MEDICAL HISTORY

2. MEDICAL HISTORY • U.S. 28 year old male, catholic, married, born on May 6, 1981, works as a tricycle driver since 2001, residing in Caloocan City with wife. • Chief Complaint: KNEE PAIN & SWELLING

3. History of Present Illness 7 Yrs PTA • White scales of the scalp resembled dandruff when scratched (no consult) • Few mos. later: pustules and papules that later coalesced to erythematous plaques topped with scales spread all over his body affecting his back, trunk, upper and lower extremities and his face  consult at UST Dermatology OPD; punch biopsy: Psoriasis – medications: PUVA therapy (once in 2002), Methotrexate 1 tab BID for 1 wk, Dermovate with Petroleum Jelly and LCD, Hydroxizine (Iterax) for pruritus 3x/day prn resolution of Symptoms 2 Yrs PTA • Reappearance of lesions • Painful swelling of distal and proximal joints of the fingers of right and left hands and feet (self-medication: Naproxen  temporary relief) • Gradual limitation of in the movement of digits • Consult to Rheumatologist, prescribed with Celebrex and requested for further lab work-ups; but patient lost to follow-up 1 Yr PTA • Pain and swelling in both knees, noted to be limping, and pain when walking down the stairs • Relieved by rest or sitting down

4. 1 month PTA • Swelling of both knees with increasing severity of pain (no consult) 1 week PTA • Pain in the hips extending down to his ankles • More difficulty in ambulating 5 days PTA • Consulted an Orthopedic Surgeon in Marikina; was told to have excess fluid in knee joints & advised arthrocentesis (pt. opted not to) 4 days PTA • Fever [undocumented] (self-medication: Paracetamol temporary lysis of fever) • Persistence of pain and fever  consult at FEU Hospital (X-Ray of leg: soft tissue swelling); advised admission but refused due to financial constraints; referred to USTH for further evaluation & management ADMISSION

5. Past Medical History • (-) DM • (-) HPN • (-) Joint surgery • (-) history of trauma • (-) Allergy • Diagnosed with dengue fever (2nd year high school) • Excision of cyst at the back (2007)

6. Family History • (+) Myocardial Infarction – father • (+) DM – father • (-) HPN • (-) stroke • (-) Psoriasis • (-) Cancer • (-) Arthrides

7. Personal & Social History • Smoker: 16-22 y/o (1-2 sticks per day) • Occasional Alcoholic Beverage Drinker • Denies Illicit Drug Use • 3 past sexual partners, all protected

8. Review of Systems • No wt. loss, no loss of appetite • No hearing loss, no nasal congestion, no cough • No dyspnea, orthopnea, cyanosis • No chest pain, palpitations • No abdominal pain, diarrhea, constipation • No dysuria, frequency, change in character of urine

9. PHYSICAL EXAMINATION General Survey • Conscious, coherent, oriented as to time, place and person, not in cardio-respiratory distress Vital Signs • BP 120/70 mmHg, PR 83 bpm, RR 20 cpm, T 36.6 °C Skin • Warm moist skin, (+) erythematous plaques topped with scales all over the body, (+) hyperpigmented patches over the extremitie, (+) oil spots, (+) nail pitting, (+) onychodystrophy

10. HEENT • Pink palpebral conjunctivae, anictericsclerae, no naso-aural discharge, no tragal tenderness, moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged Neck • Supple neck, trachea midline, no palpable cervical lymph nodes, thyroid gland not enlarged Cardiovascular • Adynamicprecordium, AB at 5th LICS, MCL; no murmurs • All pulses full and equal Respiratory • Symmetric chest expansion, no retractions, clear breath sounds on all lung fields, no crackles, no wheezes

11. Abdomen • Flat abdomen, NABS, soft, nontender, no masses Musculoskeletal • (+) sausage-shaped 4th digit of the right hand • (+) swelling and tenderness, both knees, DIP 4th R digit of the hand, R ankle • (+) flexed 5th left digit and the 4th R digit of the hand • Cannot flex the PIP and DIP of the right 2nd digit of the hand

12. Neurological • Conscious, oriented to person, place and time, can follow commands • GCS 15 E4V5M6; pupils 2-3 mm, isocoric ERTL, V1,V2,V3 intact; intact hearing, can swallow, (+) gag reflex, can shrug shoulders, tongue midline on protrusion • Motor: MMT 5/5 on both UE; 4/5 on both LE, no atrophy • Cerebellum: no deficits, can do FTNT, APST, HTST • Sensory: no sensory deficits • DTRs: 2+ on the UE, LE not assessed • (-) Babinski; no nuchal rigidity

13. SALIENT FEATURES • History of Psoriasis • Painful swelling of distal and proximal joints of the fingers of right and left hands and feet • Gradual limitation of in the movement of digits • Pain and swelling in both knees (increasing severity of pain), limping, and pain when walking down the stairs (difficulty in ambulating); Relieved by rest or sitting down • Pain in the hips extending down to ankle • excess fluid in knee joints • Persistence of pain and fever • X-ray of leg: soft tissue swelling

14. SALIENT FEATURES • (+) erythematous plaques topped with scales all over the body, (+) hyperpigmented patches over the extremitie, (+) oil spots, (+) nail pitting, (+) onychodystrophy • (+) sausage-shaped 4th digit of the right hand • (+) swelling and tenderness, both knees, DIP 4th R digit of the hand, R ankle • (+) flexed 5th left digit and the 4th R digit of the hand • Cannot flex the PIP and DIP of the right 2nd digit of the hand

15. Differential diagnosis

16. Differential diagnosis • Gout • Osteoarthritis • Reactive Arthritis • Rheumatoid Arthritis • Septic Arthritis

17. Gout • a common disorder of uric acid metabolism • can lead to deposition of monosodium urate (MSU) crystals in soft tissue and recurrent episodes of debilitating joint inflammation • if untreated - joint destruction and renal damage • definitively diagnosed based on the demonstration of urate crystals in aspirated synovial fluid

18. Gout Physical examination findings: • During an acute gout attack, examine all joints to determine if the patient's arthritis is monoarticular or polyarticular • Involved joints have all the signs of inflammation: swelling, warmth, erythema, and tenderness • The erythema over the joint may resemble cellulitis; the skin may desquamate as the attack subsides • The joint capsule becomes quickly swollen, resulting in a loss of range of motion of the involved joint • During an acute gout attack, patients may be febrile, particularly if it is an attack of polyarticular gout • Look for sites of infection that may have seeded the joint and caused an infectious arthritis that can resemble or coexist with acute gouty arthritis • The presence of tophi suggests long-standing hyperuricemia

19. Osteoarthritis • Predominantly involves the weight-bearing joints, including the knees, hips, cervical and lumbosacral spine, and feet • Other commonly affected joints - the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints of the hands • Cartilage is grossly affected • Focal ulcerations eventually lead to cartilage loss and eburnation • Subchondral bone formation also occurs, with development of bony osteophytes

20. Osteoarthritis Physical examination findings: • Mostly limited to the affected joints • Malalignment with a bony enlargement (depending on the disease severity) may occur • Most cases of osteoarthritis do not involve erythema or warmth over the affected joint(s) • however, an effusion may be present • Limitation of joint motion or muscle atrophy around a more severely affected joint may occur

21. Reactive Arthritis • Also known as Reiter syndrome, is an autoimmune condition that develops in response to an infection • Usually develops 2-4 weeks after a genitourinary or gastrointestinal infection • recent evidence indicates that a preceding respiratory infection with Chlamydia pneumoniae may also trigger the disease • about 10% of patients do not have a preceding symptomatic infection. • Both postvenereal and postenteric forms of reactive arthritis may manifest initially as nongonococcalurethritis • Mild dysuria, mucopurulent discharge, prostatitis and epididymitis in men, and vaginal discharge and/or cervicitis in women are other possible manifestations • Onset - usually acute and characterized by malaise, fatigue, and fever • An asymmetrical, predominately lower-extremity, oligoarthritis - the major presenting symptom • Low-back pain occurs in 50% of patients • Heel pain is common because of enthesopathies at the Achilles or plantar aponeurosis insertion on the calcaneus • The complete Reiter triad of urethritis, conjunctivitis, and arthritis may occur

22. Reactive Arthritis Physical examination findings: • Joints, axial skeleton, entheses • Peripheral joint involvement associated - typically asymmetric and usually affects the weight-bearing joints (ie. knees, ankles, hips), but the shoulders, wrists, and elbows may also be affected • More chronic and severe cases - the small joints of the hands and feet may also be involved; as in other spondyloarthropathies, dactylitis (ie, sausage digits) may develop. • While 50% of patients with reactive arthritis may develop low-back pain, most physical examination findings in patients with acute disease - minimal except for decreased lumbar flexion; patients with more chronic and severe axial disease may develop physical findings similar to ankylosingspondylitis • As with other spondyloarthropathies, the enthesopathy of reactive arthritis may be associated with findings of inflammation (ie. pain, tenderness, swelling) at the Achilles insertion; other sites include the plantar fascial insertion on the calcaneus, ischialtuberosities, iliac crests, tibialtuberosities, and ribs • Skin and nails • Keratodermablennorrhagica on the palms and soles is indistinguishable from pustular psoriasis - highly suggestive of chronic reactive arthritis • Erythemanodosum may develop but uncommon • Nails can become thickened and crumble, resembling mycotic infection or psoriatic onychodystrophy, but nail pitting is not observed • Circinatebalanitis may also develop • Other mucosal signs and symptoms: Painless shiny patches in the palate, tongue, and mucosa of the cheeks and lips have been described

23. Reactive Arthritis Physical examination findings: • Ocular findings • Conjunctivitis - part of the classic triad of Reiter syndrome and can occur before or at the onset of arthritis • Other ocular lesions include acute uveitis (20% of patients), episcleritis, keratitis, and corneal ulcerations; the lesions tend to recur • Enteric infections • May trigger reactive arthritis; pathogens include Salmonella, Shigella, Yersinia, and Campylobacter species; the frequency of reactive arthritis after these enteric infections - about 1-4% • Some patients continue with intermittent bouts of diarrhea and abdominal pain; lesions resembling ulcerative colitisor Crohn disease have been described when ileocolonoscopy is performed in patients with established reactive arthritis • Other manifestations • Mild renal pathology with proteinuria and microhematuria • In severe chronic cases, amyloid deposits and immunoglobulin A (IgA) nephropathy have been reported • Cardiac conduction abnormalities may develop, and aortitis with aortic regurgitation occurs in 1-2%

24. Rheumatoid Arthritis • A chronic systemic inflammatory disease of unknown cause that primarily affects the peripheral joints in a symmetric pattern • Constitutional symptoms, including fatigue, malaise, and morning stiffness are common • Extra-articular involvement of organs such as the skin, heart, lungs, and eyes can be significant • Causes joint destruction and thus often leads to considerable morbidity and mortality • Has a significant genetic component, and the shared epitope of the HLA-DR4/DR1 cluster is present in up to 90% of patients with RA, although it is also present in more than 40% of controls • Synovial cell hyperplasia and endothelial cell activation are early events in the pathologic process that progresses to uncontrolled inflammation and consequent cartilage and bone destruction • Genetic factors and immune system abnormalities contribute to disease propagation

25. Rheumatoid Arthritis Physical examination findings: • Joint involvement - the characteristic feature • In general, the small joints of the hands and feet are affected in a relatively symmetric distribution • The most commonly affected joints, in decreasing frequency, include the MCP, wrist, PIP, knee, MTP, shoulder, ankle, cervical spine, hip, elbow, and temporomandibular joints • Joints show inflammation with swelling, tenderness, warmth, and decreased range of motion • Atrophy of the interosseous muscles of the hands is a typical early finding • Joint and tendon destruction may lead to deformities such as ulnar deviation, boutonnière and swan-neck deformities, hammer toes, and, occasionally, joint ankylosis • Other commonly observed musculoskeletal manifestations • tenosynovitis and associated tendon rupture due to tendon and ligament involvement, most commonly involving the fourth and fifth digital extensor tendons at the wrist • periarticular osteoporosis due to localized inflammation; generalized osteoporosis due to systemic chronic inflammation, immobilization-related changes, or corticosteroid therapy; and carpal tunnel syndrome • most patients have muscle atrophy from disuse, which is often secondary to joint inflammation

26. Septic Arthritis • Also known as infectious arthritis • May represent a direct invasion of joint space by various microorganisms, including bacteria, viruses, mycobacteria, and fungi • Reactive arthritis, a sterile inflammatory process, may be the consequence of an infectious process located elsewhere in the body • Bacterial pathogens - the most significant because of their rapidly destructive nature • Failure to recognize and to appropriately treat septic arthritis results in significant rates of morbidity and may even lead to death

27. Septic Arthritis Physical examination findings: • The most commonly involved joint is the knee (50% of cases), followed by the hip (20%), shoulder (8%), ankle (7%), and wrists (7%) • The elbow, interphalangeal, sternoclavicular, and sacroiliac joints each make up 1-4% of cases • A thorough inspection of all joints for signs of erythema, swelling (90% of cases), warmth, and tenderness is essential for diagnosing infection • Infected joints usually exhibit an obvious effusion, which is associated with marked limitation of both active and passive ranges of motion • Frequently, these findings are apparent but may be diminished or poorly localized in cases of infection of the spine, hip, and shoulder joints

28. Cellulitis • An acute inflammatory condition of the skin characterized by localized pain, erythema, swelling and heat. • Caused by indigenous flora colonizing the skin and appendages and exogenous bacteria (e.g. Staphylococcus aureus, Streptococcus pyogenes) • May gain access through cracks in the skin, wounds, abrasions, burns • Lesions are nodular and surrounded by vesicles that rupture and discharge pus and necrotic material

29. Diagnostic Work Up

30. Laboratory Tests • Check for rheumatoid factor for coincident occurence of RA; PsA alone = (-) RF • Check also for gout • ANA, autoantibodies • For seronegative arthritis without skin changes, check for HLA-B13, -BW57, -B27. • Sudden onset is assoc. with HIV so check for HIV disease

31. Psoriatic arthritis • NO diagnostic laboratory tests • ESR and CRP  often elevated • Extensive psoriasis = uric acid may be elevated • HLA-B27 is found in 50-70% of patients with axial disease, but <15-20% if only peripheral joint involvement

32. Arthrocentesis • Examine the fluid in joints a. Gross examination – clarity, color b. Cell count – WBC per c. Microscopic examination – crystals, Gram staining d. Culture and sensitivity

33. Arthrocentesis ** Aspirating needle should never be passed through an overlying cellulitis or psoriatic plaque because of the risk of introducing infection

34. CBC (Patient’s Results)

35. Blood Chemistry

36. Radiographic Imaging

37. Peripheral PsA • DIP involvement – “pencil-in-cup” deformity

38. marginal erosions of bone and irregular destruction of joint and bone, which, in the phalanx, may give the appearance of a sharpened pencil

39. “whiskering” – marginal erosions with adjacent bony proliferation • Small joint ankylosis • Osteolysis of phalangeal and metacarpal bone with telescoping of digits • Periostitis and proliferative new bone at site of enthesitis

40. Axial PsA • Asymmetric sacroiliiitis

41. Less zygoapophyseal joint arthritis, fewer and less symmetric and delicate syndesmophytes • Fluffy hyperperiostosis on anterior vertebral bodies • Paravertebral ossification

42. Severe cervical spine involvement but relative sparing of thoracolumbar spine

43. Ultrasound and MRI demonstrate enthesitis and tendon sheath effusions

44. Histopathology • Thick S. corneum and projections of the epidermis • Parakeratosis(cell nuclei within thickened s. corneum) • Elongation of rete ridges

45. PMN leukocyte and lymphocyte infiltration of dermis and epidermis forming microabscesses of Munro in the s.corneum • exocytosis of neutrophils into epidermis producing spongiform pustules (Kogoj)

46. Pathophysiology Psoriasis Psoriatic Arthritis Cellulitis

48. aps

49. Psoriasis • Areas of Predilection • Scalp • Nails • Extensor Surface, Limbs • Umbilical region • Sacrum