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Show your Best III

Show your Best III. By: Brad Moatz MSIV. Presentation. 42 y.o. male presents with R foot pain and h/o psoriasis.

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Show your Best III

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  1. Show your Best III By: Brad Moatz MSIV

  2. Presentation • 42 y.o. male presents with R foot pain and h/o psoriasis

  3. Right foot: There are large central erosions in the first -- fifth metatarsophalangeal joints, with resultant pencil in cup deformity in these joints. There is metatarsus adductus primus, measuring 18°. There is also hallux valgus, measuring approximately 52°. There is also mild to moderate lateral deviation at the second - fourth metatarsophalangeal joints. There is bony ankylosis in the midfoot, specifically at the naviculocuneiform articulation, as well as navicular cuboid joint. There are diffuse enthesopathic changes throughout the foot, most prominent at the medial and lateral aspect of the hindfoot and midfoot. There is a prominent erosion in the dorsal aspect of the calcaneus at the site of the Achilles' tendon insertion.

  4. Psoriatic Arthritis - Presentation • Patients with psoriatic arthritis present with pain and stiffness in the affected joints • Morning stiffness lasting more than 30 minutes occurs in one-half of patients. The stiffness is accentuated with prolonged immobility, and is alleviated by physical activity. • PE- stress pain, joint line tenderness, and effusions in the affected joints are present, often in an asymmetric distribution. The DIP joints and spine are each affected in 40-50% of cases

  5. Presentation (cont.) • Dactylitis • Characteristic features of psoriasis affecting the nailbed include nail pits, onycholysis, nailbed hyperkeratosis, and splinter hemorrhages • Swelling of the hands or feet with pitting edema is sometimes a presenting feature • Ocular inflammation occurs in some patients with psoriatic arthritis

  6. Radiologic Features • The most striking radiologic feature is the coexistence of erosive changes and new bone formation in the distal joints; other typical radiological changes include lysis of the terminal phalanges, fluffy periostitis and new bone formation at the site of enthesitis, gross destruction of isolated joints, "pencil-in-cup" appearance, and the occurrence of both joint lysis and ankylosis in the same patient

  7. Psoriatic arthritis associated with pencil-in-cup abnormality in the distal interphalangeal (DIP) joints of the first and second fingers (short arrows), plus early changes in the DIP joint of the fourth finger. Other changes include ankylosis in the DIP joint in the fifth finger (long arrow) and destruction of the wrist.

  8. Treatment • The treatment of PsA usually begins with nonsteroidal antiinflammatory medications (NSAIDs) • Second-line therapies are employed when the arthritis does not respond to NSAIDs • Drugs such as methotrexate, PUVA, retinoic acid derivatives, and cyclosporine A have been shown to improve both the joint and skin manifestations of psoriasis • However, it should be noted that none of these medications have actually been shown to prevent or retard progression of joint damage. Inhibitors of tumor necrosis factor-alpha (TNF) may also be effective for both skin and joint disease

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