A 52-year-old man comes to the physician with a long history of joint pain. The patient has pain and stiffness of the small joints of his hands. The symptoms are worse in the morning and can last several hours. He also has digit swelling. The patient's hands are shown in the image below: Which of the following is the most likely diagnosis?

Question

A 52-year-old man comes to the physician with a long history of joint pain.  The patient has pain and stiffness of the small joints of his hands.  The symptoms are worse in the morning and can last several hours.  He also has digit swelling.  The patient's hands are shown in the image below:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d13c_eab5_bc81_7b6e97b9a48c_MD0003_00 The clinical history and image provided are most consistent with psoriatic arthritis. Psoriatic arthritis occurs in 5%-30% of patients who have psoriasis. Psoriatic arthritis can present with many different patterns, but the classic presentation involves the distal interphalangeal (DIP) joints. Morning stiffness is present, as it is in all inflammatory arthritides. Deformity of involved joints, dactylitis ("sausage digit," a diffusely swollen finger), and nail involvement are common. This patient shows all of the classic signs: All of the fingers (particularly the left index finger) are swollen, consistent with dactylitis; many of the nails show pitting and onycholysis (separation of nail bed); and the DIP joints are prominently involved. Furthermore, well-demarcated red plaques with silvery scaling-the classic lesions of psoriasis-are seen on the dorsum of each hand. Current treatment options for psoriatic arthritis include nonsteroidal anti-inflammatory agents, methotrexate, and anti-tumor necrosis factor agents. (Choice A) Nail changes do not accompany crystalline arthritis (gout and pseudogout). Cutaneous deposits of monosodium urate occur in chronic gout. These lesions, known as tophi, most commonly occur over joints and the helix of the ear, and they may ulcerate. tophi (Choice B) Dermatomyositis can present with Gottron's papules (violaceous plaques, slightly scaly) overlying the metacarpophalangeal (MCP) joints, which at times can look similar to psoriasis. However, dermatomyositis is not associated with dactylitis or nail changes (onycholysis or nail pitting). Gottron's papules (Choice C) Enteropathic arthritis occurs in 10%-20% of patients with Crohn disease and ulcerative colitis. It most often affects the lower extremities and sacroiliac joints and tends to wax and wane with the symptoms of bowel disease. These patients have prominent gastrointestinal symptoms and other extraintestinal manifestations of inflammatory bowel disease. (Choice D) Neuropathic arthropathy (Charcot joint) most commonly affects the lower limbs. Most cases occur with diabetes, but syphilis and alcoholism are other causes. Peripheral neuropathy is believed to result in decreased proprioception, which leads to frequent trauma and eventual destruction of the joint. (Choice E) Osteoarthritis often affects the DIP joints. However, the pain of osteoarthritis is worse with activity and improves with rest (the opposite of this patient's symptoms). Osteoarthritis is noninflammatory, and dactylitis should not occur. (Choice G) Rheumatoid arthritis also presents with morning stiffness. The MCP and proximal interphalangeal joints are prominently involved, whereas the DIP joints classically are not. Dactylitis and nail involvement are also not expected in rheumatoid arthritis. (Choice H) Polyarthritis affecting the ankles and knees sometimes occurs in sarcoidosis. Sarcoidosis causes protean cutaneous manifestations, the most common of which is erythema nodosum. These patients also often have cough, chest pain, and dyspnea. erythema nodosum Educational objective: Psoriatic arthritis occurs in 5%-30% of patients with psoriasis. The classic presentation involves the distal interphalangeal joints. Morning stiffness, deformity, dactylitis ("sausage digit"), and nail involvement are common. Current treatment options for psoriatic arthritis include nonsteroidal anti-inflammatory agents, methotrexate, and anti-tumor necrosis factor agents.

A 52-Year-Old Man Comes to the Physician with a Long