Case-Based Approach for the Management of Rheumatic Diseases - Episode 12
Transcript: Grace C. Wright, MD, PhD: Today we’re going to talk about a young woman with psoriatic arthritis. She’s a 31-year-old Caucasian woman who presents to her primary care provider complaining of intermittent body aches and difficulty in picking up her child and cleaning her house. That immediately tells me that she’s having a lot of functional consequences. Her past medical history is notable for 6 years of scalp psoriasis, which she has under control with salicylic acid shampoo, and she has a prior history of multiple sclerosis. It has not been clear how that diagnosis was made, or if that was firmly made.
On her physical exam, she has tenderness over multiple joints, which includes both elbows, the metacarpal phalangeal and proximal interphalangeal joints of both hands, as well as the distal phalangeal joints on the right hand and the right knee. She has swollen joints of the right shoulder, the proximal and distal interphalangeal joints of the right hand, really showing that she’s got some joints that have both swelling and tenderness, and others that are just tender, and there’s a bit of a symmetry in her presentation. Her neurological exams showed no sensory deficits or hyperesthesia consistent with the questionable multiple sclerosis diagnosis. Her motor examination was not very accurate because she had significant pain that was limiting her active range of motion. Chest and abdominal findings were unremarkable.
Her initial work-up confirmed that this is someone with psoriasis, and probably psoriatic arthritis because she had multiple joints involved. She was placed on methotrexate, escalating her dose with an ultimate increase to 25 mg per week. On her imaging studies, it was noted that she had erosive changes in the small joints of the hands, and those were in fact asymmetrical, paralleling her clinical presentation. She also had narrowing of the joint space in the interphalangeal joints of the hands. Laboratory values were remarkable for elevated inflammatory markers, so her erythrocyte sedimentation rate was elevated to 35 mm/hour; normal in this lab is 0 to 20 mm/hour. Rheumatoid factor was negative, her antinuclear antibody test was negative, and her C-reactive protein was 7 mg/dL; normal is less than 3 mg/dL.
Three months after this initial plan was initiated, she still complained of similar symptoms, so she really had not improved. Her sedimentation rate, however, was now 30 mm/hour, just minimally improved. Her CBC [complete blood count] and chemistries were normal, and her C-reactive protein at this point is down from 7 to 3 mg/dL.
We’re left now with a young woman with a history of scalp psoriasis, inflammatory markers on her laboratory analyses, and evidence of synovitis with swelling and tenderness in multiple joints. This is someone who I would diagnose with psoriatic arthritis. And just to point out 1 thing: When we see scalp psoriasis, the likelihood of psoriatic arthritis in this individual is 4-fold. This is someone we should have been watching and be mindful of. Scalp psoriasis is not a benign finding in patients.
When we look at patients like this, we’ve already done the laboratory analysis. It was important to exclude other inflammatory arthritides by having an elevated rheumatoid factor. That’s actually a part of our CASPAR [Classification Criteria for Psoriatic Arthritis] criteria. She does not have an elevated rheumatoid factor, and that’s a plus in saying that this is psoriatic arthritis, and we have the elevated sedimentation and C-reactive protein. The fact that we have erosions and joint space narrowing on x-rays already tells me that this person has significant burden of disease. The 1 thing we have not looked at is her axial skeleton. It’s important to really examine that, because even though patients may not complain—she’s stiff, she’s in pain, she’s barely moving, she can’t lift, she can’t clean—there are a lot of things that she has already altered just to get through her day. She might have sacroiliac or lumbar thoracic cervical spine involvement, so we need to image those, because she may not be aware that she also has disease in those domains, and that may ultimately significantly impact her ability to function. Yes, the labs are important, but we also always have to do imaging where we suspect we may find hidden disease, even if the patient is not complaining.
My therapeutic goals for this patient really are to have her feel well, be well, and function well. She has a child at home, and she wants to be able to function in her home environment. It’s important to engage her in that conversation of, “What are the things that you need to do?” From my perspective, I want to see the swollen joints disappear. I need to halt the erosions, because eventually, as you damage joints, you will destroy joints, and then we have permanent disability. I want to see that her inflammatory markers go down, that her erosions are halted, but that functionally she also feels well. Another hidden complaint we’ve uncovered is that depression is a really important part of this group of diseases. When patients come in and they’re feeling poorly, we attribute everything to, “OK, she’s just feeling poorly.” But we need to assess her mental health. Is she anxious? Is she depressed? Is that part of her disease? We can address those at the same time and get her to a good level of functioning. All the things I mentioned that are abnormal, I want them gone. I want her well. That’s my therapeutic goal for her.
Transcript Edited for Clarity