Psoriatic Arthritis Clinical Case Review

Ethan Craig, MD, Vice Chief of Clinical Affairs at Penn Rheumatology, discusses the baseline characteristics of the case.

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

"Hi, my name is Ethan Craig and I'm Assistant Professor of Clinical Medicine and Vice Chief for Clinical Affairs of the Division of Rheumatology at the University of Pennsylvania Perelman School of Medicine in Philadelphia. And I'm here to talk to you today about a case seen in our Spondyloarthritis clinic. This is a 46-year-old man who has a history of psoriasis involving the genitals, scalp, and nails. In 2011, around the age of 33, he developed dactylitis of the great toe and pain and swelling of the right ankle. He was seen by a rheumatologist and noted at the time to have nail pitting. He underwent a right ankle aspiration, which showed no crystals, but did show an inflammatory level white count and was treated with steroid taper with resolution.

There was some question of gout despite the negative crystal analysis, and he ended up being treated with a course of steroids with rapid improvement. And over subsequent years, he continued to receive periodic doses of steroids or colchicine for flares of joint pain, which resolved with treatment and would recur several times a year. In 2015, around the age of 37, he presented again with increasing flares of the pain in his toes, ankles, knees, low and new low back pain along with new onset of genital psoriasis lesions. He was started on adalimumab for a presumed diagnosis of psoriatic arthritis at the time and had a good resolution of his joint pain, though had an ongoing psoriasis.

In 2017, around the age of 39, his adalimumab, which he had maintained until then, was held for about a one month period during a flu infection, and during this time, he developed a flare of joint symptoms. The adalimumab was then increased a weekly dosing and the patient required a prolonged course of prednisone to manage this flare of joint pain, but ultimately had ongoing joint pain despite weekly dosing and was switched to etanercept with improvement in his arthritis, but unfortunately no change and in fact, worsening of his psoriasis. Three years later around 2020, around age 42, he developed a flare of arthritis on etanercept. And at this point he switched to certolizumab 200 milligrams every two weeks with improvement in the joint pain, but again still ongoing psoriasis.

In 2022, around age 44, he developed recurrent episodes of migratory joint pain and swelling, especially involving now the right foot with episodes of dactylitis, which improved with steroids. It would be somewhat self-limited. The certolizumab at this point was increased at 400 milligrams every two weeks with improvement in his joint pain flares, and skin symptoms, and he maintained it with this through 2023, around the age of 45 when he developed this new nodule on his right ear, which was resected by ENT and found to be consistent with a tophus.

At this point, he was referred to our office and at the time I saw him, he denied any joint pain or swelling on the certolizumab 400 milligrams twice weekly or every two weeks. But despite this, he has continued to have these flares of debilitating pain that last about several days to weeks and improve with steroids. The last flare was about three months ago. He also has ongoing psoriasis involving the genitals with body surface area of less than about 1%, but in a very bothersome location that does significantly impact his quality of life.

Looking at his past medical history, he has known that he has a prior diagnosis of psoriasis and psoriatic arthritis. He has unfortunately developed AVN of the bilateral hips, which was identified on MRI several years ago with a normal X-ray. He is has known hyperuricemia and irritable bowel syndrome. His family history is significant for gout in his father and psoriasis in a maternal aunt. He has no other family history of psoriasis and no history of inflammatory bowel disease, uveitis or ankylosing spondylitis. His social history is relatively non-significant. He's a never smoker. He drinks occasionally, about two to three drinks at a sitting and does use occasional marijuana.

At this initial visit, we did have lab work performed which showed a uric acid of 8.3, a CRP, which was normal and a normal CBC and CMP. He did have some right knee pain with a small effusion of further questioning and for diagnostic purposes, an aspiration was performed with the five ccs of clear yellow fluid return. Total whites count from this was 1,510, and no crystals were appreciated. He was started at this point on allopurinol and colchicine prophylaxis with a plan for titration to a goal of less than six. Now, why was the allopurinol started? At this point, we could not determine whether his recurrent episodes of joint pain and swelling were related to the psoriatic arthritis diagnosis, which we did generally agree with or to a diagnosis of gout and in setting of tophaceous material, the decision was made that it would be reasonable to treat for both conditions at this time. We did continue the certolizumab 400 milligrams every two weeks. Generally, during this time, he did quite well, and over about the next 18 months, he had several visits in which he had no further joint pain or swelling."