A 30 year Old Man Presents With Joint Pain And Nail Deformities

A 30 year old male patient is seen by a Rheumatologist for pain in his small joints of the hand and feet as well as lower back pain. He has a past history of some skin problem which is nowadays under control but he has observed that his finger nails has become dry and cracked with pitting and looks deformed. He remembers having had such nail problems previously and was treated along with his skin lesions. This time he complains of pain in his small joints of the hand and stiffness.
On examination he has warm and tender distal interphalangeal joints symmetrically in both the hands with severe nail deformities.
The picture of his hands is shown below

There is some stiffness in his neck and the vertebral column as well.

A skin lesion on his elbow is shown below:

What investigations will you order in this case?
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• Rheumatoid Factor.
• ESR
• Joint fluid aspiration and analysis.
• Joint X ray.

What is the Differential Diagnosis?

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• Rheumatoid arthritis.
• Psoriatic arthritis
• Polyarthritis rheumatica
• Fungal infection of the nails.
• Reactive arthritis ( Reiter's syndrome).

The Results are given below:

RA factor was negative, ESR was high and the X ray of the hands showed symmetric bone erosion along with bone proliferation predominately in a distal distribution. Synovial fluid analysis was inflammatory in nature with cell counts ranging from 5000- 15,000 /microliter. 

What is the final diagnosis?

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Psoriatic Arthritis.

Case Discussion:

Psoriatic Arthritis is an idiopathic inflammatory joint disorder that most commonly occurs in patients with a skin disorder known as psoriasis. ( a condition that is characterized by red patches of skin topped with silvery scales. 

Clinical features: Both posriatic arthritis and psoriasis are chronic conditions that can get worse over time but may have periods of remission with minimal or no symptoms.

The patients may present with one or more of the following features:

• Joint pain and tenderness mostly in the distal fingers and toes.
• Finger nail changes including pitting, cracking or lifting of the nail plate.
• Lower back pain.
• Skin lesions that are characterized by dark red plaques with silvery white scales and sharp margins mostly on the extensor surfaces. 
• Morning stiffness and fatigue. 

Diagnosis; Is usually with the help of clinical signs and symptoms. 

• RA factor is typically negative in posriatic arthritis
• X ray may pinpoint the specific changes of psoriatic arthritis that include a combination of erosive change with bone proliferation in the distal joints. 
• Synovial fluid is inflammatory in nature with cell counts ranging from 5000- 15,000 /microliter. 

Management: The underlying process in psoriatic arthritis is inflammation so the treatment is directed in controlling and reducing this inflammation. 

1. NSAIDs are typically the first prescribed drugs.

2. Disease modifying antirheumatic drugs like methotrexate, leflunomaide and sulfasalazine may help in slowing the progression of disease. 

3. Immunosuppresants may be used when disease gets out of control.

4. TNF alpha inhibitors can help reduce pain, inflammation and tenderness by controling the production of TNF alpha in the body( a substance that promotes inflammation).

5. Steroid injection in the affected joint can help control pain but is usually a temporary solution.

6. Sometime surgery may be needed for deformed joints and improve mobility in advanced cases.