A 65-year-old man with a history of extensive psoriasis presented with debilitating stiffness and pain. He lives an active lifestyle, but his recent pain is getting in the way of the activities he enjoys. he had seen multiple providers before he met a dermatologist who felt that his joint pain deserved a little more investigation.
Suzanne Gharib, M.D.
Dr. Gharib is a board-certified rheumatologist practicing in South Charleston, West Virginia and Morgantown, West Virginia. She graduated from West Virginia University Medical School and completed residency at the University of Kentucky and a fellowship at the University of Pittsburgh. Dr. Gharib is passionate about patient care.
DDx SEASON 2, EPISODE 4 TRANSCRIPT
More than skin deep
Raj: This episode is sponsored by Novartis Pharmaceuticals Corporation.
Raj: A 65-year-old man with an active lifestyle presents with debilitating stiffness and pain.
Raj: This is DDx, a podcast from Figure 1 about how doctors think. This season is all about dermatology. I’m Dr. Raj Bhardwaj. Today’s case comes from Dr. Suzanne Gharib. Dr. Gharib is a paid presenter for Novartis.
Suzanne Gharib: I’m a rheumatologist in a rheumatology-only practice with two partners and a nurse practitioner.
Raj: The patient was otherwise very healthy, so the cause of his stiffness wasn’t immediately apparent.
Suzanne Gharib: Well, this gentleman was very interesting. He was 65. So he was just recently retired and he’d been a schoolteacher for years and a very active man who had young grandchildren and just very active. And he was noticing kind of difficulty doing the things he liked to do. So basic stuff from caring for his grandchildren to traveling with his wife. He stays very active. He travels frequently. I think the last time I saw him, he’d just gotten back from a trip with his grandchildren so.
Raj: He’d been putting up with the discomfort for some time, but he noticed it was getting worse.
Suzanne Gharib: It was I think it was … it had gone on for several years and he had tried a variety of treatments and just wasn’t achieving relief. And I had kind of gotten gradually worse and it was impairing his lifestyle.
Raj: He had a history of extensive psoriasis, but his skin wasn’t his main concern.
Suzanne Gharib: He had seen several dermatologists for about 15 years prior to meeting me, with fairly significant psoriasis. He had it covering his chest, his back, his arms, legs and scalp. But that really was not his major complaint. He’d tried various therapies for it, including ultraviolet light. He had tried various creams as well as some systemic medications. But his big complaint when I saw him was his joints were really starting to bother him. He was having a lot of stiffness and pain in his hands, pain in his right trochanteric bursa, and he was just, it was impacting his day to day activity.
Raj: With such pervasive psoriasis, his complaints of stiffness weren’t really being heard.
Suzanne Gharib: I think that several providers didn’t think about this presentation and because, again, his psoriasis was fairly aggressive. So I think it almost blinded everybody to the other complaints that he had because he had seen multiple providers before he’d gotten to the dermatologist who felt that his joint pain deserved a little more investigation in and of itself.
Raj: But this is the point of having a DDx. You need to look at the patient as a whole, not just what you think is their most obvious symptom.
Suzanne Gharib: I think the focus was being driven more to his skin. And when I sat down and spoke with him the first time we met, he had no concerns about his skin. He’d had psoriasis for years. He wasn’t terribly concerned about the appearance of it or the severity of it. But I think it was the focus of his treatment prior to my meeting him. So I think that can tend to happen and a lot of times we presume that, you know, someone in their 60s is going to have some joint pain. So I don’t think anybody took him very seriously. And I think he had symptoms for several years before somebody kind of registered that, wait a minute, this is connected and it needs to be further addressed.
Raj: Finally, a dermatologist clued in that this was likely systemic inflammation.
Suzanne Gharib: And the dermatologist he was seeing at that time felt that he should see rheumatology, that we should become involved in his care at that point. So after discussing with him, you know, I’m getting a little more detail, he was having a lot of morning stiffness. He was having some episodic swelling in different joints in his hands. So the story really was emerging that he probably had psoriatic arthritis. At which time, I went ahead and ordered some bloodwork, some X-rays to kind of try and better understand his underlying process. And even though his X-rays at that time looked fairly normal, his bloodwork showed a very elevated C-reactive protein, which is indicative of inflammation, was about three times normal at that point in time.
Raj: X-rays are used to look for long-term damage in patients with psoriatic arthritis, and inform the urgency of treatment.
Suzanne Gharib: So, you know, the elevated CRP that he had is a marker of inflammation. That’s a pretty specific marker of inflammation. And it coincided with the symptoms he was describing, that prolonged stiffness, the recurrent swelling. And it was a nice objective look to say, how inflamed is this gentleman? And once we started him on treatment, that actually became normal.
Raj: Psoriatic arthritis is more than just stiffness. Left untreated, it can dramatically affect quality of life, or worse.
Suzanne Gharib: Well, aside from the day in, day out disability and the kind of limitations in the daily living, it can cause significant joint damage which can lead to disability and inability to work so that that can be very impactful on a patient’s livelihood even. It also carries consequences like everything else. These patients are at higher risk for heart disease. They’re a higher risk for lung disease. So there’s a lot of negative outcomes from lack of treatment.
Raj: Just because someone has psoriasis and joint pain, it doesn’t necessarily mean it’s psoriatic arthritis. Think of the DDx.
Suzanne Gharib: So there’s several things you have to walk through. I mean, patients with psoriasis tend to also have osteoarthritis, so it’s not uncommon, you have to make sure it’s not that. It’s not uncommon to see patients with psoriasis have a multitude of other autoimmune diseases. Some patients with rheumatoid arthritis also have psoriasis as well as ankylosing spondylitis or undifferentiated spondyloarthropathy. So there’s a variety of different diseases that travel in the same pathways. So you have to be cognizant of those and work through them. So I did an evaluation for all of the above.
Raj: This patient was very familiar with his psoriasis, but didn’t make the link between his rash and his joint pain.
Suzanne Gharib: I think it’s something we hear about on television. There’s commercials of people who have psoriatic arthritis and I think it’s said in passing. And I think it’s still an underrecognized form of arthritis, of inflammatory arthritis.
Suzanne Gharib: Shortly after meeting him and I saw his blood work, I said we need to start you on treatment geared less towards the skin, which while the skin is important, we really need to focus in on what’s going to be more effective for your joints. And that’s kind of how we’ve geared his treatment is joints first, skin second. And he’s responded incredibly well and very… I’ve been seeing him for several years, he’s very stable.
Raj: Even some healthcare practitioners often confuse the condition with something else, says Dr. Gharib.
Suzanne Gharib: And I think psoriatic disease kind of got lumped in with rheumatoid arthritis. And we’re starting to see within the science that it’s unique in its own right. And as we are developing that awareness, I think that gradually spreads and we learn to understand it. But I think it is just a lag in fully understanding the disease. I think it’s important to hear about it in dermatology offices. I think primary care doctors educating themselves around psoriatic disease is very important and it validates a patient’s journey.
Raj: Dr. Gharib has advice for patients who feel unheard — and for the healthcare providers treating them.
Suzanne Gharib: So I think from a self-advocacy standpoint, I think it’s important to kind of persist in saying if there are symptoms that they need to at least be worked up or that they need to be addressed by the proper practitioner. From a physician standpoint, I think it’s important to understand that this is emerging and that it’s particularly in fields where you’re seeing the manifestations of this disease. If you’re a dermatologist, you need to at least be cognizant of the joint pain and its association with psoriasis. If you’re any of the other specialties — to know the manifestations of this disease in your patient. I think it’s important that, you know, you listen to the patient because they will tell you their primary concerns. And I think it’s important to focus on those concerns because I am still shocked at how little he cared about his skin.
Thanks to Dr. Suzanne Gharib for speaking with us.
This is DDx, a podcast by Figure 1.
Figure 1 is an app that lets doctors share clinical images and knowledge about difficult-to-diagnose cases.
I’m Doctor Raj Bhardwaj, host and story editor of DDx. You can follow me on Twitter at RajBhardwajMD
Ddx is produced by David Crosbie for Earshot Podcasts.
Sound design and mixing by Chandra Bulucon.
Our theme music is by Nathan Burley.
The executive producers of DDx are Jesse Brown and Kevin Sexton.
Head to Figure1.com/ddx, where you can find full show notes, photos, and speaker bios.
This episode was brought to you by Novartis Pharmaceuticals Corporation.
Thanks for listening.