I just spoke with the Rheumatologist who took over patients from someone
else’s practice, and she is trying to sort things out.
I saw this patient today for bilateral wrist US, only the left wrist hurts.
There are bilateral erosions (not showing the right wrist here), but
active synovitis and 1st extensor tendinosis and tenosynovitis on the left
only.
Recent XRs do not look like RA to me…(I think there is subtle acro
osteolysis in the DPs) so I pulled up old films and share them here.
I am struck by the large calcaneal and patellar enthesophytes.
I’m thinking PsA.
I asked the patient if she gets skin lesions…she described some non
specific rashes…I can’t tell. She has beautifully smoothe fingernails.
What do you think?
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Arthritis-Consult-67F.pptx
I received multiple responses, all agree likely seronegative
spondyloarthropathy, favor Psoriatic Arthropathy.
Karina Todeschini commented: I agree, particularly this hyperostosis in the
right and the “hyperostant erosions”, term used by Anne Cotten, in the left
scaphoid and trapezium makes me think of Psa. For sure there is new bone
formation, which is characteristic of spondyloarthropaties, specially psa.
John Symanski said : This looks like seronegative arthritis to me.
Enthesopathy doesn’t look clean, probably inflammatory. Especially at
radial aspect of scaphoid and trapezium. Enthesopathy I’ve seen there
before has been inflammatory.
Rob Lambert responded:
Feet – unequivocal erosive disease incl. MTPJ, ant/lat corners of calcanei
on AP views, head of R1 prox phalanx etc.
Not very impressed by most toes/fingers but . . . base of R5 prox phalanx
looks like typical PsA new bone whiskering – that’s not ‘osteophytosis’;
and mature periosteal new bone in some phalanges e.g. R2 prox.
Enthesial new bone in numerous locations is likely to be PsA >> DISH.
Clearly there is some primary or secondary OA. That’s not the primary Dx
but it could be a reason why she doesn’t respond well to Rx.
L wrist is a bit of a mess – but it doesn’t look typical for simple OA.
There is a lack of definition of some of the bone contours, but the wrist
could all be old trauma and 2nd degen.
No significant osteoporosis.
Bottom line – most likely:
1. Erosive arthropathy – most likely PsA
2. Very prominent entheseal new bone – most likely PsA
3. Some 2nd OA at some sites.
I think much less likely:
1. RA
and
2. DISH
and
3.OA
and
4. Old trauma at some sites to explain all the findings
This is all very helpful…thank you!
Hilary
On Wed, Jun 23, 2021 at 10:30 AM hilary umans <hilary.umans@gmail.com>
wrote:
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