Rheuma Case: 46-year-old Man with Increasing Pain/Swelling in Fingers

00:00 All right time for the third and final case.

00:05 This is a 46 year old Carpenter with a past medical history of Lyme disease.

00:09 Diagnosed and treated about three years ago who presents with “I'm getting old doc”.

00:15 He reports that he has had six months of increasing pain and swelling and the fingers of both hands, some neck pain, back pain and general malaise. Now he attributes his symptoms to 25 years of carpentry work but he's been taking time off more and more due to discomfort when he's holding his tools.

00:33 He's a nonsmoker. He does binge drink on weekends but he's been monogamous with his wife for 20 years.

00:39 Family history is non-contributory. So no help there.

00:43 In review systems he reports eczema on his elbows and scalp for the past several years, no recent GI illness or any genital urinary symptoms. Let's look at a few key points here.

00:57 So the time course here is somewhat chronic and progressive whatever is going on is really sounds like it's been going on for the past six months.

01:05 Even if he has a baseline of some osteoarthritic kind of stuff, the pattern of joint involvement, it's a little tricky to tell right now.

01:13 He's got some fingers involved and maybe neck pain but I still can't quite tell which joints are involved.

01:18 If it's symmetric or asymmetric. We're going to need a physical exam to highlight that one.

01:22 Same thing with joint inflammation we're going to need a physical exam and systemic involvement.

01:27 It doesn't sound like it based on the review of systems but I think we need some more information.

01:32 So here's our physical exam. He's a febrile, heart rate 72 blood pressure looks okay. He appears older than his stated age but he's a no Q distress, no lymphadenopathy.

01:44 He has a four by three centimeter Erythematosus patch with scale on the right frontal parietal scalp area.

01:54 In addition on his musculoskeletal exam, we see warmth and swelling in multiple fingers on both hands.

02:00 Most notably at the DIPs more so than in the PIPs with diffuse swelling of his left index finger shown here which appears shorter than the right index finger.

02:13 No wrist involvement. He has some decreased neck range of motion.

02:16 Importantly, we did a Schober test again looking for ankylosing spondylitis which was negative. Skin and nails reveal multiple nail pits to most of his fingernails with some evidence of Onycholysis as well as the left second and third digits.

02:31 He also has erythema dispatches with scale noted to his bilateral elbows.

02:36 I guess that's what he was calling eczema and also around his Umbilicus.

02:41 This picture shown here on the right by the way shows a classic finding called Dactylitis which is diffuse finger swelling or could have also involved the toes.

02:50 We'll talk more about that in a moment.

02:53 So just some representative photos of what could be going on with our patient.

02:57 The first image here on the left shows what could be scalp Psoriasis.

03:00 We're seeing some Erythema and plaque formation around where the hair follicles are.

03:06 The middle image there shows some Erythematous patches with a little bit of silvery scale which would be pretty consistent with plaque psoriasis. Moving over to the far right we see a short arrow showing nail pitting and then the longer arrow is showing Onycholysis or separation of the nail plate from the nail bed.

03:25 Alright, so let's jump into some laboratory data.

03:28 White counts okay, mild anemia, ESR is borderline, CRP is normal and his rheumatoid factor is positive but at very low levels, ATCCP is negative which helps us to steer away from rheumatoid arthritis ANA is negative which takes lupus off the table and lyme serologies importantly are just showing past infection.

03:51 Now as I mentioned before, we can definitively say the pattern of joint involvement is asymmetric and polyarticular is a lot of different joints little joints involved. There is joint inflammation.

04:01 we do think there's some systemic involvement though it appears to just be his skin.

04:07 Okay, so which of the following is the most likely diagnosis? Well, while the patient was calling the lesions on his elbows eczema, I think we can safely say that those are psoriatic plaques.

04:21 80% of patients who develop psoriatic arthritis will have had a prior history of psoriasis and he certainly seems to fit the bill for that.

04:29 So we'll have to keep this one on our list.

04:32 Next up is rheumatoid arthritis.

04:34 Well in favor of that is involvement of the hands and fingers.

04:38 He does have a loosely positive rheumatoid factor.

04:42 But against it is that rheumatoid arthritis usually involves the wrist joints and the proximal interphalangeal joints, not the DIPs which is where the predominance of his symptoms were found.

04:53 Likewise, the negative citric central native peptide is going to really help us to take rheumatoid arthritis also off of our list.

05:01 Next up is lupus. Now there's usually a nine to one ratio for favoring lupus for women and he of course is a middle aged man, he's not meeting the demographic features at all.

05:12 Moreover, he doesn't really have evidence of systemic involvement other than the skin and the skin findings he does have are not really typical of lupus.

05:20 The one exception perhaps is the lesion on his scalp could be discoid lupus, but I'm thinking it's more likely scalp psoriasis.

05:28 Most importantly, a negative ANA takes lupus off our list.

05:33 Next up Lyme disease. Now he had negative Lyme serologies, or at least those that only showed past infection.

05:40 There is this concept of a post Lyme disease syndrome characterized by persistent fatigue, headaches, arthralgias but it very, very rarely would last more than six months and his infection was three years ago.

05:53 You also wouldn't have all this evidence of active inflammation going on.

05:57 So I think we can safely take that one off the list too.

06:00 Now, reactive arthritis. Well, it's supported by some features.

06:05 I mean, there's something that certainly looks like an axial Spondyloarthritis here, but we're not getting anything in the history about any antecedent GI or GU symptoms.

06:14 The writers of a case for the boards are going to include those things before giving you a case of reactive arthritis, so we can safely take that one off the list too.

06:23 Lastly, septic joint. You don't get Polly articular septic joint except under extreme circumstances. So that one right off the bat, it's gone.

06:33 All right. Again, we've used the process of elimination to identify psoriatic arthritis as our leading diagnosis.

06:40 So now let's revisit some key points in this case.