Weekly Case

Title : Case 664

Age / Sex : 28 / F


Chief complaint :


Erythematous painful swelling on Lt. 4th finger, scaly silvery erythematous plaque on whole body


What is your diagnosis?

Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).


Courtesy : 강우영, Kang Woo Young, 고려대학교 구로병원, Korea University Guro Hospital


Diagnosis:

Psoriatic arthritis



Discussion


Findings:


HAND PA and oblique radiograph shows soft tissue swelling, lack of osteoporosis, joint space narrowing, bony erosion, adjacent irregular bony proliferation and periostitis at 4th DIP joint of left hand.


 


Differential Diagnosis:


Other seronegative spondyloarthropathies (AS, reactive arthritis)


Rheumatoid arthritis


Erosive osteoarthritis


 


Discussion:


Psoriatic arthritis is an inflammatory arthritis that occurs in 10 to 15% of people with psoriasis. Although arthritis can coincide or antedate skin disease, the characteristic rash commonly precedes joint disease by months or years. Histocompatibility typing in patients with psoriatic arthritis has revealed a 25 to 60% incidence of HLA-B27 antigen.


Psoriatic arthritis can affect synovial and cartilaginous joints and sites of tendon and ligament attachment to bone in both the appendicular and the axial skeleton. The most typical sites of abnormality are the interphalangeal joints of the hands and foot, MCP and MTP joint, calcaneus, sacroiliac joint, and spine.


The characteristics radiographic findings of psoriatic arthritis are:


 . Enthesitis


. Bony erosion: “mouse–ear” (marginal bone erosions with adjacent irregular bone proliferation), "pencil-in-cup" deformities (protrusion of a blunted and distorted osseous surface into an adjacent expanded one)


 . Periostitis


. Joint subluxation or interphalangeal ankylosis


. Arthritis mutilans


. Ivory phalanx involving the distal phalanx of the great toe


. Sacroiliitis: often asymmetrical


. Spondylitis: asymmetric paravertebral ossifications and relative sparing of the facet joints


 


References:


Resnick, Bone and Joint Imaging, 3rd edition.


Jacobson JA, Girish G, Jiang Y, Resnick D. Radiographic evaluation of arthritis: inflammatory conditions. Radiology. 2008 Aug;248(2):378-89.


Klecker RJ, Weissman BN. Imaging features of psoriatic arthritis and Reiter’s syndrome. Semin Musculoskelet Radiol. 2003 Jun;7(2):115-26.


 



Correct Answer
Total applicants 32 Correct answers 31
Name Institution
김기욱 국군수도병원, 전문의
전인환 전문의
이연옥 선한목자병원, 전문의
여현정 전문의
윤유성 순천향대 부천병원, 전문의
이진영 전문의
강지희 전문의
최형인 군의관, 전문의
이혜란 전문의
김형민 연세의대 강남세브란스병원, 전문의
노지훈 중앙보훈병원, 전공의
김동언 국군양주병원, 전문의
김현진 서울성모병원, 전공의
이규정 고대안암병원, 전문의
이현규 전문의
이현규 전문의
조영민 전문의
조영민 전문의
조영민 전문의
조영민 전문의
손우곤 양산부산대학교병원, 전공의
임병수 전공의
박준동 마이크로병원, 전문의
김성진 365병원, 전문의
현혜란 인천사랑병원, 전문의
윤소진 분당서울대병원, 전문의
임윤진 전공의
권기언 서울아산병원, 전문의
한유비 전문의
백승진 분당차병원, 전공의
김성윤 전문의
Semi-Correct Answer
Total applicants 32 Semi-Correct answers 1
변성환 전공의


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