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Joints show inflammation with swelling, tenderness, warmth, and decreased range of
motion
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Atrophy of the interosseous muscles of the hands is a typical early finding
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Joint and tendon destruction may lead to deformities such as ulnar deviation,
boutonnière and swan-neck deformities, hammer toes, and, occasionally, joint ankylosis
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Other commonly observed musculoskeletal manifestations
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tenosynovitis and associated tendon rupture due to tendon and ligament involvement, most
commonly involving the fourth and fifth digital extensor tendons at the wrist
periarticular osteoporosis due to localized inflammation; generalized osteoporosis due to
systemic chronic inflammation, immobilization-related changes, or corticosteroid therapy; and
carpal tunnel syndrome
most patients have muscle atrophy from disuse, which is often secondary to joint inflammation
Septic Arthritis
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Also known as infectious arthritis
May represent a direct invasion of joint space by
various microorganisms, including bacteria,
viruses, mycobacteria, and fungi
Reactive arthritis, a sterile inflammatory process,
may be the consequence of an infectious process
located elsewhere in the body
Bacterial pathogens - the most significant because
of their rapidly destructive nature
Failure to recognize and to appropriately treat
septic arthritis results in significant rates of
morbidity and may even lead to death
Septic Arthritis
Physical examination findings:
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The most commonly involved joint is the knee (50% of
cases), followed by the hip (20%), shoulder (8%), ankle
(7%), and wrists (7%)
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The elbow, interphalangeal, sternoclavicular, and
sacroiliac joints each make up 1-4% of cases
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A thorough inspection of all joints for signs of
erythema, swelling (90% of cases), warmth, and
tenderness is essential for diagnosing infection
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Infected joints usually exhibit an obvious effusion,
which is associated with marked limitation of both
active and passive ranges of motion
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Frequently, these findings are apparent but may be
diminished or poorly localized in cases of infection of
the spine, hip, and shoulder joints
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An acute inflammatory condition of the skin
characterized by localized pain, erythema,
swelling and heat.
Caused by indigenous flora colonizing the skin
and appendages and exogenous bacteria (e.g.
Staphylococcus aureus, Streptococcus
pyogenes)
May gain access through cracks in the skin,
wounds, abrasions, burns
Lesions are nodular and surrounded by
vesicles that rupture and discharge pus and
necrotic material
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Check for rheumatoid factor for coincident
occurence of RA; PsA alone = (-) RF
Check also for gout
ANA, autoantibodies
For seronegative arthritis without skin changes,
check for HLA-B13, -BW57, -B27.
Sudden onset is assoc. with HIV so check for
HIV disease
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NO diagnostic laboratory tests
ESR and CRP  often elevated
Extensive psoriasis = uric acid may be elevated
HLA-B27 is found in 50-70% of patients with
axial disease, but <15-20% if only peripheral
joint involvement
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Examine the fluid in joints
a. Gross examination – clarity, color
b. Cell count – WBC per
c. Microscopic examination – crystals, Gram
staining
d. Culture and sensitivity
** Aspirating needle
should never be
passed through an
overlying cellulitis
or psoriatic plaque
because of the risk
of introducing
infection
Reference
8/27/09
Hgb
120-170 d/L
105
Hct
0.37-0.54
0.32
RBC
4-6x 10^12/L
4.03
WBC
4.5-10x 10^9/L
8.60
Neutrophil
0.50-0.70
0.70
Segs
0.50-0.70
0.70
Lympho
0.20-0.40
0.30
Mono
0-0.07
Eos
0-0.05
Plt
150-450x 10^9/L
552
MCV
87 +/-5 U^3
79.60
MCH
29+/-2 pg
26.0
MCHC
34+/-2 g/dL
32.70
RDW
25.90
13.40
Bands
Reference
8/27/09
BUN
9-23
6.9
Crea
0.5-0.2
0.76
AST-SGOT
0-32
27.3
ALT-SGPT
0-31
41.2
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DIP involvement – “pencil-in-cup” deformity
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marginal erosions of bone
and irregular destruction of
joint and bone, which, in
the phalanx, may give the
appearance of a sharpened
pencil
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“whiskering” – marginal erosions with
adjacent bony proliferation
Small joint ankylosis
Osteolysis of phalangeal and metacarpal bone
with telescoping of digits
Periostitis and proliferative new bone at site of
enthesitis
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Asymmetric sacroiliiitis
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Less zygoapophyseal joint arthritis, fewer and
less symmetric and delicate syndesmophytes
Fluffy hyperperiostosis on anterior vertebral
bodies
Paravertebral ossification
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Severe cervical spine involvement but relative
sparing of thoracolumbar spine
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Ultrasound and MRI demonstrate enthesitis
and tendon sheath effusions
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Thick S. corneum and
projections of the
epidermis
Parakeratosis(cell
nuclei within
thickened s. corneum)
Elongation of rete
ridges
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PMN leukocyte and
lymphocyte infiltration
of dermis and
epidermis forming
microabscesses of
Munro in the s.corneum
exocytosis of
neutrophils into
epidermis producing
spongiform pustules
(Kogoj)
Psoriasis
Psoriatic Arthritis
Cellulitis
Psoriasis
Psoriatic
Arthritis
Cellulitis
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Areas of Predilection
Scalp
 Nails
 Extensor Surface, Limbs
 Umbilical region
 Sacrum
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Erythematous rash
Scaling Plaques
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Silvery white
lamellar
Auspitz’s Sign
Koebner’s Phenomenon
Psoriasis
Psoriatic
Arthritis
Cellulitis
An inflammatory arthritis that occurs in a patient
with psoriasis.
Harrison’s Internal Medicine 17th edition
A form of arthritis that occurs in patients with
psoriasis with the hallmarks of an "inflammatory"
arthritis, including joint pain, erythema, and
swelling, often with prominent stiffness.
Mease, P., Menter, A. (2005) , Psoriatic Arthritis: Understanding Its Pathophysiology and Improving Its
Diagnosis and Management. Retrieved from: http://cme.medscape.com/viewarticle/509053
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Unique to Psoriatic Arthritis:
DIP joint involvement
 Nail changes
 Dactylitis
 Enthesitis
 Spondylitis Lytic and periarticular new bone
formation x-ray features
 Iritis or Uveatis

Mease, P., Menter, A. (2005) , Psoriatic Arthritis: Understanding Its Pathophysiology and Improving Its Diagnosis and Management.
Retrieved from: http://cme.medscape.com/viewarticle/509053
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Patterns of Arthropathy
1.
2.
3.
4.
5.
Arthritis of DIP joints
Asymmetric oligoarthritis
Symmetric polyarthritis
Axial involvement
Arthritis Mutilans
Distal Interphalangeal
joint arthritis
 Occurs in 15 % of cases
 Nail changes also seen
Harrison’s Internal Medicine 17th edition
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Asymmetric
Oligoarthritis
Involves the knee or any large
joint with a few small joints in
the fingers and toes
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Metarsophalangeal
Proximal interphalengeal
Distal interphalengeal
Dactylis
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Sausage shaped digits due to inflammation
of the flexor tendons and synovium and
pitting edema of the distal extremities may
be observed
Harrison’s Internal Medicine 17th edition
Symmetric polyarthritis
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Affects the Hands, wrists,
knees, and feet
symmetrically
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Proximal interphalangeal joints
Metacarpophalangeal joints
Peripheral joints are less
tender compared to RA
Harrison’s Internal Medicine 17th edition
Axial Arthropathy
 Spine and sacroiliac
joints
Harrison’s Internal Medicine 17th edition
Arthritis mutilans
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Widespread shortening or
telescoping of digits due to
osteolysis of the phalanges
and metacarpals
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coexisting with ankylosis
and contractures in other
digits
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opera-glass deformity or
pencil-in-cup radiographic
findings
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Fever
Harrison’s Internal Medicine 17th edition
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Pitting
Horizontal ridging
Onycholysis
Discoloration of nail
margins
Dystrophic
hyperkeratosis
Nail pitting
Onycholysis
Onychodystrophy
Harrison’s Internal Medicine 17th edition
Involvement of the distal and proximal
interphalangeal joints, together with tendon
sheath involvement, may give the digit a
sausage shape
Harrison’s Internal Medicine 17th edition
Inflammation at the sites of ligamentous and
tendinous insertions
Emedicine Retrieved from:
http://emedicine.medscape.com/article/1108557-overview
Psoriasis
Psoriatic
Arthritis
Risk Factors:
• Immunocompromised
due to meds
• Auspitz sign – break in
skin integrity
Cellulitis
Immunocompromised
patient due to
medications
Auspitz sign
Break in the skin integrity
Bacteria gains access to
the epidermis
Acute inflammation of the
dermis and subcutaneous
tissue
Indigenous flora
colonizing the skin
 Staphylococcus
aureus
 Streptococcus
pyogenes
Exogenous bacteria
Cellulitis
Harrison’s Principles of Internal Medicine 17th ed.
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At the involved site
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Localized pain
Erythema
Swelling
Warmth
Borders are not sharply
demarcated
Fever and chills
Malaise
Harrison’s Principles of Internal Medicine 17th ed.
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Improve patient’s quality of life
Achieve and maintain control of psoriatic
lesions
Relieve pain
Halt progression of disease
Alefacept
Efalizumab
Cyclosporine
Methotrexate
Acitretin
PUVA
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Usually for treatment of plaque psoriasis
Immunosuppressive dimeric fusion protein
Consists of extracellular CD2 binding portion of
human leukocyte function
MOA: Interferes with lymphocyte activation
resulting in the reduction in subsets of CD2
lymphocyte and circulating CD4 and CD8
lymphocyte counts
Administration: IM
Warnings: Lymphopenia, increased malignancies
and serious infections
Basic and Clinical Pharmacology, 10th Ed
Harrison’s Principles of Internal Medicine, 17th Ed
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Usually for SEVERE psoriasis
Immunosuppresive recombinant humanized anti
CD11a monoclonal antibody
MOA: Binding to CD11a inhiits the interaction of
LFA-1 on all lymphocutes with intercellular
adhesion molecule inhibiting activation, adhesion
and migration of T-Lymphocytes into skin
Administration: SC injection
Warnings: Serious infections, potential increased
malignancy, thrombocytopenia, hemolytic anema
and worsening of psoriasis
* Should not be given with other immunosuppresive
medication
Basic and Clinical Pharmacology, 10th Ed
Harrison’s Principles of Internal Medicine, 17th Ed
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Immunosuppresive agent
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Calcineurin inhibitor
MOA:Form a complex with cyclophilin that
inhibits the cysoplasmic phosphatase,
calcineurin, which is necessary for activation
of T-cell specific transcription factor
• Adverse effects: Renal dysfunction,
hypertension, hyperkalemia, hyperuricemia,
hypomagnesemia, hyperlipidemia, increased
risk of malignancies
*reported to benefit Psoriatic arthritis
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Basic and Clinical Pharmacology, 10th Ed
Harrison’s Principles of Internal Medicine, 17th Ed
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Antimetabolite
MOA: Inhibition of dihydrofolate reductase, an enzme
important in the production of thymidine and purines
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May interere with actions of interleukin-1
May also simulate increased release of adenosine, and
endogenous anti-inflammatory autocoid
May stimulate apoptosis and death of activated T Lymphocytes
Administration: Oral
Adverse effects: Hepatotoxicity, pulmonary toxicity,
panctopenia, potential for increased malignancies ,
ulcerative stomatitis, nausea, diarrhea, teratogenecity
Basic and Clinical Pharmacology, 10th Ed
Harrison’s Principles of Internal Medicine, 17th Ed
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Effective in psoriasis (especially pustular forms)
Metabolite of etretinate , an aromatic retinoid
Retinoids include natural compounds and synthetic
derivatives of retinol that exhibit vitamin A activity
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Because vitamin A affects normal epithelial differentiation, it
was investigated as a treatment for cutaneous disorders
Administration: Oral
Adverse Effects: teratogenecity, osteophyte formation,
hyperlipidemia, flare of inflammatory bowel disease,
hepatotoxicity and depression
*Ethanol should be strictly avoided during treatment and for 2
months after discontinuing therapy
Basic and Clinical Pharmacology, 10th Ed
Harrison’s Principles of Internal Medicine, 17th Ed
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Topically applied or systemically administered
psoralens are combined with UV-A
Psoralens
Tricyclic furocouramins
 intercalated into DNA exposed to UV-A form
adducts with pyrimidine basesform DNA
crosslinksdecrease DNA synthesisimprovement
of psoriasis
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Adverse Effects: skin dryness, actinic
keratoses, increased risk of skin cancer
Etanercept
Infliximab
Adalimumab
Tramadol
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Decreases the activity of TNF
Often used with methotrexate
Mechanism of Action: binds two molecules of
TNF (α and β) and prevents them from binding
to cellular receptors
Adverse Effects: risk of serious infections,
neurologic and hematologic events, increased
malignant potential
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Chimeric IgGК monoclonal antibody composed
of human and murine regions
Often used with methotrexate
Mechanism of Action: Neutralizes cytokines
by binding specifically to TNF-α
Adverse Effects: serious infections,
hepatotoxicity, hematologic events,
hypersensitivity reactions, neurologic events,
potential for increased malignancies
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Recombinant monoclonal antibody
Mechanism of Action: binds to TNF-α receptor
sites, thus inhibiting endogenous TNF-α
activity
Adverse Effects: serious infections, neurologic
events, potential for increased malignancies,
hypersensitivity reactions, hematologic events
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Used to manage moderate to moderately severe
pain
Mechanism of Action: centrally acting analgesic
that binds to μ-opioid receptor and additionally
inhibits re-uptake of Norephinephrine and
Serotonin
Adverse Effects: anaphylactoid reactions, seizures
Drug Interactions:
Carbamazepine – inc. metabolism
 Quinidine – inc. Levels of tramadol
 Avoid in patients taking SSRI’s and MAO inhibitors
