A.

CASE SUMMARY

Pn. Rosni. A 53 years old Malay lady with underlying hypertension, dyslipidemia, ischemic heart
disease and psoriasis presented with right knee pain and swelling 8 day prior to admission. The pain
occurs sudden in onset, throbbing and continuous in nature, associated with minimal swelling over
right knee joint. The pain and swelling progressively become worse as she unable to ambulate 2 day
after the initial onset, with radiating pain up to right ankle and foot region, with pain score initially
7/10 increase to 10/10. The swelling however does not increase in size. The pain relieved by taking
painkiller and resting, and exacerbate by standing or movement. It is associated with fever for 1
week duration. She had go to clinic for treatment, however the symptoms unresolved. This is the
fourth time of similar symptoms occur, which previously diagnosed and treated as psoriatic arthritis.

She had been diagnosed with psoriasis for the past 10 years, currently not under proper follow up
and only takes topical cream and anti-histamine bought from pharmacy. She had undergoes ballon
stenting done at DEMC on March 2017. Angiogram and OGDS had been done on June 2017 for
recurrent chest pain, however discharged with diagnosis of gastric ulcer.

She had positive family history of cancer as her mother died due to colon cancer. Her niece and
daughter also had psoriasis. Otherwise there are no other issues regarding her family and social
history.

Physical examination show patient is alert, conscious and not in respiratory distress. Vital sign
monitoring show normal parameter. Systemic examination revealed clear lung, dual heart rhythm
with no murmur. Dorsalis pedis artery and posterior tibial artery are both palpable with good
volume. CRT is less than 2 second..Focus examination of the knee show there is well defined sharply
demarcated boundaries of irregular shape skin lesion with silvery scale appearance over extensor of
both knees and, characteristic of psoriatic plaques, and mild swelling over knee joint, tender over
lateral side of the knee, however the swelling is not warm. Range of motion of right knee limited up
to 20 both on passive and active motion. There is mild nail pitting over 4th and 5th toes of right leg.
Sweeping test is positive but patellar tap is negative. Sensation is intact at bilateral leg.

Investigation show normal value on FBC, Renal Profile and uric acid level. However, ESR and CRP
level are increase with value of 53 and 62.9 respectively. X-Ray of the knee shows increase joint
space with no fracture seen.

The management given was KNBM with IV Drip 3 pint of normal saline for 24 hour prior to bedside
right knee aspiration under aseptic technique, KIV arthrotomy washout under general anaesthesia
after knee aspiration, and they sent the synovial fluid for culture & sensitivity, FEME and cytology
testing. Knee aspiration show 50cc of clear synovial fluid with no pus or blood noted. Synovial fluid
culture and sensitivity show few pus cell with cell count more than 500 lymphocyte suggestive
concomitant infection over the right knee.
 B. LEARNING ISSUES

1. How to differentiate Psoriatic Arthritis (seronegative arthritis) with rheumatoid arthritis?

Psoriatic arthritis (PsA) has been defined as a unique inflammatory arthritis associated with psoriasis,
and about 30% of psoriatic patients developed PsA. Risk is increased in patients with HLA-B27 or
some other specific alleles1. PsA had many similarities with Rheumatoid arthritis (RA) such as both
PsA and RA are auto-immune conditions, both affect internal organs (such as cardiovascular
disease)2, and both receive similar treatment algorithm. The impact of the disease in patients with
PsA appears to be similar to that of patients with RA as shown in a study done by Sokoll et al3.

But both of them are not similar identities as many more characteristic separates them apart. It
emerged as a clinical entity separate from RA following the discovery of the rheumatoid factor in
1948 and the observations of the late Professor Verna Wright of Leeds, UK. PsA has been associated
with human leucocyte antigen (HLA) class 1 alleles as opposed to the class 2 alleles associated with
RA. PsA had been grouped as seronegative spondyloarthritis as rheumatoid factor (RF) is usually
negative or present at low titre in only 13 % of PsA patients , opposed to RA, which positive in 80%
of the cases. PsA is included among the spondylarthopathies because it shares both clinical features
and association with HLAB27 with other spondylarthopathy members. The presence of psoriasis is a
hallmark of PsA, although joint involvement may precede skin manifestations in ~10 % of patients4.

At the cellular level, histological studies have revealed important differences between synovial tissue
in RA and PsA. Angiogenesis is dysregulated in both conditions and abnormal vessel morphology and
function has been reported. Increased straight, branching vascularisation is a prominent feature
observed in RA joints, whereas the formation of elongated, bushy, torturous blood vessels is a more
marked feature of the PsA joint. In the RA joint there is increased macrophage infiltration and
subsequent synovial invasion compared with that observed in PsA. As a result, lining layer
hyperplasia observed in RA is more striking than that observed in PsA. Conversely, PsA is
characterised by more extensive infiltration of polymorphonuclear cells. It has been reported that
the extent of T-cell and B-cell infiltration is comparable in both conditions and the formation of
germinal centres (zones of T-cell and B-cell proliferation) are observed in both PsA and RA joints5.

One study6 had been done by analyzing several classification criteria proposed by many researcher,
such as Moll and Wright, Bennett, Gladman et al, Vasey and Espinoza, the European
Spondylarthropathy Study Group (ESSG), McGonagle et al, and Fournie et al, and they combined all
the criteria into one classification criteria, namely Classification criteria for Psoriatic Arthritis
(CASPAR). The frequency of distribution of the patterns has varied, partly because different
definitions might have been used by individual investigators, and partly due to the fact that the
patterns likely change over time, such that with longer duration of PsA, patients tend to develop the
polyarticular pattern.

To meet the CASPAR criteria, a patient must have inflammatory articular disease (joint, spine, or
entheseal) with 3 points from the following 5 categories:

1. Evidence of current psoriasis, a personal history of psoriasis, or a family history of psoriasis.

2. Typical psoriatic nail dystrophy including onycholysis, pitting, and hyperkeratosis observed
on current physical examination.
 3. A negative test result for the presence of rheumatoid factor by any method except latex but
preferably by enzyme-linked immunosorbent assay or nephelometry, according to the local
laboratory reference range.
4. Either current dactylitis, defined as swelling of an entire digit, or a history of dactylitis
recorded by a rheumatologist.
5. Radiographic evidence of juxtaarticular new bone formation, appearing as ill-defined
ossification near joint margins (but excluding osteophyte formation) on plain radiographs of
the hand or foot.

While we look at American College of Rheumatology (ACR)/European League Against Rheumatism

(EULAR) collaborative initiative 2010 rheumatoid arthritis classification criteria7, they stated that any
patient with 6 or more points after the criteria have been applied is considered to have RA. Before
the criteria can be applied, patients need to have at least 1 joint with synovitis, and other reasons for
it need to be ruled out.

Joint distribution

1 large joint - 0 points

2-10 large joints - 1 point
1-3 small joints (large joints excluded) - 2 points
4-10 small joints (large joints excluded) - 3 points
>10 joints (at least 1 small joint) - 5 points.

Serology

Negative RF and negative anti-cyclic citrullinated peptide (anti-CCP) antibodies - 0 points

Low positive RF or anti-CCP antibodies (3 x upper normal limit) - 2 points
High positive RF or anti-CCP antibodies (>3 x upper normal limit) - 3 points.

Symptom duration

<6 weeks - 0 points

6 weeks - 1 point.

Acute-phase reactants

Normal CRP and ESR - 0 points

Abnormal CRP or ESR - 1 point.

Hence based on these 2 criteria, we can definitely differentiate between PsA and RA. Although it
seems likely that these conditions have a different pathogenesis, the drugs used to treat them are
the same7 albeit there is different side effect of medication for both group of disease (Hepatotoxicity
with methotrexate was more common in PsA and pulmonary toxicity with methotrexate was found
more often in RA). Structural damage in PsA is not limited to cartilage loss and bone erosions as in
RA, but some patients with PsA also show specific features of joint remodelling with new bone
formation potentially leading to joint ankylosis. Severe osteolysis clinically presenting as arthritis
mutilans is also a specific feature of this disease. Hence with increasing duration of the disease,
some PsA patient might need to undergo orthopaedic surgical treatment joint consist of sacrificing
and non-joint sacrificing procedures8.

C. REFERENCES

I. Gladman, D.D., Antoni, C., Mease, P., Clegg, D.O. and Nash, P., 2005. Psoriatic arthritis:
epidemiology, clinical features, course, and outcome. Annals of the rheumatic
diseases, 64(suppl 2), pp.ii14-ii17..
II. Han, C., Robinson, D.W., Hackett, M.V., Paramore, L.C., Fraeman, K.H. and Bala, M.V., 2006.
Cardiovascular disease and risk factors in patients with rheumatoid arthritis, psoriatic
arthritis, and ankylosing spondylitis. The Journal of rheumatology, 33(11), pp.2167-2172.
III. Sokoll, K.B. and Helliwell, P.S., 2001. Comparison of disability and quality of life in
rheumatoid and psoriatic arthritis. The Journal of Rheumatology, 28(8), pp.1842-1846.
IV. Veale, D.J. and FitzGerald, O., 2002. Psoriatic arthritis-pathogenesis and epidemiology.
Clinical and experimental rheumatology, 20(6; SUPP/28), pp.S-27.
V. Van Kuijk, A.W. and Tak, P.P., 2011. Synovitis in psoriatic arthritis: immunohistochemistry,
comparisons with rheumatoid arthritis, and effects of therapy. Current rheumatology
reports, 13(4), pp.353-359.
VI. Taylor, W., Gladman, D., Helliwell, P., Marchesoni, A., Mease, P. and Mielants, H., 2006.
Classification criteria for psoriatic arthritis: development of new criteria from a large
international study. Arthritis & Rheumatology, 54(8), pp.2665-2673.
VII. Radner, H., Neogi, T., Smolen, J.S. and Aletaha, D., 2014. Performance of the 2010
ACR/EULAR classification criteria for rheumatoid arthritis: a systematic literature review.
Annals of the rheumatic diseases, 73(1), pp.114-123.
VIII. Helliwell, P.S., Taylor, W.J. and CASPAR Study Group, 2008. Treatment of psoriatic arthritis
and rheumatoid arthritis with disease modifying drugs--comparison of drugs and adverse
reactions. The Journal of Rheumatology, 35(3), pp.472-476.
IX. Haque, N., Lories, R.J. and De Vlam, K., 2016. Orthopaedic interventions in patients with
psoriatic arthritis: a descriptive report from the SPAR cohort. RMD open, 2(2), p.e000293.