PSORIATIC ARTHRITIS

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

Ans. is `d’ i.e., All of the above

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.

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.

• 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.

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.