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This is QD Clinic. QD Clinic is brought to you by RheumNow Live twenty twenty five Dallas, Texas, February eighth and ninth. You can be there, but you know what? You can be there from home. Virtual registrations are still open.

It's going to be a good program. Today's case is new onset palmar plantar psoriatic arthritis. 41 year old woman comes in with a one year history of palmar and plantar scaly red lesions, went to her dermatologist, was, given a wrong diagnosis, went to another dermatologist, called palmar plantar disease, given steroids, and was referred to the big shot medical dermatologist in town, but prior to seeing that person, she gets an appointment with me, because she's also having, joint pains. So, addition to these refractory lesions on the palms and the soles, she has a few other rashes on the body. She's got arthralgia, swelling, stiffness, sausage like changes in her fingers with stiffness and pain, and that's pretty much it.

It's mainly in her fingers, nothing in her toes, nothing in her spine. She, denies any other medical problems other than asthma, and she has no other medical problems going on. She has a little bit of fatigue. That's about it. She comes in today complaining of the rash, stiffness and swelling in fingers, PIPs, and wrist up to two hours of stiffness in the morning.

Her pain is three to four out of 10. Again, she's only taking Tylenol. She tried taking nonsteroidals Aleve, but it gave her gastritis, and she cannot tolerate nonsteroidals. She's taking medicine for her, asthma. When you see her, she's got normal vital signs, she's got scaling and redness to the palms, motionless than the soles, she has plaque psoriasis on her extensor arms, and a little bit on the ankle and elbow.

So it's kind of plaque psoriasis with mainly a palmoplantar presentation. When you do the joint exam she has no deformity, no nodules, she has tender joints, she has up to 11 tender joints, and she has swelling of the PIPs bilaterally two through four. She has some heel pain, and that's about it. Her Sjogren's test and spine exam is normal. So, only labs that I have on her was a normal CBC, chem profile, a negative rheumatoid factor, and negative QuantiFERON test.

Not sure why that was done, but that was a good idea. So, she has active skin disease and merits treatment for that. She also has active arthritis and merits treatment for that. So, if I was treating this, my diagnosis is clear: I know I can't manage her with simple nonsteroidals, and I don't want to use steroids in a psoriasis patient. Her options are TNF inhibitors, IL-seventeen inhibitors, the twelve-twenty three inhibitors.

She had probably too many joints and dactylitis, enthesitis, that I probably wouldn't want to use aprimolast in this person. And when I saw her, I said go talk to the psoriasis expert in Dallas, and see what they recommend. But I do recommend that you start on either adalimumab, or an IL-seventeen inhibitor, or that you go on a gluten free diet. At the time I saw this patient, my partner and I, we were doing a lot of gluten free diets in patients with psoriatic and spondyloarthritis disease, and we're getting great results. I mean, I've seen people with more joints and swelling than this gal, who I told to take adalimumab plus forty milligrams a day of leflunomide, a double dose, plus steroids, and go on a gluten free diet.

And and that gentleman went on the gluten free diet and nothing else. He didn't take the biologic or the DMARD, or the steroid, and he came back, four months later with no psoriasis, and he had palom palomoplanter disease, by the way. No psoriasis, no arthritis. So, I know we can argue about the value of a gluten free diet, an anti inflammatory diet. We recommend totally gluten free and as carbohydrate free as you can get, and we feel that's as good as being on a Mediterranean diet, and that works really really well in spa, in PSA.

It doesn't work in other inflammatory arthritis, in my opinion. Anyway, she did go to the dermatologist, she did want to try a gluten free diet, and she did get better, but ultimately needed, a biologic. And she was put on IL-seventeen inhibitor because the dermatologist felt that it was probably a little bit more effective than the TNF inhibitor in what is difficult to treat psoriasis, which is palmar plantar disease. The patient did well. That's the end of the story.

You can tune in from home and register for virtual RheumNow live coming up in about a week. We'll see you there. Welcome to QD clinic. I'm Jack Cush with RheumNow. QD clinic is cases from the clinic that have, I think, instructional value.

They're often pretty straightforward. They're often the patients that you and I see all the time. And, you know, we can have little differences as to how we manage these patients. Acuity clinic's brought to you by RheumNow Live 2025. It's not too late to register and watch this virtually from home.

We've been doing hybrid meetings, meaning both live on-site and streaming for this is the seventh year. We were doing this before anyone. So it's pretty seamless at home, and the and the at home presentation this year is gonna be really unique in that, Artie Cavanaugh and I host the meeting live in Dallas, but Janet Pope is going to be the virtual host for you at home. I think you're gonna like that. And again, if you register, we're gonna send you board questions from this year's meeting and last year's meeting.

These are good review questions that are good for studying and whatnot. So today's case is about double stranded DNA without the lupus. So a patient presents, she's 40 years old with a one year history of kind of vague presentations: fatigue, aches, back pain, tingling, spots that hurt. And you know she gets referred around from primary care to neurology. Neurology notes that she has an anxiety disorder, and she also complains of numbness, an extensive workup with MRI and spinal films, EMG, spinal tap, etc, led to him giving her a diagnosis of benign fasciculation syndrome.

I don't know what that is. He said that the tests for lupus and rheumatoid were negative. She, was treated with anti anxiety agents, either clonazepam or diazepam, and then she went to see her doctor about a year later with neck and back pain. Labs were done normal or negative CBC, chem profile, HIV, UA, CK, rheumatoid sed rate, TSH, but double stranded DNA was 12, and that's positive if it's more than 10. And ANA was done, but not available.

She, took non steroidals without any relief, was still being intermittently managed for her anxiety. In her past medical history, things that could color some of this presentation is that she's got a chronic thyroid nodule that's being followed, normal TFT's, a history of conjunctivitis, but she's got all the other things that go along with fibromyalgia, myofascial pain syndrome, and that includes sleep disturbance, headaches, paresthesias, anxiety, TMJ pain, back pain, myalgia, and fatigue. She has no allergies to meds, her lupus review of systems is negative. She's never had any miscarriages, she does not have migraines. When you see her on this date, she has normal vital signs, she has a normal exam, she has livid or reticularis in the extremities, she has no swollen joints, she has no tender joints on today's exam, and she has no skin findings.

Labs done showed that she's HIV negative, UA normal, Sed rate CRP normal, chem profile normal, CBC normal, TSH normal, double stranded DNA is 15 on repeat. So the question is: aside from having an anxiety disorder and myofascial pain, sometimes extending into fibromyalgia with widespread pain, What does she have that's giving her the double stranded DNA? As you know, we know double stranded DNA has a strong predictive value. It's got great specificity, modest sensitivity. And the question is, you know, is she going to get lupus?

Or does she have lupus? And clearly she does not have lupus, and that's what the patient was told at this visit. What we told her was that, the lower the titer of the double stranded DNA, the safer she's going to be, and the lower the risk she's going to have. And there's some evidence to support that, although I'm trying to give her positive messages rather than bleak messages of a lot of pathology and a bad future, because I don't know what her future is, and I don't think it's going to be bad. But there is a literature out there.

If you look at patients who have proliferative lupus nephritis, for instance, and you look at blood samples prior to them getting lupus symptoms or even a lupus diagnosis, up to half of them will have evidence of double stranded DNAs, a year or two before they develop more signs of lupus and then ultimately lupus nephritis. So, again, it's usually not half, it's a much lower number in other studies, you know, ten-twenty percent. But, when we did repeat her serology, she was ANA positive at one to 160 in a speckled pattern, and double stranded DNA was 15. She had chest pain, vague, not pleuritic. She had hair fall, not spontaneous.

She had arthralgia, not arthritis. And she complained of swelling, but no swelling was found. So she still doesn't have lupus, right? So I firmly believe in, number one, treating what I see. Not a lab, not a patient report, what I see.

And I'm going to follow this patient because I do think there's a possibility that she could develop lupus in the future, but I think it's very low. So a patient like this is going to get managed, probably come back for a first visit in three months, and then after that will be seen every six months until we continue to find nothing for two, three, five years. Now the problem is that most of us don't follow patients for five years, right? And so, what are you going to do? I would avoid the temptation to treat her as if she might could have lupus and you're gonna give her hydroxychloroquine, Now she's saddled with that problem, that diagnosis, and all that that entails.

And, I mean, the worst is she's told she has lupus, she's put on hydroxychloroquine, she takes Tylenol, you know, eight months from now, six months from now, three years from now, she goes into the emergency room with something catastrophic sounding, and she tells them she has lupus. Oh my god, everyone's now going to be thinking like an idiot, and not doing their own assessment. So, I don't like passing around this diagnosis lightly. So, she's a double stranded DNA without SLE. Yes, there are other causes, other autoimmune diseases, including autoimmune thyroid disease, autoimmune liver disease, you know, and, you know, occult cancer, and age, and, you know, there's a number of other things that could go into why she's going to have a positive ANA, no less a positive double stranded DNA.

But it's not lupus until she develops a malar rash, alopecia, pleuritis, cytopenias, proteinuria, swollen joints. Agree or disagree? This is QT clinic. This is QT clinic. I'm Jack Cush with RheumNow.

QT clinic is brought to you by RheumNow live February eighth and ninth, coming up in one week. You know, if you register as a virtual participant, you get to download all the lectures, all the slides, all the pre learns, all the pretest learning. You get to receive the, board questions that were from last year's meeting and from this year's meeting. Last year, I think we had a 165 board questions generated from our meeting from our speakers. And, again, you have access to all the materials.

And as a registrant, you can look at that material for up to six months. So you'll you can be there all day Saturday, but Sunday you got a christening to go to. It doesn't matter. You can go back and look at Sunday's content at your leisure. Check out RheumNow live at roomnow.live.

Today's case is recurrent oligoarthritis. This is a 40 year old male who is here for recurrent acute, usually left knee swelling, but today he's got bilateral knees that are swollen. A year ago he had an acute onset of joint pain. He said that he had a metal splinter that went into his left knee. He must have just heard of I mean, he remembers having that splinter.

He never had surgery to have it removed. It never showed up on an x-ray. But he said that that got infected, and he was treated with antibiotics, and the antibiotics made him better. But a year later, he presents to his primary care with acute left knee swelling. Swelling the same knee, by the way.

And he has intermittently been treated with antibiotics, non steroidals and steroids. He denies any trauma to this knee. He denies any fevers, rash, inflammatory eye disease, bowel disease or STDs. He has an occasional right Achilles tendon pain. He has no other significant past medical history.

When you see him today, he is complaining of fatigue and heel pain, and since this all began he's gained about 10 pounds. He doesn't exercise. On exam today he has one plus effusions in both knees, worse on the left. There's a there's some mild warmth in the left knee compared to the right, but they're both a little bit swollen. He is tender along the right Achilles insertion.

His tender joint count is two. His swollen joint count is two. His, clinical disease activity index is, 13 when you factor in his HAC and his pain level. His spine exam is normal. When you look at the notes from prior orthopedists, they withdrew fluid at one time, a 100 ccs of serosanguineous fluid with a 32,000 white count.

And but he had a normal CRP at that time, and all other tests were normal. When we saw him, we aspirated, about 60 cc's of fluid. The white count was 8,500, mostly polys. All his lab CBC, chem profile, sed rate, rheumatoid factor Hep B, Hep C, B27, QuantiFERON, uric acid were all normal. However, his CRP was elevated at 4.6 milligrams per deciliter, or 46.

So what is this? This is an inflammatory oligoarthritis that recurs. You know, you could say this is palindromic rheumatism. Why not? They don't have to be rheumatoid factor positive.

He's got bilateral joints. This is palindromic rheumatism. And if you've been following me, from ACR or this year, we've talked about palindromic rheumatism as being a category that fits under the diagnosis of preclinical RA, or clinically suspect arthralgia, does it not? So that's one thing. This could also be an adult presenting with the teenage equivalent of B27 positive spondyloarthritis with oligoarthritis, and an ANA sometimes.

He doesn't have an ANA. Well, happens to be B27 negative, and he is ANA negative as well. He does respond to steroids. So in addition to giving him Depo Medrol intra articularly, we gave him ten milligrams of prednisone to take for three weeks. You know, immediately he was better on with the intra articular injection.

He only got one, by the way. He said both knees went down. But he was also on prednisone. And then three weeks later he had no arthritis and no complaints, and was back and being active. So, the question is, what happens when he returns with yet another swelling?

I've had a dozen of these young folks, and they tend to be more male than female. They tend to be always oligo. They almost always are large joint, not small joint. Small joints give me worry. Small joints I'd be biopsying and looking for strange atypical mycobacterial infections or fungal infections.

But in this gentleman, he's had, repeated synovial fluid cultures, including for AFB, that were negative. So the question is: what's the diagnosis? And I'm going to tell you, the most likely diagnosis in this man is no diagnosis. You keep treating him intermittently until this goes away, until he doesn't come back. And that's usually the case, especially in the males.

They're kind of nomadic, they don't show up, they come once, twice, three times, and then that's it. And then you're left wondering, did I cure him? I like that version. Or did he go to someone across town and speak ill of me? Well, across town, I'm sure my buddies would defend my honor, but nonetheless, most people don't have a diagnosis.

The next most likely diagnosis here, I think still is SPA, more so than clinically suspect arthralgia, maybe going to become RA, because this is now going on for two plus years. So if that's the case, you could, if he keeps recurring and having recurrences of more than two a year, thinking like it's gout. If it's more than two a year shouldn't you be doing chronic prophylaxis and gout? Let's do the same in this gentleman. By the way, synovial fluid was negative four crystals both calcium pyrophosphate and monosodium urate.

So in that case I would offer this man an IL-seventeen inhibitor, a TNF inhibitor, and Otezla or aprimolast. Yes, I think that works just as well here. Why not? And then you could use methotrexate if that's what you prefer. But you certainly have options if this goes on into a third and fourth year, and he keeps coming back to you saying, please, doctor Cush, you gotta help me.

I'm tired of these happening at inopportune moment moments before I'm giving a big board presentation, or I'm traveling on vacation, or I'm going to my daughter's, you know, or or my niece's wedding, or whatever. I think you do have treatment options here. The problem here is most of these young folk tend to not come back, and you may not know the answer ultimately. But stick around as long as me, and you'll develop a body of evidence as to how to treat them. I have, in some instances, treated them as if they were reactive arthritis, and gone with six to nine months of chronic antibiotics.

That was no more effective than intermittent steroid use. No more effective than chronic suppression with a DMARD. There is often no right answer. The right answer is being concerned and following up and giving them your cell phone and telling them come come see me when you get a flare up. Let's nip it early in the bud.

Let me see you when you're at your worst. That's it for QT clinic. We'll see you at RheumNow Live.