PSORIATIC ARTHRITIS

PSORIATIC ARTHRITIS

Q. 1 In psoriatic arthritis, if the patient has liver fibrosis, arthropathy can NOT be treated with?

 A Methotrexate

 B

Anti-TNF-alpha agents

 C

Steroids

 D

Sulfasalazine

Q. 1

In psoriatic arthritis, if the patient has liver fibrosis, arthropathy can NOT be treated with?

 A

Methotrexate

 B

Anti-TNF-alpha agents

 C

Steroids

 D

Sulfasalazine

Ans. A

Explanation:

Methotreaxte is absolutely contraindicated in liver fibrois. In case of treatment for long duration liver fibrosis should be assessed by liver biopsy.


Q. 2

Seronegative arthritis include-

 A

Ankylosing spondylitis

 B

Reiters arthritis

 C

Psoriatic arthritis

 D

All of the above

Ans. D

Explanation:

Ans. is `d’ i.e., All of the above


Q. 3

CASPAR criteria is used in diagnosis of ‑

 A

Psoriatic arthritis

 B

Rheumatoid arthritis

 C

Ankyosing spondylitis

 D

Reactive synnovitis

Ans. A

Explanation:

Ans. is ‘a’ i.e., Psoriatic arthritis

Classification criteria for psoriatic arthritis (CASPAR) is used for the diagnosis of psoriatic arthropathy.

  • The CASPAR (classification Criteria for Psoriatic Arthritis) Criteria
  • To meet the CASPAR criteria a patient must have inflammatory articular disease (joint, spine, or entheseal) with 3 points from any of the following five categories :
  1. Evidence of current psoriasis, a personal history of psoriasis, or fa family history of psoriasis.
  2. Typical psoriatic nail dystrophy observed on current physical examination.
  3. A negative test result for rheumatoid factor.
  4. Either current dactylitis or a history of dactylitis recorded by a rheumatologist.
  5. Radiographic evidence of juxtaarticular new bone formation in the hand or foot.

Q. 4

Pencil in cup deformity is seen in ‑

 A Rheumatoid arthritis

 B

Ankylosing spondylitis

 C AVN

 D

Psoriatic arthritis

Ans. D

Explanation:

Ans. is `D i.e., Psoriatic arthritis

  • Pencil-in-cup deformity is the description given to one of the appearances on plain radiographs classically associated with psoriatic arthritis.

Radiographic features

  • The appearance results from periarticular erosions and bone resorption giving the appearance of a pencil in a cup.

Q. 5

True about psoriatic arthritis are all expect ‑

 A

HLA-Cw6 association

 B

Involvement of DIP joint

 C

More common in males

 D

DOC is methotrexate

Ans. C

Explanation:Ans. is ‘c’ i.e., More common in males

  • Psoriatic arthritis does not have sex predilection.
  • The largest and most consistent reported relative risk has been with HLA-Cw6.
  • Psoriatic arthritis involves DIP joints and the DOC for psoriatic arthritis is methotrexate.

Psoriatic arthritis

  • Psoriatic arthritis refers to an inflammatory arthritis that characteristically occurs in individuals with psoriasis. Only 5% of patients with psoriasis develop arthritis. In 60-70% of cases, psoriasis precedes joint disease. In 15-20%, the two manifestations appear within 1 year of each other. In about 15-20% of cases, the arthritis precedes the onset of psoriasis and can present a diagnostic challange.

Clinical features

  • The usual age at onset is 30-50 years.
  • The patient may present with one of several patterns of joint involvement.
  • These include :
  1. Arthritis of distal interphalangeal (DIP) joints
  2. Assymetrical oligoarthritis : Most common pattern
  3. Symmetrical polyarthritis similar to RA
  4. Axial involvement (sacroiliac and spine) similar to ankylosing spondylitis
  5. Arthritis multilans
  • So, Psoriatic arthritis can present with symptoms similar to any other inflammatory arthritis (RA, AS) or with any other different pattern.
  • Shortening of digitis, called telescoping, because of underlying osteolysis is particularly characteristic of Psoriatic arthritis and there is much greater tendency than in RA for both fibrous and bony ankylosis.
  • Other findings are enthesitis, nail changes, and tenosynovitis.

Treatment of Psoriatic arthritis

  • Anti TNF – a agents eg etanercept and infliximab are newer drugs and are effective even in longstanding restistent PsA cases to previous therapy and extensive skin lesion.
  • Methotrexate is drug of choice. Other effective agents are sulfasalazine, cyclosporine, retinoic acid & psoralen & UV-A (PUV A).
  • Use of immunosuppressive therapy including anti TNF a agents, methotrexate and cycloserine are contraindi cated in HIV associated PsA.

Q. 6 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

Explanation:

Ans:C.)Psoriatic Arthritis.

Image shows:

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.

PSORIATIC ARTHRITIS

5 major presentations of Psoriatic Arthropathy (PsA)

  • a) Arthritis of DIP joints
  • b) Asymmetric oligoarthritis :Most characteristic when a finger or toe is involved leading to sausage digit or dactylitis
  • c) Symmetrical polyarthritis :Resembles RA but nodules and extraarticular features are absent
  • d) Axial involvement (spine and sacroiliac joints)
  • e) 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.

 

 




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