Psoriatic arthritis
DIP joint InvolvementNail changes
Psoriatic arthritis
Nail pitting in psoriatic arthritis
Psoriatic arthritis
Deforming arthritis
Psoriatic arthritis- pseudorheumatoid
Looks like RABut RF –psoriasis
What is this diagnosis?
Osteoarthritis
What is this diagnosis?
Osteoarthritis
Beware the rare but serious….
• Conditions that may present with inflammatory arthritis like RA– Polymyositis, dermatomyositis: should have
muscle weakness, RF can be + low titre, do CK– Vasculitis eg Wegener’s granulomatosis:
always do U/A, renal function, RF-, ANCA +, may be very resistant to usual RA therapy
– Neoplastic conditions: resistant to usual RA therapy
Case history 5
• 25 year old man, episode of diarrhoea, 3 weeks later onset of knee swelling, followed by ankle swelling and achilles tendonitis
• Unable to walk in mornings due to pain and stiffness
• By midday joints “warmed up”• No conjunctivitis, no dysuria, diarrhoea
settled, no rash
Investigations
• FBC normal
• ESR 53, CRP 36
• UEC normal
• RF negative
• ANA negative
• Stool cultures- negative
Clinical picture
Left knee effusion
Achilles tendonitis
Diagnosis
• Sero-negative inflammatory arthritis reactive arthritis– Think of this group if past history of diarrhoea
(eg salmonlla), dysuria (eg chlamydia), sore throat (strep)
– Typical joint distribution: lower limb asymmetrical, knee, ankle, enthesitis with achilles tendonitis, plantar fasciitis, sausage toes (dactylitis)
Case history 6
• 35 year old man
• 3 year history of low back, buttock pain
• Worse in the morning, improves with walking around.
• Wakes him in early hours of the morning
• Past history of red eye many years ago, treated with steroid drops
Examination and investigations
• No peripheral joint synovitis
• Back movements: some limitation of lumbar flexion, nil else
• FBC normal
• ESR, CRP normal
• Diagnosis?
• Further investigations?
Diagnosis
• Inflammatory back pain
• Sero-negative spondyloarthropathy
• Do pelvic Xray to look at sacro-iliac joints
• HLA-B27 antigen– Not diagnostic test for ankylosing spondylitis– 10% normal population HLA-B27+– 90% AS HLA-B27+
Sacri-iliitis
Psoriatic arthritis
Ankylosing spondylitissubtype
Joint distribution
• Symmetrical, small joint arthritis, MCP, PIP, wrists, MTPs +/- other joints– Think RA, psoriatic, SLE or viral
• Asymmetrical, predominantly lower limb, ankle knee, enthesitis– Think sero-negative spondyloarthropathies– Psoriatic, Reactive, ankylosing spondylitis
• Sacro-iliac (buttock) pain, spinal stiffness– Think sero-negative spondyloarthropathies, eg ankylosing
spondylitis