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Help with diagnosis please

Discussion in 'General Issues and Discussion Forum' started by zsuzsanna, Jul 22, 2015.

  1. zsuzsanna

    zsuzsanna Active Member


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    A 55 year old lady came to my surgery complaining of painful toes. The 3rd and 4th digits were red and swollen with the nail plate almost non existent. She said she had been to her GP and has been complaining with this problem for some considerable time. I was very puzzled. I took photos and sent off some skin samples for fungal tests and also asked her to request a referral to a dermatologist.

    Has anyone any idea what the problem might be?
    I would appreciate some suggestions.
     

    Attached Files:

  2. Greg Fyfe

    Greg Fyfe Active Member

    Hi

    Not much history to go on, so looking at the swollen toes I went from there , here's some possibilities.


    The term sausage digit refers to the clinical and radiologic appearance of diffuse fusiform swelling of a digit due to soft-tissue inflammation from underlying arthritis or dactylitis.

    The common causes of sausage digit are :

    psoriatic arthropathy http://www.dermnetnz.org/scaly/psoriatic-arthritis.html
    osteomyelitis
    sickle cell anemia
    sarcoidosis
    tuberculous dactylitis (spina ventosa)
    leukemia
    syphilitic dactylitis
    gout

    Regards
    Greg
     
    Last edited: Jul 25, 2015
  3. zsuzsanna

    zsuzsanna Active Member

    Thank you Greg,
    Your reply was most useful, I believe she has psoriasis and this could be the link.
    I will contact her again and ask some questions.

    Regards

    Zsuzsanna
     
  4. Catfoot

    Catfoot Well-Known Member

    Hi Zuszanna,
    Red nails/red lunulae is a rare discolouration of nail. It is associated with systemic lupus erythematosus, alopecia and can accompany drug eruptions.

    Perhaps you could ask a few more questions?

    HTH

    Catfoot
     
  5. W J Liggins

    W J Liggins Well-Known Member

    Hello

    Agree with Greg. Def. requires (initially) an X-ray.

    All the best

    Bill
     
  6. blinda

    blinda MVP

    Hi Zuszanna,

    Great pics :drinks

    What was the medical/familial history, occupation/social/sporting activities of this pt? Any dermatological or systemic conditions elsewhere?

    I agree with Bill and Greg, an X-ray is warranted here to ascertain any erosive change to the DIP joints.

    Cheers,
    Bel
     
  7. drhunt1

    drhunt1 Well-Known Member

    Psoriatic arthritis until proven otherwise.
     
  8. blinda

    blinda MVP

    Without a full med hx and further investigation, you cannot categorically provide a diagnosis, drhunt1.
     
  9. marie parrott

    marie parrott Member

    Psoriatic arthritis .
     
  10. blinda

    blinda MVP

    It could well be, which is why Bill, Greg and I recommended further investigation in the form of x-ray to check for erosive change, i.e; the 'Pencil-in-cup' deformity. Without the results of such tests and detailed medical/social history then we can only offer differential diagnoses - One of which is certainly PsA.
     
  11. TL74

    TL74 Active Member

    X-ray, recommend conversation with GP for possible immunology referral. Can never go wrong with more information! Good luck.
     
  12. drhunt1

    drhunt1 Well-Known Member

    How long would a patient have to have psoriatic arthritis before the plain film radiograph reveals the 'pencil-in-cup' presentation?
     
  13. HUGHESA1

    HUGHESA1 Member

    I Agree likely Psoriatic Arthritis, XR and inflammatory blood screen required.
     
  14. blinda

    blinda MVP

    Rate of articular erosion will vary from one individual to another, Matthew, depending on influencing factors such as; extent of psoriatic skin involvement, family history of psoriasis and onset of disease. Thus, extensive epidermal plaques, a strong familial connection and diagnosis before 20 years of age tend to render the condition more aggressive.

    Whilst it is true that the classic `pencil-in-cup` presentation is usually recognised in the later stages of the condition, early signs of peri-articular erosions and bone resorption can be identified by X-ray as destruction of bone tissue progresses. Which is why, in my original post, I wrote;
    As I said before, you cannot provide a diagnosis on pictures alone. If PsA is suspected, then a full medical history of the patient and their family`s, along with blood tests and imaging will provide a definitive diagnosis.

    Cheers,
    Bel
     
  15. drhunt1

    drhunt1 Well-Known Member

    I'm quite familiar with this presentation, as I am with the long vs. short term clinical aspects...that's why I asked the question. So if a patient presents in your office/clinic never having had the diagnosis made previously, with recent symptoms, {as was described above originally), then one wouldn't expect to observe "pencil-in-cup" erosions on radiographs...would they? That was my point.
     
  16. blinda

    blinda MVP

    It depends, Matthew....on the extent of erosion. I have seen X-rays demonstrating the `pencil-in-cup` deformity in previously undiagnosed patients, manifesting inflamed DIPJ`s and nail dystrophy - as seen in the original post.

    Hope that helps.
     
  17. drhunt1

    drhunt1 Well-Known Member

    Not really. You wrote that a family history of psoriatic arthritis can be predictive in determining "rate of erosion", which is not true. Further, a "pencil-in-cup" presentation is observed in long standing psoriatic arthritis, not in the early stages. Considering the fact that I've been in private practice longer than you've been alive, I've had many more opportunities to address these types of patients. You wrote in a post that has since been deleted that you've treated thousands of patients. That's quite an achievement considering you appear to have started your practice in 2007. Perhaps the difference lies in the different health care systems between the US and the UK. Rarely do I initially diagnose psoriatic arthritis...but back in the '80's, more so...much like with diabetes mellitus.

    If you read the initial post above again, this patient was not diagnosed with PsA prior to the visit to the Podiatrist, therefore, one can assume that this is very early in the process of creating pain. The dermatologic ramifications can be present for quite a long time before the patient seeks medical advice, but arthritic pain is another story. Early arthritic changes are found in the DIPJ, (as the pics demonstrate), which are swollen and tender. This presentation occurs long before the erosive changes are noted on plain film. X-Rays are taken for completeness sake, and to R/O other possible anomalies. Like I wrote above:

    Psoriatic Arthritis until proven otherwise.
     
  18. blinda

    blinda MVP

    No, I said;
    Strong familial history is just one of many influencing factors, not the same as predictive by any means.

    Yes, that is indeed what I said here;
    I have been in practice long before 2007 (which was when I gained ONE of my qualifications) and you are not privy to the full extent of my medical and dermatological training, nor practice. In your post, which was deleted for its xenophobic content, you said; "Get back to me when you have treated thousands of patients." I merely replied, truthfully, that I have. What this, my age, or that you`re close to retirement, has to do with this thread is beyond me.

    Again, not relevant to the original post or thread.

    That is an incorrect assumption. Zsuzanna stated the pt "has been complaining with this problem for some considerable time". Diagnosis is not always obtained at onset of arthralgic symptoms, as these can be misdiagnosed for other conditions, eg; Reiters, OA, RhA , etc. Hence the absolute requirement for taking a full medical, familial history and further blood tests and investigations to obtain a definitive diagnosis, not pictures alone.

    True.

    False. I repeat what I said earlier;
    Bone proliferation results in an irregular, `fuzzy` appearance to the bone around the affected join, along with detectible enthesitis and marginal bone erosions.

    Partly true. X-Rays are performed to rule out differential diagnosis and form part of the investigation process to reach a definitive diagnosis. PsA is diagnosed and assessed with X-ray, which is the cornerstone in assessing and monitoring inflammatory arthritides such as PsA. These findings are reproducible and allow for the continuous serial monitoring of patients....not completeness.

    Let me know if I can help you with any other dermatological conditions, Matthew.

    Cheers,
    Bel
     
  19. drhunt1

    drhunt1 Well-Known Member

    LMBO! You'll be the first person I consult when/if I should ever need any help. As far as the xenophobic post your refer to...I had the wrong country, but correctly identified the nasty demeanor, which was confirmed by two contributors pm's that hail from your neck of the woods. You must abide by the Simon Spooner Rules of Social Grace.

    Not retiring anytime soon. In fact, I have several projects in mind for research on the heels of the Growing Pains/RLS article I wrote. And I'm giving my first lecture on the subject in little over a month to a group of nurses/docs/patients. It will be epic...and just the beginning. However, years in practice has a predictive value when the topic of clinical skills is ever mentioned. For instance, my determination of the cause/source of GP/RLS was only achieved because of my long term exposure to the problem. It's not something I would expect a younger Pod to discover, simply because they haven't seen it enough times. The same is true with a lot of "what we do"...not excluding dermatological manifestations in joints. When one sees that presentation a lot, it makes the practice of medicine less guess work and saves everyone, including the patient, time.

    But tell me....how does a family history of PsA offer any predictive value of how far along the member is in the process of developing arthritis? Simply put...it doesn't. Hope this helps.
     
  20. blinda

    blinda MVP

    I never said it did. I merely stated;
    Influencing factors and predictive value are not interchangeable terms.

    With regards to the rest of your off-topic post, I could detail my publications and teaching profile, too...but that would be completely irrelevant to the thread and quite frankly, a bit naff.
     

  21. ------------------------------------------------------------------------------------------------

    The confidence of amateurs is the envy of professionals :rolleyes:
     
  22. drhunt1

    drhunt1 Well-Known Member

    I think I adequately made my point.

    Cheers to you...
     
  23. blinda

    blinda MVP

    You most certainly did.

    Good luck with your lectures, Matthew :drinks

    Sincerely,
    Bel
     
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