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PATIENT STORY

A 50-year-old woman presents with new complaint of pain in several fingers. She has had psoriasis for many years; however, she only developed joint pain last year. Her examination is significant for swelling and tenderness at the distal interphalangeal (DIP) joints of her second, third, and fourth fingers (Figure 97-1, A). She had an elevated erythrocyte sedimentation rate (ESR) and radiographs with erosive changes (Figure 97-1, B). Choices for therapy include nonsteroidal anti-inflammatory drugs (NSAIDs) in conjunction with a conventional synthetic disease-modifying anti-rheumatic drug (csDMARD), such as methotrexate. Many other medications are now available for patients who do not respond to initial therapy.

FIGURE 97-1

Psoriatic arthritis at initial presentation in a 50-year-old woman with psoriasis and new-onset hand pain. A. Note the prominent involvement of the distal interphalangeal joints. B. Radiography showing early psoriatic arthritis changes with periarticular erosions seen at the distal interphalangeal joints. (Reproduced with permission from Richard P. Usatine, MD.)

INTRODUCTION

Arthritis means joint inflammation; however, the term is used for any disease or condition that affects joints or the tissues around the joints. Joint pain can be classified as monoarticular or polyarticular and inflammatory or noninflammatory. Diagnosis is based on a combination of clinical presentation, synovial fluid analysis, other laboratory tests, and radiographic findings. Management goals include minimizing joint damage, controlling pain, maximizing function, and improving quality of life.

EPIDEMIOLOGY

  • More than 50 million adults in the United States have been diagnosed with arthritis by a physician.

  • Arthritis is more common in women than men with age-adjusted prevalence of 23.5% compared to 18.1%.1

  • Arthritis is the most common cause of disability in the United States. Twenty-three million adults have functional limitations because of arthritis.1

  • Fifty percent of adults age 65 years or older have been diagnosed with arthritis.1

  • One in every 250 children younger than the age of 18 have some form of arthritis.2

  • In 2003, the total cost attributable to arthritic conditions was $128 billion.1

ETIOLOGY AND PATHOPHYSIOLOGY

Arthritis can be caused by one of several mechanisms.

  • Noninflammatory arthritis (i.e., osteoarthritis) is caused by bony overgrowth (osteophytes) and degeneration of cartilage and underlying bone (Figures 97-2 and 97-3).

  • Autoimmune arthritis (i.e., rheumatoid arthritis, systemic lupus erythematosus [SLE], psoriatic arthritis) is caused by an inappropriate immune response.

  • Crystalline arthritis (i.e., gout, calcium pyrophosphate dehydrate deposition disease) is caused by deposition of uric acid crystals (gout) or calcium pyrophosphate dehydrate crystals (CPPD) resulting in episodic flares with periods of remission.

  • Septic arthritis can be caused by many types of infectious agents, but is most commonly caused ...

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