Case Diagnosed as Rheumatoid Arthritis .. Turned to be Psoriatic Arthritis.

2. Short Case
Ahmed EL-Belasy
MSc Rheumatology
Alexandria University
Egypt

3. Personal History
• 27 years old , housewife.
• complaining of
o Pain and swelling of right wrist and small joints of
both hands of 5 month duration .

4. Present History
• Condition started 5 month ago by gradual onset of pain
, swelling of small joints of both hands and right wrist.
• She had medical treatment ( NSAIDs ) with no
improvement.

5. Present History
• 3 month later the condition progressed to include
pain and swelling of both wrist joints , MCPs , PIPs of
both hands and bilateral ankle joint pain.
• She has morning stiffness lasting for ½ hour.
o There was no fever.
o No ocular manifestations.
o No chest or cardiac complains.

6. Drug History
• Diclofenac 150mg MR Tab
Past History
• No Hypertension
• No DM
once/day
orally

7. Family History
• Parents : negative consanguinity.
• Irrelevant family history.

8. Examination
• General condition is good
• Vital signs :
o Pulse : 78 / min regular equal on both sides
o B.P : 120/ 80 mmhg
o Temp : 36.8 C
o R.R : 18/ min

9. Examination
• Head and neck:
o Clinically free
• Chest examination:
o Clinically Free.
• Heart :
o Clinically Free.
• Abdomen:
o Clinically Free.
• Neurologically :
o clinically Free
• Skin lesions:
o Clinically free

10. Joints Examination
• Tenderness of :
o Bilateral Wrist
joints.(swelling)
o Bilateral MCP joints.
o Bilateral PIP joints.
o Bilateral ankle joints.
Tender swollen joints.
Tender joints.
o ROM is limited due to pain.

11. Laboratory Investigations:
Routine
Investigations
Hb : 11.2 gm
WBC: 5,300
PLT: 279.000
S.Creatinine: 0.8 mg/dl (N. 0.5-1.2)
SGPT: 49 U/L (N. up to 65 )
SGOT: 31 U/L (N. up to 37 )

12. Laboratory Investigations:
Serum Uric acid : 4.0 mg/dl( normal 2-6 mg/l)
C – Reactive protein (CRP): 20 mg/l ( normal : 6 mg/l)
ESR: 60 - 97 mm/hr
Rheumatoid factor (Latex): Negative 8 ( normal : 16 units/l)

13. Laboratory Investigations:
ANA (ELISA) : Positive 45 ( normal 25 unit/ml )
ACPA (Anti CCP) : Negative 12 ( normal : 20 unit/ml )

14. Diagnosis
Sero-Negative
Rheumatoid
Arthritis

15. • Me t h o t r e x a t e
i n j e c t i o n
20 m g / w e e k S .C
• F o l i c a c i d 1 mg
o f
i n t h e f o r m
2 t a b l e t s
500 u g /d a y
• L e f l u n o m i d e 20m g
o n c e d a i l y o r a l l y
t a b l e t

17. 3 Month Later ….

19. Follow up visit
o Joint complain improved.
o She started complaining about her nails
and
asked
medications?
if
it
is
related
to
the

21. Her nails affection was suspected
as a psoriatic lesion.
She was referred to a Dermatologist.

23. Psoriatic Arthritis

25. Clinical presentations
of
Psoriatic skin lesions

26. Common sites affected by psoriasis
• Can affect any
part of the body
–
typically
scalp, elbow, kne
es and sacrum
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

27. Classic Psoriasis
o Well-defined and sharply
demarcated
o Round/oval-shaped
lesions
o Usually symmetrical
o Erythematous, raised
plaques
o Covered by white, silvery
scales
1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –
dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. Fast facts: psoriasis. 2nd ed.
Oxford: Health Press, 2004.

28. Types of psoriasis
• Chronic plaque
• Guttate
• Flexural
• Erythrodermic
• Pustular
o Localised and generalised
• Local forms
o Palmoplantar
o Scalp
o Nail (psoriatic
onychodystrophy)
1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Rossi S, ed. Australian medicines
handbook. Adelaide: AMH, 2010.

29. Chronic plaque psoriasis
o Most
common
type
–
affects approximately 85%
o Features pink, well-defined
plaques with silvery scale
o Lesions may be single or
numerous
o Classically
elbows,
knees,
affects
buttocks
and scalp
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice
essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

30. Chronic plaque psoriasis

31. Chronic plaque psoriasis

32. Chronic plaque psoriasis

33. Guttate psoriasis
o Numerous and small
lesions – 1 cm diameter
o Pink with less scale than
plaque psoriasis
o Commonly found on
trunk and proximal limbs
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2.
Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice
essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 4. Menter A et al. J Am Acad Dermatol
2008; 58(5): 826–50.

34. Flexural psoriasis
o Lesions in skin folds
o Particularly
groin, gluteal
cleft, axillae and
submammary
regions.
o Often minimal or
absent scaling
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
2. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912.

35. Erythrodermic psoriasis
o Generalized erythema
covering entire skin
surface
o May evolve slowly from
chronic plaque psoriasis
or appear as eruptive
phenomenon
o Relatively uncommon
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2.
Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing
Company, 2005.
3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

36. Pustular psoriasis
o Two forms:
• Localized form
• More common
• multiple small pustules
on palms and soles
• Generalized form
• Uncommon
• widespread pustules
across inflamed body
surface
1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Griffiths CEM et al. Psoriasis. In: Burns T et al., eds. Rook’s
textbook of dermatology. 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

37. Palmoplantar psoriasis
o Can be
hyperkeratotic or
pustular
o Possibly aggravated
by trauma
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

38. Scalp psoriasis
o Varies from minor
scaling with erythema to
thick hyperkeratotic
plaques
o May extend beyond
hairline
o Patient scratching may
produce asymmetric
plaques
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

39. Nail psoriasis
o Can take several forms:
• Pitting: discrete, well-circumscribed depressions on nail surface.
• Subungual hyperkeratosis: silvery white crusting under free edge of nail
with some thickening of nail plate.
• Onycholysis: nail separates from nail bed at free edge.
• ‘Oil-drop sign’: pink/red color change on nail surface.

40. Nail psoriasis

41. Nail psoriasis

42. No need for a
Dermatologist then
?

43. You will always need
my knowledge & I will
prove it to you

44. Localised patches/plaques
Tinea corporis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Psoriasis

45. Localised patches/plaques
Discoid eczema
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Psoriasis

46. Localised patches/plaques
o Superficial basal cell
carcinoma/Bowen’s
disease
Bowen’s disease
Psoriasis
1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis.
2nd ed. Oxford: Health Press, 2004.

47. Localised patches/plaques
o Seborrhoeic dermatitis
Dermatitis
1. Marks R et al. Dermatology within the pharmacy. Australia: Department of
Dermatology, St Vincent’s Hospital, 1998. 2. Menter A et al. Fast facts: psoriasis. 2nd ed.
Oxford: Health Press, 2004.
Psoriasis

48. Localised patches/plaques
Psoriasis
Mycosis fungoides
1. Fry L. An atlas of psoriasis. Spain: Taylor & Francis, 2004. 2. Menter
A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

49. Want more ?

50. Guttate psoriasis
< Psoriasis
^ Pityriasis rosea
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Press, 2004.
50

51. Guttate psoriasis
< Psoriasis
^ Secondary syphilis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Press, 2004. 2. Van de Kerkhof P, ed. Textbook of psoriasis.
2nd ed. Melbourne: Blackwell Publishing, 2003.
51

52. Flexural psoriasis
< Psoriasis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
2. Fischer, G. How to treat: atopic dermatitis. Australian Doctor. 16 April 2010: 29–36.
^ Atopic eczema
52

53. Palmoplantar psoriasis
o Tinea manum
Tinea corporis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Psoriasis
53

54. Palmoplantar psoriasis
o Hand and foot eczema
Eczema
Psoriasis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Press, 2004. 2. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed.
Melbourne: Blackwell Publishing, 2003.
54

57. Take Home Message