Evaluation and Management of Rheumatic Diseases: A Case-Based Review - Episode 1
Schwartzman, MD: The first patient is a 31-year-old Caucasian woman who first presented to her primary care physician with intermittent myalgias, difficulties with taking care of her child, and doing some of her normal daily activities, like cleaning a house. She did have a longstanding history of psoriasis, predominantly affecting her scalp, though it was controlled with a shampoo. A pertinent medical history component was that there was a question at one time as to whether or not she had multiple sclerosis.
On physical examination by the primary care provider, the patient did have some tenderness. This was somewhat diffuse, predominantly in the upper extremities but also affecting the right knee. She did have some swollen joints, including the PIPs of the right hand and the right shoulder.
Importantly, since she had this questionable history of MS, a neurological exam was normal. Her examination was significant enough that she had difficulty with her motion, and the limitation of motion was predominantly due to the synovitis.Otherwise, her physical exam was essentially normal.
She had imaging done revealed asymmetric, erosive changes in the swollen joints of the hands and some narrowing of the interphalangeal joints. She fits very nicely, even with just that information, into a potential diagnosis of psoriatic arthritis, and her laboratory tests supported that. She did have an elevation in her SED rate and her CRP, with a negative rheumatoid factor and ANA that was likewise negative
She easily fulfills the CASPAR classification criteria for psoriatic arthritis. Even though we’re not supposed to use that for making a diagnosis, I think that that information does provide us with the most common manifestations of psoriatic arthritis and, as such, the diagnosis was essentially clinched.
What would be the therapeutic goals for this patient? There are studies on treat-to-target in psoriatic arthritis, but in clinical practice, there isn’t an easy outcome measure that we can utilize for what I call ‘psoriatic disease because I think it’s an umbrella of different components that impacts on your treatment choices. For example, many drugs are approved for psoriatic arthritis. Some tend to do better on the skin, for example, than on the joints. We have the reverse as well.
Transcript Edited for Clarity