A 47-year-old man comes to the office due to several months of worsening pain, stiffness, and swelling of the bilateral wrists and hand joints. The symptoms are worse in the morning or after prolonged rest and gradually improve with continued use. He also has had occasional pain in the ankles and low back, which he attributes to working in the construction industry for many years. The patient has no significant medical history. He takes ibuprofen as needed for the pain and over-the-counter emollients for dry skin, but otherwise takes no medications. He has smoked a pack of cigarettes daily for 20 years and drinks 4 or 5 beers on weekends. Vital signs are within normal limits. Physical examination shows swelling and tenderness of the bilateral wrists and hand joints, including the distal interphalangeal joints. Nail examination findings are shown in the exhibit below. Which of the following is the most likely cause of this patient's symptoms?

Question

A 47-year-old man comes to the office due to several months of worsening pain, stiffness, and swelling of the bilateral wrists and hand joints.  The symptoms are worse in the morning or after prolonged rest and gradually improve with continued use.  He also has had occasional pain in the ankles and low back, which he attributes to working in the construction industry for many years.  The patient has no significant medical history.  He takes ibuprofen as needed for the pain and over-the-counter emollients for dry skin, but otherwise takes no medications.  He has smoked a pack of cigarettes daily for 20 years and drinks 4 or 5 beers on weekends.  Vital signs are within normal limits.  Physical examination shows swelling and tenderness of the bilateral wrists and hand joints, including the distal interphalangeal joints.  Nail examination findings are shown in the exhibit below.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d2c5_867f_bc81_598a6c2f4a74_MD0003_00 This patient has swelling and tenderness in the wrist and hand joints with significant morning stiffness, indicating inflammatory polyarthritis. Although a number of rheumatologic conditions (eg, rheumatoid arthritis, ankylosing spondylitis) can cause inflammatory polyarthritis, the presence of nail pitting and involvement of the distal interphalangeal joints (DIP) are highly characteristic of psoriatic arthritis (PA). nail pitting PA occurs in 15%-30% of patients with psoriasis and usually arises in those with long-standing psoriatic skin disease (risk is 2%-3% per annum). However, a minority of patients with PA have little (eg, dry skin) or no skin involvement at the time of diagnosis. Manifestations of PA can arise in the peripheral or axial skeleton; most patients have asymmetric oligoarthritis or symmetric polyarthritis that often (~50%) involves the DIP joints. Significant morning stiffness and improvement with use are almost always seen. Nail lesions (eg, pitting, onycholysis, hyperkeratosis, splinter hemorrhage) occur in >90% of cases and are an important diagnostic clue. Soft tissue manifestations such as dactylitis ("sausage digit") or enthesitis (inflammation of insertion points of tendons or ligaments) can also occur. (Choice A) Gout usually presents with an acute monoarthritis in the first metatarsophalangeal joint or knee. Chronic gouty arthritis can lead to polyarticular symptoms but is typically asymmetric and associated with soft tissue tophi. tophi (Choice B) Hypertrophic osteoarthropathy is a paraneoplastic syndrome associated with intrathoracic malignancy and other pulmonary diseases (eg, cystic fibrosis). Although it can cause a polyarthropathy, it is generally associated with digital clubbing and periostosis (excessive bone formation). (Choice C) Osteoarthritis commonly involves the DIP joints but manifests with bony enlargement (eg, Heberden nodes) rather than swelling. Morning stiffness is typically brief, and nail abnormalities are not seen. (Choice E) Rheumatoid arthritis typically presents with a symmetric polyarthritis and is often associated with prolonged morning stiffness, but involvement of the DIP joints and nail pitting are more consistent with PA. Educational objective: Psoriatic arthritis is common in those with long-standing psoriatic skin disease and usually presents with asymmetric oligoarthritis or symmetric polyarthritis (resembling rheumatoid arthritis). Important diagnostic clues are the involvement of the distal interphalangeal joints (present in ~50%) and characteristic nail changes such as pitting (present in >90%).

A 47-Year-Old Man Comes to the Office Due to Several