A patient suffering from skin and nail disease,presented with following changes in hands and spine.What can be the most possible diagnosis?
A. Ankylosing Spondylitis
B. Rheumatoid Arthritis
C. Psoriatic Arthritis
D. Reiter’s syndrome
Ans:C. Psoriatic Arthritis.
First:Radiograph of both hands demonstrates cup-and-pencil deformities of both thumbs and erosion of DIP joint of left middle finger,
Second:Radiograph of both hands demonstrates ankylosis of numerous proximal and distal interphalangeal joints (white arrows), flexion deformities and lack of significant osteoporosis.
Third: There are large, asymmetric osteophytes (white arrow). They are thicker than the syndesmophytes of ankylosing spondylitis and their asymmetric distribution should raise suspicion of psoriatic disease.
5 major presentations of Psoriatic Arthropathy (PsA)
- Arthritis of DIP joints
- Asymmetric oligoarthritis :Most characteristic when a finger or toe is involved leading to sausage digit or dactylitis
- Symmetrical polyarthritis :Resembles RA but nodules and extraarticular features are absent
- Axial involvement (spine and sacroiliac joints)
- Arthritis mutilans – widespread shortening of digits (telescoping)
Clinical features :
- Pustular psoriasis is associated with severe disease.
- Dactylitis, enthesitis and tenosynovitis are common.
- Shortening of digits because of underlying osteolysis is particularly characteristic of PsA.
- Rapid ankylosis of proximal interphalangeal (PIP) joints early in the course of disease is common.
- Nail involvement is seen in almost all patients.
- Uveitis and aortic insufficiency are seen after long standing disease.
- Most are HLA-B27 positive, RA factor negative
Radiological features :
- Characteristics of peripheral PsA include DIP involvement along with
- Classic pencil-in-cup deformity
- Marginal erosions with adjacent bony proliferation (whiskering)
- Small-joint ankylosis
- Osteolysis of phalangeal and metacarpal bone, with telescoping of digits
- Characteristics of axial PsA include asymmetric sacroiliitis (when compared to ankylosing spondylitis)
- Less zygapophyseal joint arthritis
- Fluffy hyperperiostosis on anterior vertebral bodies
- Severe cervical spine involvement, tendency to atlantoaxial subluxation
- Relative sparing of the thoracolumbar spine
- Paravertebral ossification
- Asymmetric sacroileitis
- Atypical syndesmophytes.
- Treatment: etanercept, infliximab, adalimumab and golimumab.