NYU Medicine Grand Rounds Clinical Vignette

Julia Manasson, PGY2

November 20th, 2013

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 27 year old woman presents with pain and stiffness in both wrists for four months.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Two years prior to current presentation the patient developed diffuse joint pain. An auto-immune work-up was performed, which was reportedly unremarkable.•Her symptoms fluctuated until four months prior to presentation when the patient developed joint pain and stiffness, most notably in the wrists bilaterally. She was seen by a hand surgeon and underwent an MRI which was only significant for ganglion cysts.•On presentation, she reported bilateral knee pain, left greater than right. She also reported left hand pain and diffuse swelling of the proximal interphalangeal joints, particularly the 3rd digit.•She described the pain as constant, unrelated to activity, and minimally responsive to non-steroidals.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:•Inverse psoriasis: diagnosed at age 12, treated with topical medications (tacrolimus and steroids)

•Past Surgical History:•Denies

•Social History:•Denies tobacco and illicit drug use. Drinks alcohol on occasion, on average 1 drink/week.

•Family History:•Father with psoriasis

•Allergies: •No Known Drug Allergies

•Medications:•Betamethasone 0.12% foam, apply topically twice daily•Tacrolimus 0.1% ointment, apply topically twice daily•Sertraline 150 mg by mouth daily•Methylphenidate 20 mg by mouth every morning•Birth control 1 tablet daily

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•General: well appearing, no acute distress•Vital Signs: T: afebrile, BP: 110/55, HR: 72•Skin: Plaques over buttocks and intergluteal crease.•MSK: Diffuse tenderness to palpation of proximal interphalangeal joints. The left 3rd interphalangeal joint notable for swelling and synovitis.•Remainder of physical exam unremarkable.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Dactylitis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

http://www.cdaarthritis.com/images_slides/images_slides_43.htm

Laboratory Findings

•CBC: WBC 8.5, Hb 12.2, Plt 214•BMP: Unremarkable, BUN 10, Cr 0.67•Hepatic panel: Unremarkable•Erythrocyte sedimentation rate: 23•C-reactive protein: 4.3•Rheumatoid factor: 4.6•Anti-cyclic citrullinated peptide IgG/IgA: 5•HLA: A*29:KBF•Quantiferon: Negative•Hepatitis B: Immune•Hepatitis C: Negative

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•Bilateral hand/wrist x-ray: -No acute fracture or dislocation. -Joint spaces and alignment are maintained. -Focal soft tissue swelling about the proximal interphalangeal joint of long finger, most pronounced along the ulnar aspect, within the spectrum of sausage digit. -Soft tissues are otherwise unremarkable.

•Bilateral foot x-ray: -Unremarkable

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Hand X-ray

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

PA

Lateral

Wrist XR

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

AP

Lateral

Foot XR

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

AP

R Lateral

L Lateral

XR Descriptions

•Bilateral hand/wrist XR: - No acute fracture or dislocation. - Joint spaces and alignment are maintained. - Focal soft tissue swelling about the proximal interphalangeal joint of long finger, most pronounced along the ulnar aspect, within the spectrum of sausage digit. - Soft tissues are otherwise unremarkable.

•Bilateral foot XR: - Unremarkable

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Given the patient’s prior history of psoriasis, new complaints of joint stiffness and pain, physical exam, and imaging studies, the patient was diagnosed with psoriatic arthritis.

Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Patient was started on Methotrexate 10 mg weekly and Folic acid 1 mg daily. Plan was to uptitrate the dose of Methotrexate as tolerated while monitoring labs.

• If no response within 3 months, the patient would need to be started on a TNF inhibitor.

Treatment

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS