Arthritis Mutilans in a Patient with Psoriasis - PDF Document

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  1. International Journal of Science and Research (IJSR) ISSN (Online): 2319-7064 Index Copernicus Value (2016): 79.57 | Impact Factor (2017): 7.296 Arthritis Mutilans in a Patient with Psoriasis Dr. E. Archana1, Dr. N. Jeeva2, Dr. S. Prasanth3 1Postgraduate, Department of General Medicine, Vinayaka Mission’s Research Foundation–Deemed To Be University, Vinayaka Mission’s Medical College & Hospital, Karaikal 2Professor& Unit Chief, Department of General Medicine, Vinayaka Mission’s Research Foundation–Deemed To Be University, Vinayaka Mission’s Medical College & Hospital, Karaikal 3Postgraduate, Department of General Medicine, Vinayaka Mission’s Research Foundation–Deemed To Be University, Vinayaka Mission’s Medical College & Hospital, Karaikal Abstract: Psoriatic arthritis is a seronegative spondyloarthropathy occurring in 7 -10% of patients with psoriasis. Arthritis mutilans is a rare and severe form occurring in 3 to 5 % of psoriatic arthritis. It is an aggressive, progressive and destructive form of arthritis involving small joints of hand and foot ,ending in severe joint deformity thereby causing disability. Here we report a case of 72 year male patient with psoriatic skin lesions of 10 years duration not on treatment, now presented with classical “opera glass hands”(3) - telescoping finger deformity, the hall mark of arthritis mutilans. Patient also has systemic hypertension. Keywords:Psoriasis; Psoriatic Arthritis; Arthritis Mutilans 1.Introduction Psoriatic arthritis is a chronic inflammatory arthritis with the incidence of 7-10% in psoriatic patients. Usually psoriatic skin lesions precede arthritis. In 15 -20% arthritis can occur prior to skin disease. Nail changes are seen in 90% psoriatic arthritis(1). Arthritis mutilans is a severe form of progressive and destructive arthritis involving usually small joints of hand and foot. It can occur in psoriasis as well as in rheumatoid arthritis. In psoriatic arthritis mutilans, rheumatoid factor will be negative. 2.Case report A 72 years male, nondiabetic, hypertensive of 1 year duration and skin lesions of 10 years duration now presented with the complaints of paniful swelling and shortening of the digits in both hands. On general examination his BP was 200/110mmhg and he was having extensive skin lesions in the form of erythematous squamous plaque with silvery white scales over bilateral extensor aspect of the forearm and hand,bilateral gluteal region,bilateral lateral aspect of thigh ,umbilicus and scalp. On examination of hand: Sausage digits (swelling of the entire digit) in middle finger of both hands, Flexion deformity of the hand - telescoping appearance,” opera glass hands”-The hallmark sign of arthritis mutilans in the hand. Other systems were clinically normal. The following investigations were done Investigation Urine Routine TC ESR Urea Creatinine LFT URIC ACID Rheumatoid factor CRP ANTI-CCP Serum Electrolytes Lipid Profile Chest X Ray PA ECG LVH WITH STRAIN pattern. Echo Concentric LVH, grade 1 diastolic dysfunction, EF-55%. X Ray Hand narrowing, articular surface irregularity. MRI LS Spine Lumbar degenerative disc disease, bilateral Result Normal 8700cells/cubmm3 4/10mm 39 1.1 Normal 4.8mg/dl Negative Negative Negative Normal Normal Normal study Bilateral subchondral sclerosis, joint space sacro ilitis. Diagnosis was made as psoriatic arthritis mutilans with hypertension. Patient was started on T.Methotrexate 7.5 mg weekly once and T.Losartan 50mg BD. His BP was controlled. He was discharged Rheumatologist for expert management. 3.Discussion This patient had erythymatous squamous plaques with silvery white scales over bilateral extensor aspect of the forearm and hand,bilateral gluteal region, bilateral lateral and referred to Painful swelling of all proximal interphalyngeal joints, shortening of ring and little finger of both hands, Pitting of nail in all fingers, Multiple transverse skin folds over the digits, Volume 7 Issue 7, July 2018 www.ijsr.net Licensed Under Creative Commons Attribution CC BY Paper ID: ART20183961 DOI: 10.21275/ART20183961 778

  2. International Journal of Science and Research (IJSR) ISSN (Online): 2319-7064 Index Copernicus Value (2016): 79.57 | Impact Factor (2017): 7.296 [2]The Heart in Systemic Autoimmune DiseasesF. Atzeni∗, ...P. Sarzi-Puttini||, in Autoimmune Diseases, 2017 [3]Arthritis mutilans in a patient with psoriasis Mubina gaffer. [4]Arthritis Mutilans: A Case Report, Ashfaq ul Hassan1*, Farah Sameem2, Qazi Masood Ahmad3 and Ghulam Hassan4 1Department of Anatomy, SKIMS Medical College, Bemina Srinagar, Kashmir, India. 2MD Dermatology, SMHS Hospital Srinagar, Kashmir, India. 3MD Dermatology, Prof and Head, SMHS Hospital Srinagar, Kashmir, India. 4MS, Al Qassim University, Buraiadah, Saudi Arabia Author Profile Dr. E. Archana is Postgraduate, Department of General Medicine, Vinayaka Mission’s Research Foundation –Deemed to Be University, Vinayaka Mission’s Medical College & Hospital, Karaikal aspect of thigh ,umbilicus and scalp. This is consistent with the diagnosis of psoriasis because of the nature and site of the lesion. The incidence of psoriatic arthritis is 7-10% among psoriatic patients. There are five clinical subsets of psoriatic arthritis(1) namely asymmetric oligoarthritis, spondylitic polyarthritis(incidence DIP(15%),spondylitis and sacroilitis(20 -40%),arthritis mutilans(3-5%).There is a link between HLA B27 carrier state and spondylitic form of psoriatic arthritis. In arthritis mutlilans there is severe inflammation and marked destruction of cartilage and bone damaging the joints of hand and feet resulting in deformities. It can also affect spine. Osteolysis of phalynges with soft tissue collapse results in shortening of the digits and the excess skin causes transverse folds. The appearance of short fingers with transverse skin folds is called as “opera glass hand” or telescoping finger, which is considered as phenotype of arthritis(3) mutilans. In addition to this, dactylitis and sausage digits(swelling of the entire digit) is also a classical picture of arthritis multilans(3). In our patient there was opera glass hand deformity and also sausage digit. Pencil in cup deformity is a classical radiological sign in psoriatic arthritis(1) which is due to bone proliferation at base of distal phalanx with tapering of proximal phalanx. Incidence of sacroilitis is 10 – 25% in moderate to severe psoriasis(4). In our patient there was bilateral sacroilitis. Nail changes is common in 90% cases of psoriatic arthritis(1) which was present in our case in the form of pitting nail. Arthritis mutilans can occur in psoriasis and also in RA. Dactylitis, spondylitis, sacroilitis are common in psoriatic arthritis rather than RA(3). In our patient absence of rheumatoid factor and presence of dactylitis, sacroilitis and pitting nails confirm the diagnosis of psoriatic arthritis mutilans. Our patient is having systemic hypertension and ECG revealed LVH with strain pattern and echo shows concentric LVH and diastolic dysfunction. Psoriatic arthritis itself is a potential risk factor for cardiovascular disease and so patient should be screened for involvement(2) .High prevalence of macrovascular disease, endothelial dysfunction, arterial stiffness and left ventricular diastolic dysfunction in psoriatic arthritis patient without any clinically evident signs of artherosclerosis or its complications.(2) 4.Conclusion This case, Psoriatic arthritis mutilans is reported because of its rarity. As it is a progressive and destructive arthritis resulting in deformity and persistent disability, we emphasise the early diagnosis, proper treatment and regular follow up is needed in all psoriatic patients for prevention or early detection of arthritis mutilans. They should also be screened for cardiovascular disease because of its high prevalence in psoriatic arthritis. References [1]HARRISON’S Principles of Internal Medicine 19th edition. Kasper, fauci, hauser, longo, jameson, loscolzo. Handbook of Systemic 40 %),predominant subclinical cardiovascular Volume 7 Issue 7, July 2018 www.ijsr.net Licensed Under Creative Commons Attribution CC BY Paper ID: ART20183961 DOI: 10.21275/ART20183961 779