Show your Best III

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Show your Best III

• By Brad Moatz MSIV

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Presentation

• 42 y.o. male presents with R foot pain and h/o
  psoriasis

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(No Transcript)
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• Right foot There are large central erosions in
  the first -- fifth metatarsophalangeal joints,
  with resultant pencil in cup deformity in these
  joints. There is metatarsus adductus primus,
  measuring 18. There is also hallux valgus,
  measuring approximately 52. There is also mild
  to moderate lateral deviation at the second -
  fourth metatarsophalangeal joints. There is bony
  ankylosis in the midfoot, specifically at the
  naviculocuneiform articulation, as well as
  navicular cuboid joint. There are diffuse
  enthesopathic changes throughout the foot, most
  prominent at the medial and lateral aspect of the
  hindfoot and midfoot. There is a prominent
  erosion in the dorsal aspect of the calcaneus at
  the site of the Achilles' tendon insertion.

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Psoriatic Arthritis - Presentation

• Patients with psoriatic arthritis present with
  pain and stiffness in the affected joints
• Morning stiffness lasting more than 30 minutes
  occurs in one-half of patients. The stiffness is
  accentuated with prolonged immobility, and is
  alleviated by physical activity.
• PE- stress pain, joint line tenderness, and
  effusions in the affected joints are present,
  often in an asymmetric distribution. The DIP
  joints and spine are each affected in 40-50 of
  cases

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Presentation (cont.)

• Dactylitis
• Characteristic features of psoriasis affecting
  the nailbed include nail pits, onycholysis,
  nailbed hyperkeratosis, and splinter hemorrhages
• Swelling of the hands or feet with pitting edema
  is sometimes a presenting feature
• Ocular inflammation occurs in some patients with
  psoriatic arthritis

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Radiologic Features

• The most striking radiologic feature is the
  coexistence of erosive changes and new bone
  formation in the distal joints other typical
  radiological changes include lysis of the
  terminal phalanges, fluffy periostitis and new
  bone formation at the site of enthesitis, gross
  destruction of isolated joints, "pencil-in-cup"
  appearance, and the occurrence of both joint
  lysis and ankylosis in the same patient

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• Psoriatic arthritis associated with pencil-in-cup
  abnormality in the distal interphalangeal (DIP)
  joints of the first and second fingers (short
  arrows), plus early changes in the DIP joint of
  the fourth finger. Other changes include
  ankylosis in the DIP joint in the fifth finger
  (long arrow) and destruction of the wrist.

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Treatment

• The treatment of PsA usually begins with
  nonsteroidal antiinflammatory medications
  (NSAIDs)
• Second-line therapies are employed when the
  arthritis does not respond to NSAIDs
• Drugs such as methotrexate, PUVA, retinoic acid
  derivatives, and cyclosporine A have been shown
  to improve both the joint and skin manifestations
  of psoriasis
• However, it should be noted that none of these
  medications have actually been shown to prevent
  or retard progression of joint damage. Inhibitors
  of tumor necrosis factor-alpha (TNF) may also be
  effective for both skin and joint disease