A 45-year-old woman is evaluated in the jail clinic for pain and swelling of her right knee. The pain started 2 weeks ago without any associated trauma. She has no fever, dysuria, vaginal discharge, or history of arthritis. She has had fatigue, poor appetite, and an unintentional weight loss of 9 kg (20 lb) over the past 6 months. Several scaly and erythematous skin lesions have also appeared during this time. She takes ibuprofen as needed. She has a 30-pack-year history of smoking, used to drink occasionally, and does not use illicit drugs. She has been in jail for 3 years.
Her vitals signs are normal. She has several white-to-yellowish flaky scales on the scalp and in the nasolabial folds. No scleral injection or oral ulcers are noted. The right knee joint has moderate-size effusion. The second toe of the left foot appears swollen with slight bluish discoloration and is slightly tender. There is a lesion on the left knee (shown below) and similar lesions on the extensor aspect of the elbows, chest, and upper back. The remainder of the physical examination is within normal limits.

The right knee is aspirated, and synovial fluid analysis is as follows:

Which of the following is most likely worsening this patient's illness?

Question

A 45-year-old woman is evaluated in the jail clinic for pain and swelling of her right knee.  The pain started 2 weeks ago without any associated trauma.  She has no fever, dysuria, vaginal discharge, or history of arthritis.  She has had fatigue, poor appetite, and an unintentional weight loss of 9 kg (20 lb) over the past 6 months.  Several scaly and erythematous skin lesions have also appeared during this time.  She takes ibuprofen as needed.  She has a 30-pack-year history of smoking, used to drink occasionally, and does not use illicit drugs.  She has been in jail for 3 years.
Her vitals signs are normal.  She has several white-to-yellowish flaky scales on the scalp and in the nasolabial folds.  No scleral injection or oral ulcers are noted.  The right knee joint has moderate-size effusion.  The second toe of the left foot appears swollen with slight bluish discoloration and is slightly tender.  There is a lesion on the left knee (shown below) and similar lesions on the extensor aspect of the elbows, chest, and upper back.  The remainder of the physical examination is within normal limits.

The right knee is aspirated, and synovial fluid analysis is as follows:

Which of the following is most likely worsening this patient's illness?

Quizplus · Accepted Answer

This patient's presentation of acute oligoarthritis with inflammatory knee effusion, dactylitis, and erythematous plaque with sliver scales on the knee is consistent with sustained and destructive psoriatic arthritis. Psoriatic arthritis is more aggressive when associated with HIV infection. It occurs with similar frequency in non-HIV patients, but more severe disease can occur in HIV-associated patients, especially those off antiretroviral therapy. NSAIDs are frequently used but are ineffective in these patients. Treatment usually involves methotrexate, sulfasalazine, or TNF inhibitors in some cases. Antiretroviral therapy may also help the psoriasis. (Choice A) Acute hepatitis B infection can present with polyarthritis and skin involvement in the lower extremities, but it is usually an eruptive urticaria or maculopapular rash. Joint disease is usually symmetrical and can involve the hands, knees, wrists, ankles, elbows, and shoulders. (Choice B) Hepatitis C infection can cause a clinical picture similar to rheumatoid arthritis. It is due to immune complex deposition resulting in mixed cryoglobulinemia with arthritis, glomerulonephritis, and vasculitis. (Choice D) Gonococcal infection can cause a septic arthritis of the knee without a rash. However, disseminated gonococcal infection usually causes diffuse pustular rash with polyarthralgias and tenosynovitis. (Choice E) Tuberculosis can affect the spine and weight-bearing joints (eg, knee) with similar synovial fluid findings. However, this patient's skin findings are not associated with tuberculosis. Educational objective: Psoriasis can be a presenting feature of HIV infection. Psoriatic arthritis is more aggressive when associated with HIV infection and can include palmoplantar involvement and nail disease. Treatment involves methotrexate, sulfasalazine, or TNF inhibitors in some cases. __________ References: HIV-associated psoriasis: pathogenesis, clinical features, and management. (http://www.ncbi.nlm.nih.gov/pubmed/20610329) Psoriasis in patients with HIV infection: from the medical board of the National Psoriasis Foundation. (http://www.ncbi.nlm.nih.gov/pubmed/19646777)

A 45-Year-Old Woman Is Evaluated in the Jail Clinic for Pain