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Case 86

Psoriatic arthropathy

A man with painful swollen hands

This 50 year old man presented with painful swollen hands. The metallic foreign body over the right index finger is incidental, related to an old injury.

He also complained of a chronic skin complaint for which he had been under treatment for many years. His rheumatoid factor was found to be negative.

Findings

There is a widespread erosive arthropathy, particularly involving the right index and left little fingers. The erosions are marginal and poorly defined. There is relatively little osteopaenia. There is soft tissue swelling of the affected digits, so called sausage shaped digits. There is some periosteal reacton of the proximal phalanx of the left little finger. There is a pencil in cup deformity of the right index finger DIP joint.

The distribution is asymmetrical, and distal (includes the DIP joints).

Diagnosis

Psoriatic arthropathy

Discussion

Many of the features described above are the typical features of psoriatic arthropathy, the commonest of the seronegative spondarthropathies. The asymmetry and distribution are against rheumatoid arthritis, as is the negative rheumatoid factor. Periosteal reaction and lack of osteopaenia also favour psoriasis.

The patient had suffered with psoriasis of the skin for many years. Note however that the arthropathy can predate or exist without the skin changes.

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