Diagnosisand treatment of psoriatic arthritiswith concealed rash:a case report

Teng Huang1,Shaopeng Du2,Xiaojing Liu2,Zhenhua Liu2,Bin Hao2*

1Hebei university,Baoding,Hebei,China.2Chinese people's liberation Army 252 Hosptital,Baoding,Hebei,China.

Abstract Psoriatic arthritis is a kind of arthritis associated with psoriasis.The clinical manifestations of psoriatic arthritis with arthritis as the first symptom are often similar to ankylosing spondylitis and rheumatoid arthritis.Thus differential diagnosis should be made in clinical practice so as to improve the therapeutic effect.Psoriatic arthritis skin lesions are usually papules or plaques,with scales on the surface and punctate hemorrhage on the basement.About 10%of patients with psoriatic arthritis have skin rash after the onset of arthritis.In order to provide a reference for clinicians,our study the analyzed the clinical diagnosis of psoriatic arthritis in combination with a case of psoriatic arthritis with concealed skin rash and related literatures.

Keywords:psoriatic arthritis;concealed rash;clinical diagnosis

Introduction

Psoriatic arthritis(PsA)is a kind of disease with inflammatory joints which is related to psoriasis.Patients with PsA usually have psoriasis rash and inflammatory joints,which appear as the pain,swelling,stiffness and dyskinesia of joints and surrounding soft tissues.Some patients may have sacroiliac arthritis and/or spondyloarthritis[1].The pathogenesis of the disease is still unclear and the pathogenetic processis slow and insidious.In about 90%of the patients,the rash appears before or at the same time as arthritis.About 10%of the patients have rashes after the onset of arthritis,and even some patients have rashes several years or more after arthritis,leading difficult to diagnose in clinical practice[2].Presently,the study reviewed a case of PsA with latent rash in our department and related literatures,so as to provide a reference for clinical diagnosis of the disease.

Casepresentation

Case history

Ms.Liang,58 years old,complained of blunt pain in the right waist and right groin without obvious inducement 15 years ago,and followed by the pain in the joints of both fingers and toes symmetrically two weeks later,with morning stiffness for 1 hour.These symptoms were relieved after activity.There was no history of fever,no other joint pain,no swelling,no joint deformity,no rheumatic nodules,no special changes in nails,and no skin rash.She was diagnosed as rheumatoid arthritis and was give drugs orally in a hospital of Hebei province(related examination results and detailed information of drugs can not be obtained).After treatment,the above-mentioned symptoms were mild-to-severe and repeated.Six years ago,the above symptoms worsened,especially in the proximal interphalangeal joints of hands and feet,and gradually progressed to the deformity of joints.One and a half years ago,the patient went to another hospital in Baoding (Hebei Province),and continued to be diagnosed as"rheumatoid arthritis"(test results can not be obtained).Then oral medicines such as Tripterygium wilfordii, methotrexate, Paeonia lactiflora and hydroxychloroquine were given to the patient for relieving symptoms.After that,all medicines were discontinued by herself because of stomach pain.Three months ago,the pain of both hands and feet joints become severe significantly.On April 8,2019,the patient came to our hospital and was admitted to our department for further diagnosis and treatment.

History of osteoporosis was more than 6 years;History of chronic gastritis was 2 years,and currently intermittent pain and discomfort in the stomach;History of compression fracture of thoracic 9 vertebral body was 4 months,and the condition is stable at present.There was no history of infectious diseases or hereditary diseases in the family.

Physical examination

Temperature 36.8℃,pulse 83 times per minute,breathing 20 times per minute,blood pressure 121/76mmHg, body weight 49kg.Normal development,moderate nutrition,clear mind,automatic posture, cooperation of physical examination,mild anemia.There are scattered erythema and papules with scales on the skin of both lower limbs(Figure 1).Normal activity of cervical spine and lumbar spine,Sausage-like changes in the index finger,middle finger and ring finger of both hands,changes in the shape of the little finger of both hands(Figure 2A).Bipedal valgus deformity (Figure 2B),bilateral knee enlargement deformity with limited movement.Swelling and tenderness of metacarpophalangeal and proximal phalangeal joints of both hands,no tenderness of wrists,elbows and shoulders,slight tenderness of knees with normal movement.The"4"test on the right side was positive and the"4"test on the left side was negative.There was no edema in both lower limbs.The muscle strength of the limbs was grade V and the muscle tension was moderate.Pathological reflex was not elicited.

Auxiliary examination

Blood routine:white blood cells 3.41x10^9/L;erythrocyte sedimentation rate(ESR)26mm/h;Creactive protein(CRP)12.380mg/L;tuberculosis antibody was negative;urinary routine was normal;Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody(anti-CCP)antibody were negative;liver and kidney function were normal.

CT examination of sacroiliac joints(2019.04.09)showed inflammatory changes of bilateral sacroiliac joints(Figure 3);Hand DR(2019.04.09)showed the degenerative changes and osteoporosis of both hands (Figure 4A); Bipedal DR(2019.04.09)showed bipedal malformation with valgus,partial flexion of phalanges,and bipedal osteoporosis(Figure 4B).

Diagonosis and treatment

Erythema and papules were scattered in the patient's lower limbs.The patient's medical history was further questioned and the skin rash had existed more than one year.There was no systematic diagnosis and treatment on the skin rash.Then clinician from the dermatology department was invited to assist in the diagnosis and treatment.According to its clinical manifestations and rash characteristics,the preliminary diagnosis was considered as psoriasis.Classification criteria of PSA based on Moll and Wright：①There is at least one arthritis that lasts for more than three months;②At least one psoriasis lesion and/or one finger(toe)nail with 20 thimble-like pits or nail peeling③Serum IgM type RF negative.Combined with the clinical manifestations and medical history of the patients,it can be clearly diagnosed aspsoriatic arthritis.

Figure 1 The scattered erythema and papules with scales on the skin of both lower limbs of the

Figure3 The CT examination of sacroiliac jointsof the patient

Figure 4 The hand DR and bipedal DR of the patient

According to the clinical manifestation(scattered erythema and papules in the lower limbs with obvious basal infiltration,painful hand and foot joints,intermittently discomfort stomach)and the four diagnostic methods in traditional Chinese medicine(TCM)(Table 1),TCM syndrome type was classified as the Syndrome of Liver and Kidney Yin Deficiency.TCM diagnosis:Bi Zheng.

After hospitalization,patients were treated with integrated traditional Chinese and Western medicine:celecoxib capsule 0.2g orally 2/day;methotrexate 10mg orally 1/week(increased to 12.5mg 1/week after one month);total glucosides of paeony capsule 0.6g orally 2/day;tripterygium wilfordii polyglycoside tablet 20mg orally 3/day;calcitriol soft capsule 0.5ug orally 1/day;vitamin D2 phosphorus staphylococcum tablet 2 tablets orally 3/day;Biqi capsule 1.2g orally 3/day;Xianlinggubao capsule 1.5g orally 2/day;omeprazole enteric-coated tablet 20mg orally 1/day;calcipotriol ointment 10g and desonide cream 15g,interchangeably,externally 2/day.The main treatment of TCM was"tonifying liver and kidney,dredging collaterals and relieving pain".The prescriptions were as follows:

Notopterygium 15g,Radix Angelicae Pubescentis 15g,Mulberry Parasitic 10g,Dried Rehmannia Root 12g,Cortex Moutan 15g,Caulis Spatholobi 10g,Raw Angelica 12g,Saponikovia 10g,Asarum 3g,Ligusticum Wallichii 15g,Cassia Twig 10g,Poria Cocos 10g,Eucommia 15g,Medicinal Cyathula Root 10g,Raw Astragalus 25g,Nutmeg 12g,Dendrobium 15g.All medicines were decocted with water and taken orally twice a day for 7 days.

Haematological index was reexamined after a week in hospital:Leukocyte count 3.76x10^9/L;ESR 8 mm/h;CRP 6.94 mg/L (Table 2).Meanwhile,the pain of lumbar,back and limb joints was relieved.The lower limbs were scattered in rash with itching and molting on the surface.The manifestation of the four diagnostic methods in TCM were shown in Table 1.From the above results,we can see that the patient's clinicalsymptoms and reexamination tests improved significantly.Then the patient leave hospital voluntarily.After discharge,the oral dose of Western medicine was maintained and the Chinese medicine was taken continuously for two weeks.After two weeks,the patient will be reviewed and the TCM herbs will be adjusted in outpatient department according to the change of the condition.

Table 1 Four diagnostic methods in TCM

Table2 Comparison of theresults of examinationsbefore and after hospitalization

Discussion

PsA is a type of disease of seronegative spondyloarthropathy and an inflammatory arthropathy closely related to psoriasis.According to statistics,the prevalence of PsA in China is about 0.123%[3].Sex and course of disease are closely related to the occurrence and development of sacroiliac arthritis[4].If arthritis is the first symptom of the disease,the rash is usually concealed,even several years before it appears,which makes the clinical diagnosis of PsA more difficult, and even the phenomenon of misdiagnosis occur,affecting its curative effect.However,if patients have the following symptoms:asymmetric major arthritis of lower extremities;synovitis and tenosynovitis of distal and proximal interphalangeal joints,such as sausage-like fingers/toes;family history of psoriasis;negative RF and antinuclear antibody;nail changes,such as transverse crest of deck,needle-like depression of fingernail apex,nail peeling;and sacroiliac arthritis with positive H-B27,these symptoms will provide a basis for further definite diagnosisof PsA.

In patients with psoriatic arthritis with concealed rash,the rash symptoms are not obvious and the joint symptoms are prominent.In clinical diagnosis,if the physician lacks the experience of PsA diagnosis,the clinical characteristics of PsA patients with firstepisode arthritis can not be grasped accurately,and the imaging characteristics of PSA patients are not clear.It is easy to be confused with other inflammatory arthritis such as ankylosing spondylitis(AS),rheumatoid arthritis(RA)and so on.It should be recognized clinically that PsA patients may involve multiple joints of the whole body asymmetrically.Ossification of cervical and lumbar vertebral ligaments can form bone bridges.Imaging findings show that distal joint deformations can form pen-cap-like changes and sacroiliac arthritis.The main manifestations of RA were symmetrical arthritis,which mostly invaded proximal interphalangeal joints,and sacroiliac joints were less involved.AS patients had no skin or nail lesions,and the involvement of spine and sacroiliac joints was often symmetrical.In addition,the thoracic vertebral ligaments in patients with PsA were not involved and distributed in a jump pattern,which could be differentiated from AS.This case was initially diagnosed as RA.There was no special nail changes or family history of psoriasis.Several years later,psoriatic skin rash appeared on the skin.According to its clinical and imaging characteristics and the diagnostic criteria of PsA,psoriatic arthritis could be diagnosed.Due to the complexity of the condition,further follow-up is recommended to make adefinite diagnosis.

PsA modern medical treatment can refer to RA clinical treatment.Drug treatment mainly includes non-steroidal anti-inflammatory drugs, antirheumatic drugs, glucocorticoids, botanical preparations and other drugs.But on this basis,PsA should take into account the treatment of psoriasis lesions,in order to prevent further expansion of the extent of lesions.According to the latest medical research report[6],the new biological agents have good effect in improving the condition of joint inflammation and skin damage,and can effectively inhibit the imaging progress of joint lesions.However,due to the side effects of long-term use of Western medicine,patients can not tolerate and stop taking drugs by themselves,thus aggravating the development of thedisease.

There is no record of this disease in TCM.According to its clinical characteristics,most doctors classify it as"Bai Bi"and"Bi Zheng".As recorded in Wai ke zheng zhi quan shu(Qing Dynasty,1831 A.D.):Itchy skin,like a rash with white color at the beginning;the dandruff fall when scraped;the skin of limbs gradually become dry and even bleeding,suffering painful.TCM believes that the pathogenesis of this disease is based on the deficiency of its origin,and the invasion of exogenous pathogens is its mark.Liver governs tendon and kidney governs bone.Deficiency of liver and kidney leads to wind,cold and dampness easily invading the body,which makes meridians and collaterals blocked.Over a long period of time,it will accumulate into heat,which will damage the body's fluid.Blood deficiency and wind dryness will make the skin lose its nourishment.At this time,the disease will occur.In clinical treatment,the method of"invigorating the liver and kidney,removing blood stasis and dredging collaterals" is adopted,supplemented by expelling wind and nourishing blood,treating both the symptoms and pathogens.In clinical application, Radix Angelicae Pubescentis,Mulberry Parasitic,Acanthopanax senticosus and Achyranthes bidentata are commonly used to invigorate liver and kidney;

Ligusticum Wallichii,Safflower,Angelica and Peach Seeds are used to invigorate blood and nourish blood circulation,to promote meridians and collaterals;Saponikovia,Notopterygium and

Jingmustard are used to dispel wind evil.Professor Yan Xiaoping,a modern physician,believes that the pathogenesis of pulmonary fever should be recognized in the case of skin rash[5].In the treatment,the pulmonary fever should be cleared and the pulmonary Qi should be disseminated,and good clinical effects have been achieved.Long-term clinical practice shows that TCM can effectively alleviate clinical symptoms,delay the recurrence of the disease,and reduce the side effects of Western medicine.To a certain extent,TCM can reduce the burden of patients and improve thequality of life.

In this case,due to the patient's long illness and the history of chronic gastritis,coupled with long-term oral western medicine on gastrointestinal tract stimulation,the patient's compliance is poor,thus affecting the long-term treatment of the disease.According to the dialectics of TCM,the patient is deficient in vital energy.The so-called"If positive Qi exists in the body,evil can not invade in".On the basis of protecting gastric mucosa with Western medicine,we used Astragalus membranaceus to invigorate Qi and spleen,and added Dendrobium to invigorate stomach and promoting body fluid in TCM prescription.After treatment,the symptoms of patients improved significantly, which illustrated the effectiveness of integrated traditional Chinese and Western medicine,and confirmed the advantages of TCM in theclinical treatment of such disease.

To sum up,psoriatic arthritis with skin rash concealed usually showed primary symptom of arthritis.It is difficult to make a definite diagnosis in clinic.Doctors should inquire about the history of psoriatic arthritis and search for its symptoms in detail.According to its clinical characteristics and imaging changes,we should give a definite diagnosis as soon as possible and give timely treatment of integrated traditional Chinese and Western medicine,in order to give full play to the advantages of traditional medicine,alleviate the suffering of patients and improve the quality of life.