Case of psoriatic arthritis

Psoriatic arthritis by Dr. Faridul Islam

1. Case Presentation Department of Medicine EAST west MEDICAL COLLEGE And Hospital Presented by Dr. Faridul Islam

2. Particulars of the patient: Name : Md. Hamidur Rahman Age : 35 years Sex : Male Religion : Muslim Occupation : Businessman Date and time of admission: 16/2/2017 at 9:00 am Date and time of examination: 16/02/2017 at 9:05 am

3. Chief complaints: Multiple joint pain for 2 months Multiple skin eruption for 2 years.

4. History of present illness: According to patient’s statement, he was reasonably well 2 years back since then he has been suffering from skin eruption which was multiple reddish, scaly lesions of different shapes and size involving the extensor surface of the both extremities, scalp, over the sacrum and natal cleft. The scales are dry, thick, white and in some place large sheet like. There is no oozing or discharge but there is occasional itching. He noticed bleeding over scratching of the lesion and appearance of the new lesion on the scratch area. Cont.

5. In the scalp the lesion doesn’t causes hair fall. He was treated with some topical emollients and anti-histamines as prescribed by local doctor. But the lesion recurs after some days. The lesions are gradually increasing and aren’t associated with exposer to any allergen or food or sunlight . After few days he developed multiple joint pain involving the lower limbs predominantly more marked on both knee and ankle joint. Pain is associated with swelling of the joints and marked morning stiffness. On query he also complains of nail changes but not associated with any redness of eye, oral ulceration, alopecia and alteration of bowel habit. He is a known case of hypertension, diabetes mellitus. With these complaints he admitted in this hospital for better management.

6. History of past illness: He is a known case of chronic active Hepatitis B infection. Immunization history: Immunized. Family history: Nothing significant. Personal history: Non alcoholic, non betel nut chewing. Drug history: He took anti-diabetic, anti-hypertensive and antiviral drugs regularly. Socio-economic history: He belongs to middle class family. Allergic history: Nothing significant.

7. General examination: Appearance: Ill looking Body built: average Co-operation: Co-operative Decubitus: ON choice Anemia: Absent Jaundice: Absent Cyanosis: Absent Koilonychias: Absent Leukonychia: Absent Clubbing: Absent Edema: Absent Dehydration: Absent Pulse: 76 beats/min BP: 120/70 mm of Hg Temperature: Normal Thyroid gland: Not enlarged Lymph node: Not palpable JVP: Not raised Skin condition: There are multiple well-defined, erythematous, scaly plaques with silvery white scales involving scalp, elbow, knee, sacrum and extensor surface of the both extremities. Nail: There is pitting, ridging, thinning and hyperkeratosis involving the hand and feet.

8. Systemic examination: Skin: There are multiple well-defined, erythematous, scaly plaques with silvery white scales involving scalp, elbow, knee, sacrum and extensor surface of the both extremities. “Auspitz sign”  positive . “Koebner’s phenomenon”  positive .

9. Joints: Inspections : swollen(knee and ankle joints), erythematous, restrictions of active movements, muscle wasting (Knee joints ). Palpation : Tender joint margin, restrictions of passive movements , raised temperature and patellar tap is positive .

10. Nail: There is pitting, transverse ridging, hyperkeratosis and onycholysis. Spine : Spine is normal. SI joint: Intorsion  Tender (Both SI joints) Extortsion  Tender (Both SI joints) Direct compression over sacrum  Tender SI joints Respiratory system, cardiovascular system, Alimentary system and Nervous system  Unremarkable .

11. Salient Feature : Md Hamidur Rahman 35 years businessman hypertensive and diabetic male present with the complains of multiple joint pain for 2 months and multiple whitish skin eruption for 2 years. He has been suffering from skin eruption which was multiple reddish, scaly lesions of different shapes and size involving the extensor surface of the both extremities, scalp, over the sacrum and natal cleft. The scales are dry, thick, white and in some place large sheet like. There is no oozing or discharge but there is occasional itching. He noticed bleeding over scratching of the lesion and appearance of the new lesion on the scratch area. In the scalp the lesion doesn’t causes hair fall. He was treated with some topical emollients and anti-histamines as prescribed by local doctor. But the lesion recur after some days. The lesions are gradually increasing. The lesion aren’t associated with expose to any allergen or food or sunlight. After few days he developed multiple joint pain involving the lower limbs predominantly more marked on both knee and ankle joint. Pain is associated with swelling of the joints and marked morning stiffness. Cont.

12. On query he also complains of nail changes but not associated with any redness of eye, oral ulceration, alopecia and alteration of bowel habit. On examinations, of skin there are multiple well-defined , erythematous, scaly plaques with silvery white scales involving scalp, elbow, knee, sacrum and extensor surface of the both extremities. “Auspitz sign” positive. “Koebner’s phenomenon” positive. Joints are swollen, erythematous, restrictions of active movements, muscle wasting (Knee joint), tender joint margin, restrictions of passive movements, raised temperature and patellar tap is positive. Nails are pitting, transverse ridging, hyperkeratosis and onycholysis. SI joint examination, Intorsion tender (Both SI joints),Extortion tender (Both SI joints) Direct compression over sacrum tender SI joints.

13. Provisional Diagnosis: Psoriatic arthritis with hypertension with diabetes mellitus with HBV . Investigations: 1. CBC: ESR: 120 mm in 1st hour WBC: 14000/ cumm of blood (leukocytosis) 2. CRP: Positive (+) 3. `Liver function test: Serum bilirubin: 0.6mg/dl SGPT: 28 U/L (previous  149 U/L) 4. Serum creatinine: 0.7 mg/dl

14. Serum uric acid: 3mg/dl Fating blood sugar: 4.9 mmol/L PPBS: 7.4mmol/L RA test: Negative (-) X-ray foot: Calcaneus Spur Joint space narrowing Marginal sclerosis HLA-B27: Pending HBsAg : Positive HBeAG : Negative HBV DNA: Undetected Anti HCV antibody: Negative HIV serology: Proposed

15. Ongoing Treatment: For Skin lesion: Clobetasol propionate ointment [ Dermasol ointment] mixed with coconut oil 2 times daily. Methotrexate[Inj. MTX(50mg/vial)] 2/3 rd vial I/V every Sunday for 4 weeks Loratidin [Tab. Oradin (10mg)] 1 tablet at night for 1 month Folic acid [Tab. Folison (50mg)] 1 tablet at noon On Monday Anti- histamin [Tab. Oradin (10mg)] 1 tablet at night for 1 month For Pain management: Tramadol hydrochloride [Tab Anadol (50mg)] 1tablet 8hourly after meal for 1 week Paracetamol [Tab. Napa (500mg)] 1 tablet 8 hourly SOS For diabetic: Gliclazide [ Comprid XR (30mg)] 1 tablet at morning before meal (continue) Linagliptin [ Linatab (5mg)] 1 tablet at night (continue) For hypertension: Diltiazem hydrochloride [Tab. Cardizem(90mg)] 1 tablet at night before meal (continue) Anxiolytic drug: Clonazepam [Tab. Pase (0.5mg)] 1 tablet at bed time (for 2 weeks) Antiviral Drugs: Entecavir [ Enteca (0.5mg)] 1 tab at noon after meal

16. THANK YOU