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Short Case
Ahmed EL-Belasy
MSc Rheumatology
Alexandria University
Egypt
Personal History
• 27 years old , housewife.
• complaining of
o Pain and swelling of right wrist and small joints of

both...
Present History
• Condition started 5 month ago by gradual onset of pain
, swelling of small joints of both hands and righ...
Present History
• 3 month later the condition progressed to include
pain and swelling of both wrist joints , MCPs , PIPs o...
Drug History
• Diclofenac 150mg MR Tab

Past History
• No Hypertension
• No DM

once/day

orally
Family History
• Parents : negative consanguinity.
• Irrelevant family history.
Examination
• General condition is good
• Vital signs :
o Pulse : 78 / min regular equal on both sides
o B.P : 120/ 80 mmh...
Examination
• Head and neck:
o Clinically free

• Chest examination:
o Clinically Free.

• Heart :
o Clinically Free.

• A...
Joints Examination
• Tenderness of :
o Bilateral Wrist

joints.(swelling)
o Bilateral MCP joints.

o Bilateral PIP joints....
Laboratory Investigations:
Routine
Investigations
Hb : 11.2 gm
WBC: 5,300

PLT: 279.000
S.Creatinine: 0.8 mg/dl (N. 0....
Laboratory Investigations:
Serum Uric acid : 4.0 mg/dl( normal 2-6 mg/l)

C – Reactive protein (CRP): 20 mg/l ( normal :...
Laboratory Investigations:

ANA (ELISA) : Positive 45 ( normal 25 unit/ml )
ACPA (Anti CCP) : Negative 12 ( normal : 20 ...
Diagnosis
Sero-Negative
Rheumatoid
Arthritis
• Me t h o t r e x a t e

i n j e c t i o n

20 m g / w e e k S .C
• F o l i c a c i d 1 mg
o f

i n t h e f o r m

2 t a ...
3 Month Later ….
Follow up visit
o Joint complain improved.
o She started complaining about her nails

and

asked

medications?

if

it

is...
Her nails affection was suspected
as a psoriatic lesion.

She was referred to a Dermatologist.
Psoriatic Arthritis
Clinical presentations
of
Psoriatic skin lesions
Common sites affected by psoriasis
• Can affect any
part of the body
–
typically
scalp, elbow, kne
es and sacrum

1. Mente...
Classic Psoriasis
o Well-defined and sharply

demarcated
o Round/oval-shaped
lesions
o Usually symmetrical
o Erythematous,...
Types of psoriasis
• Chronic plaque
• Guttate
• Flexural

• Erythrodermic

• Pustular
o Localised and generalised

• Local...
Chronic plaque psoriasis
o Most

common

type

–

affects approximately 85%
o Features pink, well-defined
plaques with sil...
Chronic plaque psoriasis
Chronic plaque psoriasis
Chronic plaque psoriasis
Guttate psoriasis
o Numerous and small
lesions – 1 cm diameter
o Pink with less scale than
plaque psoriasis

o Commonly fo...
Flexural psoriasis
o Lesions in skin folds

o Particularly
groin, gluteal
cleft, axillae and
submammary
regions.
o Often m...
Erythrodermic psoriasis
o Generalized erythema
covering entire skin
surface
o May evolve slowly from
chronic plaque psoria...
Pustular psoriasis
o Two forms:
• Localized form
• More common
• multiple small pustules
on palms and soles
• Generalized ...
Palmoplantar psoriasis
o Can be
hyperkeratotic or
pustular
o Possibly aggravated
by trauma

1. Dermatology Expert Group. T...
Scalp psoriasis
o Varies from minor

scaling with erythema to
thick hyperkeratotic
plaques
o May extend beyond
hairline
o ...
Nail psoriasis

o Can take several forms:
• Pitting: discrete, well-circumscribed depressions on nail surface.
• Subungual...
Nail psoriasis
Nail psoriasis
No need for a
Dermatologist then
?
You will always need
my knowledge & I will
prove it to you
Localised patches/plaques

Tinea corporis

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

...
Localised patches/plaques

Discoid eczema
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

P...
Localised patches/plaques
o Superficial basal cell
carcinoma/Bowen’s
disease

Bowen’s disease

Psoriasis

1. van de Kerkho...
Localised patches/plaques
o Seborrhoeic dermatitis

Dermatitis
1. Marks R et al. Dermatology within the pharmacy. Australi...
Localised patches/plaques

Psoriasis
Mycosis fungoides
1. Fry L. An atlas of psoriasis. Spain: Taylor & Francis, 2004. 2. ...
Want more ?
Guttate psoriasis

< Psoriasis

^ Pityriasis rosea

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Press...
Guttate psoriasis

< Psoriasis

^ Secondary syphilis

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Pre...
Flexural psoriasis

< Psoriasis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
2. Fischer, ...
Palmoplantar psoriasis
o Tinea manum

Tinea corporis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Pres...
Palmoplantar psoriasis
o Hand and foot eczema

Eczema

Psoriasis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford:...
Take Home Message
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
Short case Rheumatoid Arthritis or Psoriatic Arthritis ?
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Short case Rheumatoid Arthritis or Psoriatic Arthritis ?

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Case Diagnosed as Rheumatoid Arthritis .. Turned to be Psoriatic Arthritis.

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Short case Rheumatoid Arthritis or Psoriatic Arthritis ?

  1. 1. Short Case Ahmed EL-Belasy MSc Rheumatology Alexandria University Egypt
  2. 2. Personal History • 27 years old , housewife. • complaining of o Pain and swelling of right wrist and small joints of both hands of 5 month duration .
  3. 3. Present History • Condition started 5 month ago by gradual onset of pain , swelling of small joints of both hands and right wrist. • She had medical treatment ( NSAIDs ) with no improvement.
  4. 4. Present History • 3 month later the condition progressed to include pain and swelling of both wrist joints , MCPs , PIPs of both hands and bilateral ankle joint pain. • She has morning stiffness lasting for ½ hour. o There was no fever. o No ocular manifestations. o No chest or cardiac complains.
  5. 5. Drug History • Diclofenac 150mg MR Tab Past History • No Hypertension • No DM once/day orally
  6. 6. Family History • Parents : negative consanguinity. • Irrelevant family history.
  7. 7. Examination • General condition is good • Vital signs : o Pulse : 78 / min regular equal on both sides o B.P : 120/ 80 mmhg o Temp : 36.8 C o R.R : 18/ min
  8. 8. Examination • Head and neck: o Clinically free • Chest examination: o Clinically Free. • Heart : o Clinically Free. • Abdomen: o Clinically Free. • Neurologically : o clinically Free • Skin lesions: o Clinically free
  9. 9. Joints Examination • Tenderness of : o Bilateral Wrist joints.(swelling) o Bilateral MCP joints. o Bilateral PIP joints. o Bilateral ankle joints. Tender swollen joints. Tender joints. o ROM is limited due to pain.
  10. 10. Laboratory Investigations: Routine Investigations Hb : 11.2 gm WBC: 5,300 PLT: 279.000 S.Creatinine: 0.8 mg/dl (N. 0.5-1.2) SGPT: 49 U/L (N. up to 65 ) SGOT: 31 U/L (N. up to 37 )
  11. 11. Laboratory Investigations: Serum Uric acid : 4.0 mg/dl( normal 2-6 mg/l) C – Reactive protein (CRP): 20 mg/l ( normal : 6 mg/l) ESR: 60 - 97 mm/hr Rheumatoid factor (Latex): Negative 8 ( normal : 16 units/l)
  12. 12. Laboratory Investigations: ANA (ELISA) : Positive 45 ( normal 25 unit/ml ) ACPA (Anti CCP) : Negative 12 ( normal : 20 unit/ml )
  13. 13. Diagnosis Sero-Negative Rheumatoid Arthritis
  14. 14. • Me t h o t r e x a t e i n j e c t i o n 20 m g / w e e k S .C • F o l i c a c i d 1 mg o f i n t h e f o r m 2 t a b l e t s 500 u g /d a y • L e f l u n o m i d e 20m g o n c e d a i l y o r a l l y t a b l e t
  15. 15. 3 Month Later ….
  16. 16. Follow up visit o Joint complain improved. o She started complaining about her nails and asked medications? if it is related to the
  17. 17. Her nails affection was suspected as a psoriatic lesion. She was referred to a Dermatologist.
  18. 18. Psoriatic Arthritis
  19. 19. Clinical presentations of Psoriatic skin lesions
  20. 20. Common sites affected by psoriasis • Can affect any part of the body – typically scalp, elbow, kne es and sacrum 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  21. 21. Classic Psoriasis o Well-defined and sharply demarcated o Round/oval-shaped lesions o Usually symmetrical o Erythematous, raised plaques o Covered by white, silvery scales 1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  22. 22. Types of psoriasis • Chronic plaque • Guttate • Flexural • Erythrodermic • Pustular o Localised and generalised • Local forms o Palmoplantar o Scalp o Nail (psoriatic onychodystrophy) 1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Rossi S, ed. Australian medicines handbook. Adelaide: AMH, 2010.
  23. 23. Chronic plaque psoriasis o Most common type – affects approximately 85% o Features pink, well-defined plaques with silvery scale o Lesions may be single or numerous o Classically elbows, knees, affects buttocks and scalp 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.
  24. 24. Chronic plaque psoriasis
  25. 25. Chronic plaque psoriasis
  26. 26. Chronic plaque psoriasis
  27. 27. Guttate psoriasis o Numerous and small lesions – 1 cm diameter o Pink with less scale than plaque psoriasis o Commonly found on trunk and proximal limbs 1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 4. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
  28. 28. Flexural psoriasis o Lesions in skin folds o Particularly groin, gluteal cleft, axillae and submammary regions. o Often minimal or absent scaling 1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912.
  29. 29. Erythrodermic psoriasis o Generalized erythema covering entire skin surface o May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon o Relatively uncommon 1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
  30. 30. Pustular psoriasis o Two forms: • Localized form • More common • multiple small pustules on palms and soles • Generalized form • Uncommon • widespread pustules across inflamed body surface 1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Griffiths CEM et al. Psoriasis. In: Burns T et al., eds. Rook’s textbook of dermatology. 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
  31. 31. Palmoplantar psoriasis o Can be hyperkeratotic or pustular o Possibly aggravated by trauma 1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  32. 32. Scalp psoriasis o Varies from minor scaling with erythema to thick hyperkeratotic plaques o May extend beyond hairline o Patient scratching may produce asymmetric plaques 1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  33. 33. Nail psoriasis o Can take several forms: • Pitting: discrete, well-circumscribed depressions on nail surface. • Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate. • Onycholysis: nail separates from nail bed at free edge. • ‘Oil-drop sign’: pink/red color change on nail surface.
  34. 34. Nail psoriasis
  35. 35. Nail psoriasis
  36. 36. No need for a Dermatologist then ?
  37. 37. You will always need my knowledge & I will prove it to you
  38. 38. Localised patches/plaques Tinea corporis 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. Psoriasis
  39. 39. Localised patches/plaques Discoid eczema 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. Psoriasis
  40. 40. Localised patches/plaques o Superficial basal cell carcinoma/Bowen’s disease Bowen’s disease Psoriasis 1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  41. 41. Localised patches/plaques o Seborrhoeic dermatitis Dermatitis 1. Marks R et al. Dermatology within the pharmacy. Australia: Department of Dermatology, St Vincent’s Hospital, 1998. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. Psoriasis
  42. 42. Localised patches/plaques Psoriasis Mycosis fungoides 1. Fry L. An atlas of psoriasis. Spain: Taylor & Francis, 2004. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  43. 43. Want more ?
  44. 44. Guttate psoriasis < Psoriasis ^ Pityriasis rosea 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 50
  45. 45. Guttate psoriasis < Psoriasis ^ Secondary syphilis 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 51
  46. 46. Flexural psoriasis < Psoriasis 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Fischer, G. How to treat: atopic dermatitis. Australian Doctor. 16 April 2010: 29–36. ^ Atopic eczema 52
  47. 47. Palmoplantar psoriasis o Tinea manum Tinea corporis 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. Psoriasis 53
  48. 48. Palmoplantar psoriasis o Hand and foot eczema Eczema Psoriasis 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 54
  49. 49. Take Home Message

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