What's Your Diagnosis? Hand Arthritis in 57 year old Man Save

A 57 year old male is referred for arthritis of the hands for the last 8 years. He complains of pain, swelling, stiffness in the fingers only. He denies rash, bowel, urologic or ocular complaints. Over-the-counter NSAIDs have provided only partial relief.  

What is your differential diagnosis?

Differential diagnosis: Cases such as this may be a toss-up between psoriatic arthritis and erosive (inflammatory) osteoarthritis (EOA) of the hand - wherein the presence or absence of cutaneous/nail psoriasis, synovial swelling and the placement of erosions (marginal in PsA and central in erosive OA) or spurs are the final arbitors.  Schett and colleagues have suggested the site of spurs differ between PsA and EOA (citation source http://buff.ly/1TgATUb). PsA spurs tend to be on the radial side of the joints (i.e., MCP2 or PIP2) and that entheseal spurs are more common in PsA

Another possibility is pseudogout. It is not uncommon for EOA to have evidence of chondrocalcinosis, further obscuring the diagnosis and treatement of such patients. Least likely would be the occurrence of gout involving the DIPs or PIPs - as this seldom happens and usually in older women with "nodal" OA, renal insufficiency and chronic diuretic use. Such patients are at risk for gouty attacks occuring in Heberden's (DIP) or Bouchard's (PIP) nodes of OA.

Diagnosis: this patient was diagnosed and treated as psoriatic arthritis based on fusiform swelling, synovitis, onycholysis, minimal cutaneous psoriasis and radiographs.

This case and photo was a kind contribution from Dr. Daniel Ricciardi of Brooklyn, NY.