Introduction

Psoriatic arthritis (PsA) is a chronic inflammatory disease, characterized by a wide spectrum of clinical manifestations that can vary over time.¹ PsA is associated with psoriasis in up to 42% of cases, and up to 15% of patients with psoriasis have undiagnosed PsA. Diagnosis is based on a family or personal history of psoriasis, genetic markers, presence of dactylitis, enthesitis, and pattern of joint occurrence. Wright and Moll´s work classify PsA into polyarticular, asymmetric oligoarticular, distal interphalangeal joint, spondylitis and muti-lating arthritis. The most common presentation is an overlap between various forms of PsA.² Mutilating arthritis is a rare, aggressive, and an advanced clinical form, in which osteolysis and destructive changes in joints lead to irreversible deformities and loss of function of the fingers.³

Case Report

A 84-years-old woman, with a history of 50 years of evolution of PsA with refusal of medical follow-up and treatment, was admitted in the emergency room prostrated. On examination she had a cachectic appearance, psoriatic skin lesions, nail changes, axial ankylosis and hands with “telescopic fingers” (Fig. 1). The radiography of the hands (Fig. 2) revealed “pencil-in-cup” deformities, involvement of distal interphalangeal bones, resorption of the bone with dissolution of the joints and fusion of fingers.

Figure 1: Picture of patient’s hands showing psoriatic skin lesions with involvement of nails and “telescopic fingers”, which refers to when the bones dissolve and the soft tissues can not hold the fingers up allowing a telescopic-like movement. 

Figure 2: Radiography of the hands showing absence of bilateral carpal bones, with cubit and radius continuous to the metacarpo-phalangeal joints, a separation of the base of the phalanges with narrowing of the metacarpal tips (“pencil-in-cup” deformities), with involvement of the distal interphalangeal joints and significant resorption of the bone, with dissolution of the joints and fusion of fingers. 

Discussion

PsA is a disease of destructive and progressive nature, that can have significant impact on people´s quality of life.⁴ Mutilating arthritis is the most severe and destructive form of PsA, and its incidence range from 3.7% to 6.7%. The specific characteristics of mutilating arthritis are well documented and include telescope finger, digital shortening, deformities “pencil-in-cup”, osteolysis, involvement of the distal interphalangeal joints and other small joints of the hands.⁵ Early recognition and treatment of this pathology allow a better prognosis of the disease. Nowadays severe deformities, as the ones pre-sent in this case, are extremely rare.^4,6

Declaração de Contribuição / Contributorship Statement:

C. Fernandes, M. Silva, J. Braga, A. S. Barroso - Elaboração e Revisão do artigo