Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Journal of Pakistan Association of Dermatologists 2013; 23 (4): 458-460. Case Report A case of psoriatic arthritis with severe deformities resembling rheumatoid arthritis Manish Bansal, Tulika Rai Department of Dermatology and Venereology, I.M.S, B.H.U, Varanasi, India Abstract Psoriatic arthritis (PsA) is a chronic and inflammatory arthritis that occurs in association with skin psoriasis. The prevalence of psoriasis in the general population is about 1–3%,1 2 and about 6–42% of patients with psoriasis develop PsA. Inflammatory joint disease with psoriatic skin and nail changes with a negative serological test for rheumatoid factor suggests the diagnosis of psoriatic arhritis. We present a case of fifty-five year old male who had severe, deforming arthritis mimicking rheumatoid arthritis who later on developed chronic plaque psoriasis. Key words Psoriatic arthritis, rheumatoid arthritis, psoriasis. Introduction Psoriatic arthritis is a member of the seronegative group of disorders that affects mainly the entheses, synovium, spine and sacroiliac joints. It is defined as an inflammatory arthritis associated with psoriasis of the skin and/or nails, with usually a negative serological test for rheumatoid factor and the absence of rheumatoid nodules.1 Psoriatic arthritis (PsA) is a chronic and inflammatory arthritis that occurs in association with skin psoriasis. The prevalence of psoriasis in the general population is about 13%,1,2 and about 6–42% of patients with psoriasis develop PsA.2,3 A review of population-based studies estimated the population prevalence of psoriatic arthritis at 0.02-0.1%. The population prevalence of psoriatic arthritis is in the range of 2-10 per 10,000 although this is probably an underestimate as those with sacroiliac Address for correspondence Dr. Tulika Rai, Department of Dermatology and Venereology, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221005, India Email: [email protected] involvement only are not included. There are currently no incidence figures from population samples. The disease is slightly more common in females than males, although there is variation in the sex ratio by disease subgroup. There is evidence that hormonal and environmental factors play a role in the occurrence of disease.4 The age of onset of psoriatic arthritis is generally later than the skin disease, usually in the fourth decade. In one series of 180 patients, the mode of onset was studied ad skin lesions preceded arthritis in 65%, arthritis antedated skin lesions in 19% and in 16% of the cases the two occurred simultaneously. The peak age of onset in this series was between 40 to 60 years.5 The Moll and Wright classification classifies psoriatic arthritis in five clinical groups.6 Case Report Fifty-five-year-old male patient presented with the chief complaints of pain in multiple joints and progressive deformities of hands and feet for ten years. Three years after the onset of joint pain, patient had itchy, scaly, red raised lesions scattered all over the body following which he 458 Journal of Pakistan Association of Dermatologists 2013; 23 (4): 458-460. Figure 1 Clinical photograph showing deformities in hands. Figure 2 Clinical photograph showing deformities in feet. Figure 3 X-ray of hand showing ankylosis and flexion deformity of distal interphalangeal joints. consulted a dermatologist where he was diagnosed to have chronic plaque psoriasis with psoriatic arthritis. He had received oral methotrexate and oral steroids over the span of ten years. On examination, well-defined erythematous plaques with silvery white scaling were present mainly over anterior aspect of lower one-third of leg and bilateral feet. PASI score was 4.6 and there was sparing of palms and soles. Pitting was present in the nails and these were more than sixty in number. No other nail findings were present in the finger nails. Toe nails showed subungual hyperkeratosis, nail plate dystrophy but a scraping KOH mount didn’t show fungal hyphae. Patient was investigated and the findings revealed iron deficiency anemia, ELISA for HIV was nonreactive, RA factor was negative, serum calcium and phosphate were within normal limits, serum alkaline phosphatase was 469.4 ( mildly raised), serum albumin was 3.3 gm/dl (low), rest of liver function and renal function test were within normal limits. DEXA (dual energy X ray absorptiometry) revealed a T score of -4.8 and Z score of -3.3 suggestive of osteoporosis. Boutonniere deformity of the fingers was present along with ulnar drift. Sausage swelling of the right middle finger was seen. On X ray of hands, joint space in intercarpal joints was reduced, flexion at PIP and hyperextension at DIP joint of left little finger suggestive of boutonniere deformity, ankylosis of PIP and DIP joint of left index finger and ankylosis of left index finger DIP joint was seen leading to boutonniere deformity. Erosions and pencil-incup deformity seen in psoriatic arthritis were not seen on radiography. Foot examination findings revealed high arched foot, hammer toes, sausage deformity and fibular deviation of toes. The patient also had back pain and morning stiffness. Kyphosis of the spine was present. Treatment in the form of 15mg methotrexate weekly was given intravenously. Patient was given indomethacin 75 mg for pain and zoledronic acid 4 mg was given as infusion for severe osteoporosis. 459 Journal of Pakistan Association of Dermatologists 2013; 23 (4): 458-460. Discussion Inflammatory joint disease with psoriatic skin and nail changes with a negative serological test for rheumatoid factor suggests the diagnosis of psoriatic arhritis.7 Our patient had severe polyarticular arthritis with deformities mimicking rheumatoid arthritis. Methotrexate at the dose of 0.3 mg/kg weekly, intravenously was given to the patient. Methotrexate is a folic acid analogue used widely in the treatment of psoriasis and psoriatic arthritis. Despite a paucity of high quality clinical data, methotrexate (MTX) remains one of the most commonly used medications in the treatment of patients with psoriatic arthritis (PsA).8 Traditional systemic therapies for psoriasis, such as methotrexate, cyclosporin A, retinoids or PUVA therapy, have a potential for long-term toxicity and may not always provide sufficient improvement of the disease. The development of novel therapies targeting key steps in the pathogenesis of psoriasis and psoriatic arthritis now provide new and efficient treatment options. Biological therapies for the treatment of psoriasis and/or psoriatic arthritis are widely used these days and are defined by their mode of action and can be classified mainly into three categories: the T-cell modulating agents (alefacept and efalizumab), the inhibitors of tumour necrosis factor-α (TNFα blockers, e.g. adalimumab, certolizumab, etanercept, golimumab and infliximab) and the inhibitors of interleukin (IL) 12 and IL-23 (e.g. ustekinumab and briakinumab). The new biological agents have been shown to be efficient treatment options for patients suffering from psoriasis and PsA. Furthermore, they seem to have proven an acceptable risk-benefit ratio. As psoriasis is considered a life-long disease and no causal therapy for the disease is yet available, the need for safe and efficacious long-term treatments is of major importance.9 We considered methotrexate in our patient because it is an effective drug and cheaper as compared to the newer drugs. References 1. 2. 3. 4. 5. 6. 7. 8. 9. Moll JMH, Wright V. Psoriatic arthritis. Semin Arthritis Rheum. 1973;3:55-78. Shbeeb M, Uramoto KM, Gibson LE et al. The epidemiology of psoriatic arthritis in Olmsted Country, Minnesto, USA, 1982– 1991. J Rheumatol. 2000;27:1247-50. Green L, Meyers OL, Gordon W, Briggs B. Arthritis in psoriasis. Ann Rheum Dis. 1981;40:366-9. O’ Neill T, Silman AJ. Psoriatic arthritis: historical background and epidemiology. Bailliere’s Clin Rheumatol. 1994;8:245-61. Scarpa R, Oriente P, Pucino A et al. Psoriatic arthritis in psoriatic patients. Br J Rheumatol. 1984;23:246-50. Moll JMH. Psoriatic arthropathy. In: Mier PD, Van de Kerkhof PCM, eds. Textbook of Psoriasis. Edinburg: Churchill Livingstone; 1986. P. 55-83. Moll JMH. The clinical spectrum of psoriatic arthritis. Clin Orthopaed. 1979;143:66-75. Ceponis A, Kavanaugh A. Use of methotrexate in patients with psoriatic arthritis. Clin Exp Rheumatol. 2010;28:S132-7. Weger W. Current status and new developments in the treatment of psoriasis and psoriatic arthritis with biological agents. Br J Pharmacol. 2010;160:810-20. 460