PsA Exam

Question 1

Hx 1

Answer 1

• Patient has Psoriasis; family Hx of psoriasis suggests hereditary pattern.
• develops between 35-55 yrs, (can occur at any age)
• 15 % of psoriasis patients develop psoriatic arthritis.*
• 20% of patients, arthritis appears before the psoriasis.

Question 2

Common SSx- Systemic

Answer 2

• clinical subtypes of PsA
• possible to have multiple subtypes
• common systemic SSx
• fever
• fatigue
• weight loss
• malaise
• conjunctivitis (redness / pain)

Question 3

Common SSx- Articular

Answer 3

• Arthritis:
• Pain; heat; swelling; ↓ed ROM; usually low-grade inflammation
• Morning stiffness and fatigue
• Commonly affects wrists, knees, ankles, SIJs and DIPs of fingers & toes
• “Sausage” fingers/toes caused by uniform joint inflammation & tendinitis.
• Enthesitis: Achilles tendon and plantar fascia are commonly affected
• Inflammation of periarticular soft tissue
• Tendinitis: Tenderness, pain and swelling over tendons
• Nail lesions
• nail pitting & nail lifting from bed (onycholysis) (80% of patients with PsA).

Question 4

Clinical Forms- Asymmetric Oligoarthritis

Answer 4

• Most common presentation of PsA (30-50%)
• Generally mildest form
• Asymmetric involvement of 1-3 large & small joints;
• digits of the hands & feet are usually affected first;
• Small joints: DIPs , PIPs and MCPs
• Large joints: knee, hip, ankle or wrist
• Dactylitis (arthritis & tendinitis in ray distribution) may occur in hand involvement

Question 5

Clinical Forms- Symmetric Polyarthritis

Answer 5

• most common form (25-50% Pts)
• c.f. RA -> usually milder with less deformity; may evolve from asymmetric form
• F>M
• Symmetric joint involvement commonly affecting >4 joints
• Commonly affects: fingers and toes
• Also : wrists, elbows, & ankles
• Can be severe & disabling -> joint deformity
• May have prominent nail involvement
• Swelling of digital tuft
• Severe Psoriasis associated

Question 6

Clinical Forms- DIP Dominant Peripheral Arthritis

Answer 6

• less common
• M>F
• DIPs in fingers, toes
• Nail and skin changes are common / prominent
• Nail Pitting: ice pick-like depressions
• Nail ridging
• Nail splitting
• Nail discoloration (yellow / orange)
• Onycholysis: separation of nail from the nail bed

Question 7

Clinical Forms- Axial Arthritis

Answer 7

• less common
• M>F
• asymmetric spondylitis & sacroiliitis
• Stiffness, pain & ↓ed ROM
• Structures affected
• Cx spine, Lx spine, SIJ:
• peripheral joints in the hands, arms, hips, legs and feet.
• Enthesitis is common

Question 8

Clinical Forms- Arthritis Mutilans

Answer 8

• rare
• severe, erosive, destructive, deforming arthritis
• asymmetric
• Structures affected:
• small joints (esp. DIPs) of the hands and feet;
• shortening of digits because of severe joint or bone lysis
• neck or lower back
• Enthesitis is common
• Observe exacerbations & remissions coincidental with skin flare ups.

Question 9

Common SSx- Extra Articular

Answer 9

• Mucous membrane lesions:
• Small, painless ulcers on the soft palate & tongue;
• Urethritis
• GIT Manifestations:
• Dysentery: mild recurrent abdominal complaints and of diarrhoea
• Cardiac Manifestations:
• Aortic regurgitation
• Ocular Manifestations:
• Conjunctivitis is the most common
• redness
• blurred vision
• irritation
• photophobia
• Generalised fatigue

Question 10

DDx

Answer 10

• similarities with aspects of:
• RA (but w/o Rh. nodules)
• ReA
• Gout
• presence of skin & nail lesions supports diagnosis of PsA