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NYU Medicine Grand Rounds
Clinical Vignette
Julia Manasson, PGY2
November 20th, 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 27 year old woman presents with pain and
stiffness in both wrists for four months.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Two years prior to current presentation the patient developed
diffuse joint pain. An auto-immune work-up was performed,
which was reportedly unremarkable.
•Her symptoms fluctuated until four months prior to presentation
when the patient developed joint pain and stiffness, most notably
in the wrists bilaterally. She was seen by a hand surgeon and
underwent an MRI which was only significant for ganglion cysts.
•On presentation, she reported bilateral knee pain, left greater
than right. She also reported left hand pain and diffuse swelling
of the proximal interphalangeal joints, particularly the 3rd digit.
•She described the pain as constant, unrelated to activity, and
minimally responsive to non-steroidals.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Inverse psoriasis: diagnosed at age 12, treated with topical medications
(tacrolimus and steroids)
•Past Surgical History:
•Denies
•Social History:
•Denies tobacco and illicit drug use. Drinks alcohol on occasion, on average 1
drink/week.
•Family History:
•Father with psoriasis
•Allergies:
•No Known Drug Allergies
•Medications:
•Betamethasone 0.12% foam, apply topically twice daily
•Tacrolimus 0.1% ointment, apply topically twice daily
•Sertraline 150 mg by mouth daily
•Methylphenidate 20 mg by mouth every morning
•Birth control 1 tablet daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: well appearing, no acute distress
•Vital Signs: T: afebrile, BP: 110/55, HR: 72
•Skin: Plaques over buttocks and intergluteal
crease.
•MSK: Diffuse tenderness to palpation of
proximal interphalangeal joints. The left 3rd
interphalangeal joint notable for swelling and
synovitis.
•Remainder of physical exam unremarkable.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Dactylitis
http://www.cdaarthritis.com/images_slides/images_slides_43.htm
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: WBC 8.5, Hb 12.2, Plt 214
•BMP: Unremarkable, BUN 10, Cr 0.67
•Hepatic panel: Unremarkable
•Erythrocyte sedimentation rate: 23
•C-reactive protein: 4.3
•Rheumatoid factor: 4.6
•Anti-cyclic citrullinated peptide IgG/IgA: 5
•HLA: A*29:KBF
•Quantiferon: Negative
•Hepatitis B: Immune
•Hepatitis C: Negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•Bilateral hand/wrist x-ray:
-No acute fracture or dislocation.
-Joint spaces and alignment are maintained.
-Focal soft tissue swelling about the proximal
interphalangeal joint of long finger, most pronounced
along the ulnar aspect, within the spectrum of sausage
digit.
-Soft tissues are otherwise unremarkable.
•Bilateral foot x-ray:
-Unremarkable
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hand X-ray
Lateral
PA
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Wrist XR
Lateral
AP
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Foot XR
R Lateral
AP
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
L Lateral
XR Descriptions
•Bilateral hand/wrist XR:
- No acute fracture or dislocation.
- Joint spaces and alignment are maintained.
- Focal soft tissue swelling about the proximal
interphalangeal joint of long finger, most pronounced
along the ulnar aspect, within the spectrum of sausage
digit.
- Soft tissues are otherwise unremarkable.
•Bilateral foot XR:
- Unremarkable
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Diagnosis
• Given the patient’s prior history of
psoriasis, new complaints of joint stiffness
and pain, physical exam, and imaging
studies, the patient was diagnosed with
psoriatic arthritis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Treatment
• Patient was started on Methotrexate 10
mg weekly and Folic acid 1 mg daily. Plan
was to uptitrate the dose of Methotrexate
as tolerated while monitoring labs.
• If no response within 3 months, the patient
would need to be started on a TNF
inhibitor.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS