Psoriatic Arthritis Clinical Case Review

Philip Mease, MD, rheumatologist at Swedish Health Services in Washington, discusses the baseline characteristics for the case.

Editor’s note: The following is an automatically generated transcript of the above video.

"Our case today is that of a 35-year-old Caucasian female. She’s had psoriasis since she was 25. Initially, it was quite severe. It was treated with methotrexate, as well as topical steroid creams, but in recent years, it’s been managed with just topical agents because it’s not been quite as severe. She was referred by her dermatologist because she has developed musculoskeletal complaints and findings, pain and swelling in both wrists, several finger joints, and she’s had a swollen left toe like a sausage. From time to time, her left Achilles tendon has become painful. She mentions that she has back pain that acts up when she spends a long time gardening. She works as a programmer in a tech company, is married, and is actively discussing having a family with her husband.

On physical exam, she shows evidence of psoriasis patches behind her ears, on her elbows and two patches on her back. Nail pitting is noted. Also, she has several joints that are tender or tender and swollen. For example, the left second and third MCP joints are tender, as are the right third PIP and fourth MCP joints. Both wrists are tender and swollen. Her right sternoclavicular joint is tender, as are the left fourth and fifth metatarsal joints. Her left fourth toe is dactalytic, meaning it is swollen wholly like a sausage. Also, her left Achilles tendon, when pressing right at the heel insertion, and the right plantar fascia also beneath on the heel is painful. Her laboratory evaluation shows a sed rate of 15 and a CRP of 0.5 milligrams per deciliter, both within normal limits. Rheumatoid factor and CCP antibodies are negative, and HLA-B27 gene marker is also negative. Imaging, well, we started with a pelvis X-ray, which showed normal sacroiliac and hip joints. A lumbar X-ray showed modest degenerative changes at L4 and 5. We went on to get an MRI of the pelvis to further ascertain whether she might have evidence of inflammation in the SI joints, even though she did not have evidence of structural damage on X-ray, and she did have evidence of mild bone marrow edema of the left sacroiliac joint, which the radiologist and I felt could be consistent with an inflammatory sacroiliitis."