Case 2: 26-Year-Old Woman With PsA

Anthony M. Turkiewicz, MD: Another case, case number 2. We’ll have Sheetal run this one. A 26-year-old female coming in with a near history of pain in multiple joints. Pain started in the knees with some mild intermittent swelling, a fairly insidious onset of pain, and then over the next 2, 3 months, it migrated to involve the symmetric ankles, elbows, feet, and shoulders. She complained of some persistent inflammatory low back pain—so they actually call out inflammatory low back pain—associated with morning stiffness going on for about 2 hours. Then for the past month before coming, she has developed these lesions that seem to spare the face, the palms, and the soles. She complained of some fever and fatigue. On exam, she had some mild knee tenderness with some mild swelling, MCP [metacarpophalangeal joints], PIP [proximal interphalangeal joint], pretty diffuse involvement. They don’t talk much about the skin exam, but we’ll assume that the lesions are where they said they were. Routine blood testing, the CBC [complete blood count], comprehensive metabolic panel were normal. CRP [c-reactive protein], SED [erythrocyte sedimentation] rate was elevated, RF [rheumatoid factor] was negative. The only imaging result we have thus far is a hand radiograph that showed right second PIP erosion, and then right fifth PIP fixed flexion deformity. We have intermittent history of exam here, but that being said, initial impressions, testing, then of course looking at the fatigue part of this as well. Give me some thoughts on how you would start approaching this patient.

Sheetal Desai, MD: If I’m pretending a fellow is presenting this patient and coming out of the room, I would say, it’s a young female, 26-year-old, around the age that we would see psoriatic arthritis about, close to 30 years old, 30 to 50, 1 to 1. Even though the last case was female and she’s female, we see it with equivalent levels in both men and females. The arthritis has been going on for some time. We have a chronic arthritis that has an inflammatory component, symmetric polyarticular arthritis, like the old Moll and Wright criteria would be RA [rheumatoid arthritis] -like in this situation. She also has inflammatory back pain with prolonged morning stiffness. This patient has psoriasis only over the last month, but I guess she’s had a year history of inflammatory arthritis. I would focus on how psoriasis does precede the majority of patients who get psoriatic arthritis approximately 70% of the time, but in a minority of patients, 15% of them, the psoriasis and the arthritis can present simultaneously, and then in another 15%, you can get the psoriasis after they have the inflammatory arthritis.

She has significant fatigue. She is CR negative, rheumatoid factor, has elevation in her inflammatory markers, and after 1 year of disease, she has an erosion seen on radiograph, and has ankylosis. It’s concerning to me that this is somewhat of a rapid progressor with significant polyarticular symmetric psoriatic arthritis with a good amount of progression. I would feel comfortable with the diagnosis of psoriatic arthritis here. For further testing, I’d recommend some imaging of her sacroiliacs, of her spine if she complains of any other areas like cervical disease just to get an idea if we can find inflammation and finding sacroiliitis.

When it comes to the treatment regimen we would recommend, it would be reviewing the domains involved. Her domains involved are her peripheral arthritis, she has axial involvement, she has skin involvement. She has no mention, at least in this stem that I’m reading right here, of dactylitis or enthesitis, although I find that unless you go looking, you won’t find it. I find the more I look for enthesitis, the more I find enthesitis. But currently, the domains based on the stem we have are peripheral joint, axial inflammation, and skin. There’s no mention made of nail changes. It would be going along the lines of agents that would work in these areas. Because we have axial involvement, we would be straying away from the conventional synthetic DMARDS [disease modifying anti-rheumatic drugs]. In this patient we would be looking at a combination of, for her arthritis, possibly NSAIDs [nonsteroidal anti-inflammatory drugs] plus a biologic, but for her skin disease, it would be the biologic. The biologics that I would consider here, I’m not reading any concerning features of demyelination as a comorbidity or inflammatory bowel disease symptoms, but we do need to ask them if they have any diarrhea, mucus, or blood in their stools on a frequent basis. If she doesn’t, then I would be open to anything along the lines from a TNF [tumor necrosis factor] or an IL-12/23, an IL-23, IL-17. There’s nothing that’s stopping me from consideration. One would argue that given her axial involvement, though, maybe we would put the TNF and possibly even the IL-23 family a bit higher than the other families.

Anthony M. Turkiewicz, MD: They call out the fatigue as well. There’s some consideration, but they all do a good job. It’s interesting that they call that out.

Sheetal Desai, MD: Right, this is how I think through it. It’s nice that we have some data on the IL-23 MOA [mechanism of action] with the guselkumab [Tremfya] with fatigue. My hope, as Len said, that we’ll start to look at some of these more patient important metrics in the future clinical trials in PsA [psoriatic arthritis].

Anthony M. Turkiewicz, MD: Excellent.

Ana-Maria Orbai, MD, MHS: Can I add something?

Anthony M. Turkiewicz, MD: Please.

Ana-Maria Orbai, MD, MHS: This case is nice because it asks the question of how would you differentiate her pain and fatigue from fibromyalgia? This is important. This patient, this woman clearly has inflammatory disease. She has clinically inflamed joints, she has elevated inflammatory markers, I would say that even if she has overlapping fibromyalgia, this is not so relevant because it’s not going to influence my choice of therapy. It can complicate measuring improvement down the road, but I don’t think that this would be particularly relevant at the first visit because she would also be in pain and fatigued due to her active disease.

Sheetal Desai, MD: Thank you for highlighting that, Ana-Maria. I agree with you. In this situation, differentiating the pain and fatigue from her inflammatory conditions vs fibromyalgia is clearer because she has a clear inflammation that becomes much grayer when they don’t have much inflammation on exam and then they have these metrics and you’re trying to figure out what it is. Len, were you saying something?

Leonard H. Calabrese, DO: Yes. I would only add, in fact I agree with everything, it’s a first visit and you know how you’re going to start this therapy. She probably has fibromyalgia and that may become more important down the line as Ana-Maria said. I would get more aggressive earlier in sorting out this inflammatory back pain and whether this is like the pseudo fibromyalgia of spondyloarthritis that we’re trying to understand in young women. Maybe she has a mixed picture of this. Obviously, we’d start with a pelvis film and maybe somewhere down the line, if it was negative, get MR [magnetic resonance] imaging of this. But I agree with everything otherwise. Right now, she has clearly inflammatory disease and needs to be treated.

Anthony M. Turkiewicz, MD: First off, sometimes when you see this much of inflammation in a particularly young patient, female or male for that matter, and they do describe IBP, inflammatory back pain, that well, I start believing it more, which is not necessarily fair. You almost start reading into the most subtle changes on the radiograph that you might not otherwise. But, with what’s going on peripherally, we need to be thinking fast that she’s going to be needing something beyond just most likely a conventional DMARD. But I agree, there’s a lot on the checklist to do that first visit, but, at a minimum, getting a radiograph of the sites.

Transcript Edited for Clarity