NYU Medicine Grand Rounds Clinical Vignette Julia Manasson, PGY2 November 20 th, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

27 year old woman presents with pain and stiffness in both wrists for four months. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Two years prior to current presentation the patient developed diffuse joint pain. An auto-immune work-up was performed, which was reportedly unremarkable. Her symptoms fluctuated until four months prior to presentation when the patient developed joint pain and stiffness, most notably in the wrists bilaterally. She was seen by a hand surgeon and underwent an MRI which was only significant for ganglion cysts. On presentation, she reported bilateral knee pain, left greater than right. She also reported left hand pain and diffuse swelling of the proximal interphalangeal joints, particularly the 3 rd digit. She described the pain as constant, unrelated to activity, and minimally responsive to non-steroidals. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Additional History Past Medical History: Inverse psoriasis: diagnosed at age 12, treated with topical medications (tacrolimus and steroids) Past Surgical History: Denies Social History: Denies tobacco and illicit drug use. Drinks alcohol on occasion, on average 1 drink/week. Family History: Father with psoriasis Allergies: No Known Drug Allergies Medications: Betamethasone 0.12% foam, apply topically twice daily Tacrolimus 0.1% ointment, apply topically twice daily Sertraline 150 mg by mouth daily Methylphenidate 20 mg by mouth every morning Birth control 1 tablet daily U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Physical Examination General: well appearing, no acute distress Vital Signs: T: afebrile, BP: 110/55, HR: 72 Skin: Plaques over buttocks and intergluteal crease. MSK: Diffuse tenderness to palpation of proximal interphalangeal joints. The left 3rd interphalangeal joint notable for swelling and synovitis. Remainder of physical exam unremarkable. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Dactylitis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Laboratory Findings CBC: WBC 8.5, Hb 12.2, Plt 214 BMP: Unremarkable, BUN 10, Cr 0.67 Hepatic panel: Unremarkable Erythrocyte sedimentation rate: 23 C-reactive protein: 4.3 Rheumatoid factor: 4.6 Anti-cyclic citrullinated peptide IgG/IgA: 5 HLA: A*29:KBF Quantiferon: Negative Hepatitis B: Immune Hepatitis C: Negative U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Other Studies Bilateral hand/wrist x-ray: -No acute fracture or dislocation. -Joint spaces and alignment are maintained. -Focal soft tissue swelling about the proximal interphalangeal joint of long finger, most pronounced along the ulnar aspect, within the spectrum of sausage digit. -Soft tissues are otherwise unremarkable. Bilateral foot x-ray: -Unremarkable U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Hand X-ray U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS PA Lateral

Wrist XR U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS AP Lateral

Foot XR U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS AP R Lateral L Lateral

XR Descriptions Bilateral hand/wrist XR: - No acute fracture or dislocation. - Joint spaces and alignment are maintained. - Focal soft tissue swelling about the proximal interphalangeal joint of long finger, most pronounced along the ulnar aspect, within the spectrum of sausage digit. - Soft tissues are otherwise unremarkable. Bilateral foot XR: - Unremarkable U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Given the patient’s prior history of psoriasis, new complaints of joint stiffness and pain, physical exam, and imaging studies, the patient was diagnosed with psoriatic arthritis. Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

Patient was started on Methotrexate 10 mg weekly and Folic acid 1 mg daily. Plan was to uptitrate the dose of Methotrexate as tolerated while monitoring labs. If no response within 3 months, the patient would need to be started on a TNF inhibitor. Treatment U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS