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Medscape
29-05-2025
- General
- Medscape
Skill Checkup: A Man With Plaque Psoriasis and Joint Pain
A 46-year-old White man with a 10-year history of moderate to severe plaque psoriasis presents with worsening joint symptoms. He has been treated with topical steroids for the past 2 years but reports that his psoriasis flare-ups have become more frequent and more severe over the past 6 months. Over the past 3 months, he has developed progressive joint pain, swelling, and stiffness primarily affecting the distal interphalangeal (DIP) joints of his hands. He notes that the stiffness is worst in the morning, lasting more than an hour, but improves with activity. He denies having recent trauma, fever, or infectious symptoms. On physical exam, there is visible swelling of several fingers and toes (described as "sausage digits," consistent with dactylitis) and nail pitting. No tenderness or decreased range of motion is noted in the axial skeleton. Laboratory results show an elevated C-reactive protein level and erythrocyte sedimentation rate, but rheumatoid factor (RF) and antinuclear antibody are negative. This patient's psoriasis history, DIP joint involvement, dactylitis, and nail pitting are characteristic of psoriatic arthritis (PsA). The presence of active psoriasis and nail changes strongly points to PsA as the most likely cause of this patient's joint disease as well. In contrast, rheumatoid arthritis (RA) typically causes a symmetric polyarthritis of the hands that favors the proximal joints (metacarpophalangeal and proximal interphalangeal joints), while DIP joints are usually not involved. Positive RF or anti–citrullinated peptide (anti-CCP) antibodies are seen in most cases; the patient's asymmetric DIP joint arthritis and negative RF make RA unlikely. Osteoarthritis (OA) can affect DIP joints, but it is a noninflammatory degenerative arthritis that usually presents at an older age with brief morning stiffness and pain that worsens with activity, often with bony enlargements (Heberden's nodes) rather than diffuse swelling; unlike PsA, OA does not often cause intense inflammation, dactylitis, or nail pitting. OA DIP joint changes are usually due to osteophytes ("bone spurs") without the psoriatic nail lesions. Reactive arthritis (ReA) is a seronegative spondyloarthritis like PsA and can cause asymmetric oligoarthritis with enthesitis/dactylitis; however, ReA is usually triggered by a recent infection and often involves the lower extremities (knees, ankles, and toes) with extra-articular features like urethritis or conjunctivitis, which are not seen here. PsA classically produces erosive changes with new bone formation on radiographs. In advanced disease, DIP joints can erode into a pencil-in-cup deformity, where the phalanx tapers and "cups" into an eroded adjacent bone. Though this can occur in other inflammatory diseases, it is most commonly associated with PsA. Such combined erosive and proliferative bone changes are highly suggestive of PsA and are not typically seen in RA (which shows only erosions with osteopenia) . Positive anti-CCP antibody more strongly supports RA rather than PsA, as PsA is usually seronegative for RA markers, such as the RF and anti-CCP antibodies. Uric acid crystals in joint fluid would more likely indicate gout, not PsA. While patients with PsA have been shown to experience a higher risk for gout, the presentation in this case (chronic DIP joint arthritis with nail changes) is not consistent with it. HLA-B27 antigen is associated with PsA in those who have axial (spinal) involvement, but it is less common patients with PsA and without spine disease. The patient has no axial symptoms, so HLA-B27 testing would be of limited value. Moreover, HLA-B27 is not required to diagnose PsA. The Classification of PsA (CASPAR) criteria is the internationally accepted standard for classifying PsA. It requires the presence of inflammatory arthritis (joints, spine, or entheses) plus a total of at least 3 points from features including: Current psoriasis (2 points) or personal/family history of psoriasis (1 point); psoriatic nail changes (pitting or onycholysis, 1 point); dactylitis (swelling of an entire digit, 1 point); negative RF (1 point); and juxta-articular new bone formation on radiography (1 point). PsA is diagnosed using the CASPAR criteria in patients with inflammatory arthritis who score at least 3 points, with the criteria demonstrating high specificity and sensitivity and serving as the preferred diagnostic tool once other differentials are excluded. This patient meets the CASPAR criteria as he has inflammatory arthritis with psoriasis, nail pitting, and dactylitis and is RF-negative. The American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) criteria are typically used for RA, not PsA, and emphasize symmetric joint involvement and RA-specific antibodies (RF/anti-CCP) and do not apply here. The modified New York criteria are used to classify ankylosing spondylitis, focusing on axial skeletal findings (eg, sacroiliitis on radiography and low back pain), which are not the primary issue in this patient. The Jones Criteria are designed for acute rheumatic fever diagnosis and are unrelated to PsA. The patient is diagnosed with moderate to severe PsA, and given his dactylitis, arthritis, and skin involvement, he is given methotrexate as initial therapy owing to cost-effectiveness; however, he returns to his next appointment, and his PsA remains active. In a patient with moderate to severe PsA that is inadequately controlled on a conventional synthetic DMARD (methotrexate), experts recommend escalating to a biologic DMARD. Tumor necrosis factor (TNF) inhibitors (such as adalimumab, etanercept, or infliximab) are a proven biologic choice for PsA, effective for both joint and skin symptoms. The latest Group for Research and Assessment of Psoriasis and PsA (GRAPPA), ACR, and EULAR guidelines endorse using a TNF inhibitor (or another biologic/targeted therapy) once conventional DMARD therapy fails to achieve remission. In this case, adding a TNF inhibitor is appropriate to control joint inflammation and prevent further damage while also improving psoriasis. Switching to another conventional DMARD (like sulfasalazine or leflunomide) is generally less effective in patients with moderate to severe disease; this method is typically more effective in mild to moderate cases. Oral corticosteroid are generally not recommended for routine PsA management, as they might worsen disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help symptomatically, but they are most appropriate in mild PsA, not moderate to severe disease. This patient has active polyarthritis and progressive symptoms, requiring disease-modifying therapy, and using NSAIDs without advancing systemic treatment would allow ongoing joint damage. An oral phosphodiesterase 4 (PDE-4) inhibitor can be used as an alternative for patients who prefer an oral medication and want to avoid injections. Further, current GRAPPA guidelines and ACR guidelines include PDE-4 inhibitors among the recommended treatment options for active PsA. The potency of PDE-4 inhibitors (such as apremilast) are likely not as strong as Janus kinase inhibitors in moderate to severe cases of PsA. However, the latter needs to be weighed carefully against PDE-4 inhibitors due to higher risks for infection among other long-term side effects. In moderate to severe cases of PsA, 5-aminosalicylic acid derivatives, such as sulfasalazine, are typically not very effective; they are reserved for add-on therapy in case of mild disease activity. Calcineurin inhibitor can help severe psoriatic skin lesions, but they are not a preferred therapy for PsA joint manifestations. Antimalarial drugs can be considered when previous DMARDs use is ineffective or if joint inflammation remains a significant concern, but they are not typically recommended in PsA as they might lead to psoriasis flare-ups. Editor's Note: Skill Checkups are wholly fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
CNN
09-02-2025
- CNN
Residents in Cincinnati confronted White supremacist demonstrators, three months after neo-Nazi march in another Ohio city
Local residents confronted and drove off neo-Nazi demonstrators waving large swastika-emblazoned flags along a highway overpass on Friday between Lincoln Heights and Evendale, Ohio, home to a historically Black community that has endured a long history of racism. White nationalist groups in Ohio have recently grown increasingly brazen in expressing hateful rhetoric and racist ideologies. Last November, Hate Club, a newly formed White supremacist organization, paraded through a Columbus neighborhood, waving swastika flags and shouting racist slurs. About a dozen neo-Nazis, wearing all black clothing and red face masks the marchers in Columbus also wore, were seen on traffic cameras waving the swastika flags. They had also pinned red swastika banners on the fence of the overpass and a sign reading 'America for the White Man,' according to photos shared with CNN. Swastikas are a notorious symbol of hate, antisemitism and White supremacy tracing to the murderous legacy of Germany's Nazi Party and the Holocaust. In footage documented by CNN affiliate WLWT, people can be seen walking up to the demonstrators as police officers stood in between them. Moments within confronting them, the neo-Nazis quickly backed up, jumped into a U-Haul box truck and left the scene. Law enforcement officials at the scene can also be seen ushering the demonstrators into the U-Haul truck and waving at them to go. Police became aware of 'unannounced protest activity' around 2 p.m. on Friday on Vision Way overlooking Interstate 75, the Evendale Police Department said in a news release. Evendale is about 12 miles north of downtown Cincinnati. 'The protest, while very offensive, was not unlawful,' police said. 'The protest was short lived in duration. The protestors left the area on their own. No further action was taken by the Evendale Police Department.' Events organized or attended by White supremacists in the United States hit a new high in 2023, the Anti-Defamation League reported. Public gatherings of White nationalists or people with Nazi flags have unfolded in recent years in Nashville, New Hampshire, Boston, Virginia, Michigan and Washington, DC. 'We are underestimating the dangers of the police not even attempting to identify them. Who are they trying to protect? Because it isn't us,' local resident Kachara Talbert, who confronted the protesters, told CNN. 'It could be another Hitler behind those masks. It could be a school shooter behind those masks.' The Vision Way overpass connects Evendale to the village of Lincoln Heights, the first all-Black, self-governing city north of the Mason-Dixon Line, according to the Cincinnati Preservation Association. Evendale is also just two miles away from Reading, which used to be one of thousands of White-only communities throughout the US known as 'sundown towns,' where local laws prohibited Black people and other people of color to be out after sunset to intimidate them from living in the area. 'The sign they posted said 'America for the White Man' and it makes me ask, what makes this group, that literally originated in another country, think they are more entitled to America than me and my folks?' Talbert said. 'This country was made of Black blood, sweat and tears, so why do these colonizers feel so comfortable?' The Hamilton County Sheriff's Office responded to the scene and helped de-escalate the situation 'and make sure that no one was hurt,' Sheriff Charmaine McGuffey said in a statement. 'Lincoln Heights residents are understandably upset,' the statement read. 'We continue to work with the community, and emphasize that there is no place for hate in Hamilton County.' Cincinnati Mayor Aftab Pureval also released a statement on X condemning the incident and said it was 'shocking and disgusting to see swastikas displayed in Evendale today.' 'This is not what we stand for, and it will never be what we stand for,' the mayor added. 'Messages of hate like this have no place in our region.' CNN has reached out to the mayor, Ohio Gov. Mike DeWine, the Evendale Police Department and the Hamilton County Sheriff's Office for additional comment but did not receive a reply. The statements from officials and law enforcement upset local residents who said the lack of effort to hold the racist demonstrators accountable will enable them to return and sends a message to Americans that what they are doing is acceptable. 'Their statements talk about how hate has no place here, but no justice was served. These are terrorists we're talking about,' Talbert said. 'Seeing the flag being represented here and seeing the police stand there in what looked like unity, not disgust, made us feel like they're saying what the Nazis stand for is OK.' News of the demonstrators' display spread quickly throughout the city as photos and videos were shared all over Facebook. One by one, dozens of residents, including Talbert, showed up to form a crowd that did not hesitate to approach the neo-Nazis and pull one of their flags, which they later set on fire. 'Anger and rage just came over me. I literally got there in about 15 minutes,' Talbert told CNN. 'The Nazis were disrespecting my family, my lineage, my heritage. I took it very much personally. I needed to be there to take that flag down, and I needed to push those people out of our community.' As they approached the neo-Nazis, the demonstrators, which Talbert said were carrying guns, called them the N-word. Video posted by an unknown account on Facebook obtained by local community members showed what appeared to be the demonstrators from Friday using the N-word and other derogatory language to refer to approaching residents who were coming to confront them. 'Look at the n***ers coming,' one masked demonstrator says, as multiple others echo the racist slur. Another says, 'the cops are going to give us an escort to Freddy's car,' and another replies 'f**k yeah.' Talbert said the chaotic confrontation lasted just minutes before the demonstrators hurriedly ran off in the U-Haul. 'Members of my community ripped the flag out of their hand and burned it up, we spit on it, and if needed, it really could have gotten ugly,' Talbert said. 'We will not hesitate to protect our community. And after the show they put on, every Black community that you can think of is going to show up for us 100%.' The lack of action from law enforcement to question and obtain the identities of the demonstrators was an 'insult' to the community, Talbert said, which she says has seen the same police department interrogate locals and minors for simple, non-dangerous offenses like congregating on sidewalks. 'I've watched Black men all my life in this community being frisked and detained without probable cause,' she said. 'But I didn't see any rubber bullets that day. I didn't see anybody getting shot, like during Black Lives Matter protests. I didn't see gas. The calmness of the police overall, the way they were standing in front of them, it made us very upset.' Teressa Brooks, who is also from Lincoln Heights, said the demonstrators called her an 'N-word b*tch.' During the confrontation between the neo-Nazis and local residents, Brooks said police told them they were exercising their freedom of speech. Shya Smith, another Lincoln Heights resident who stood up to the demonstrators, told CNN her community believes President Donald Trump and his administration have given the White nationalists the confidence to show up without fear of being punished. 'It is so upsetting to see how a group of extremist people who promote hate can 'peacefully' protest while openly carrying rifles just 700 yards away from an elementary school,' she said. 'And it's a slap in the face to watch the police protect them while a predominantly African American neighborhood fears for their safety and well-being.' Despite the fear, anger and pain that has reverberated through the community in the wake of this reprehensible incident, it is unwavering love and unyielding unity that has emerged in response, sending a clear message to the hate-filled demonstrators: their behavior is not welcome here. Throughout the following morning and afternoon, local residents and neighbors from nearby towns gathered at the same overpass, this time holding signs and posters of solidarity, including one that read, 'My father fought Nazis, and so will I.' As they were doing so, three cars belonging to the peaceful demonstrators had their rear windshields shattered by unknown perpetrators, according to Kim Lachance, whose car was broken into. 'I came here because I couldn't just sit by and not do anything for any longer,' Lachance, who grew up in Lincoln Heights during desegregation, told CNN from the parking lot where her car had been vandalized. 'We have to fight back.' Lachance was holding a sign that said 'love' when two women drove by and stopped their cars to come out to give her a hug. 'They were crying because they said yesterday they were so heartbroken,' Lachance said. 'We have to take care of our communities, especially ones that have gone through things like this and continue to go through things like this.' The presence of White supremacist groups in Ohio is not new. In the early 20th century, the Ku Klux Klan bombed the University of Dayton, held rallies in the state and assembled in towns such as Westerville, where the group established a stronghold. 'When you have years and years of oppression and you have Nazi supporters in office, as police officers, judges, that is what's making these people feel confident to do something like that,' Talbert said. 'America needs to stand up and stop this madness, because it's only going to get worse and it's going to get dangerous.'
Yahoo
09-02-2025
- Yahoo
Residents of historic Black community near Cincinnati confront White supremacist demonstrators, months after neo-Nazi march
Local residents confronted and drove off neo-Nazi demonstrators waving large swastika-emblazoned flags along a highway overpass on Friday in Evendale, Ohio, home to a historically Black community that has endured a long history of racism. White nationalist groups in Ohio have recently grown increasingly brazen in expressing hateful rhetoric and racist ideologies. Last November, Hate Club, a newly formed White supremacist organization, paraded through a Columbus neighborhood, waving swastika flags and shouting racist slurs. About a dozen neo-Nazis, wearing all black clothing and red face masks the marchers in Columbus also wore, were seen on traffic cameras waving the swastika flags. They had also pinned red swastika banners on the fence of the overpass and a sign reading 'America for the White Man,' according to photos shared with CNN. Swastikas are a notorious symbol of hate, antisemitism and White supremacy tracing to the murderous legacy of Germany's Nazi Party and the Holocaust. In footage documented by CNN affiliate WLWT, people can be seen walking up to the demonstrators as police officers stood in between them. Moments within confronting them, the neo-Nazis quickly backed up, jumped into a U-Haul box truck and left the scene. Law enforcement officials at the scene can also be seen ushering the demonstrators into the U-Haul truck and waving at them to go. Police became aware of 'unannounced protest activity' around 2 p.m. on Friday on Vision Way overlooking Interstate 75, the Evendale Police Department said in a news release. Evendale is about 12 miles north of downtown Cincinnati. 'The protest, while very offensive, was not unlawful,' police said. 'The protest was short lived in duration. The protestors left the area on their own. No further action was taken by the Evendale Police Department.' Events organized or attended by White supremacists in the United States hit a new high in 2023, the Anti-Defamation League reported. Public gatherings of White nationalists or people with Nazi flags have unfolded in recent years in Nashville, New Hampshire, Boston, Virginia, Michigan and Washington, DC. 'We are underestimating the dangers of the police not even attempting to identify them. Who are they trying to protect? Because it isn't us,' local resident Kachara Talbert, who confronted the protesters, told CNN. 'It could be another Hitler behind those masks. It could be a school shooter behind those masks.' The Vision Way overpass connects Evendale to the village of Lincoln Heights, the first all-Black, self-governing city north of the Mason-Dixon Line, according to the Cincinnati Preservation Association. Evendale is also just two miles away from Reading, which used to be one of thousands of White-only communities throughout the US known as 'sundown towns,' where local laws prohibited Black people and other people of color to be out after sunset to intimidate them from living in the area. 'The sign they posted said 'America for the White Man' and it makes me ask, what makes this group, that literally originated in another country, think they are more entitled to America than me and my folks?' Talbert said. 'This country was made of Black blood, sweat and tears, so why do these colonizers feel so comfortable?' The Hamilton County Sheriff's Office responded to the scene and helped de-escalate the situation 'and make sure that no one was hurt,' Sheriff Charmaine McGuffey said in a statement. 'Lincoln Heights residents are understandably upset,' the statement read. 'We continue to work with the community, and emphasize that there is no place for hate in Hamilton County.' Cincinnati Mayor Aftab Pureval also released a statement on X condemning the incident and said it was 'shocking and disgusting to see swastikas displayed in Evendale today.' 'This is not what we stand for, and it will never be what we stand for,' the mayor added. 'Messages of hate like this have no place in our region.' CNN has reached out to the mayor, Ohio Gov. Mike DeWine, the Evendale Police Department and the Hamilton County Sheriff's Office for additional comment but did not receive a reply. The statements from officials and law enforcement upset local residents who said the lack of effort to hold the racist demonstrators accountable will enable them to return and sends a message to Americans that what they are doing is acceptable. 'Their statements talk about how hate has no place here, but no justice was served. These are terrorists we're talking about,' Talbert said. 'Seeing the flag being represented here and seeing the police stand there in what looked like unity, not disgust, made us feel like they're saying what the Nazis stand for is OK.' News of the demonstrators' display spread quickly throughout the city as photos and videos were shared all over Facebook. One by one, dozens of residents, including Talbert, showed up to form a crowd that did not hesitate to approach the neo-Nazis and pull one of their flags, which they later set on fire. 'Anger and rage just came over me. I literally got there in about 15 minutes,' Talbert told CNN. 'The Nazis were disrespecting my family, my lineage, my heritage. I took it very much personally. I needed to be there to take that flag down, and I needed to push those people out of our community.' As they approached the neo-Nazis, the demonstrators, which Talbert said were carrying guns, called them the N-word. Video posted by an unknown account on Facebook obtained by local community members showed what appeared to be the demonstrators from Friday using the N-word and other derogatory language to refer to approaching residents who were coming to confront them. 'Look at the n***ers coming,' one masked demonstrator says, as multiple others echo the racist slur. Another says, 'the cops are going to give us an escort to Freddy's car,' and another replies 'f**k yeah.' Talbert said the chaotic confrontation lasted just minutes before the demonstrators hurriedly ran off in the U-Haul. 'Members of my community ripped the flag out of their hand and burned it up, we spit on it, and if needed, it really could have gotten ugly,' Talbert said. 'We will not hesitate to protect our community. And after the show they put on, every Black community that you can think of is going to show up for us 100%.' The lack of action from law enforcement to question and obtain the identities of the demonstrators was an 'insult' to the community, Talbert said, which she says has seen the same police department interrogate locals and minors for simple, non-dangerous offenses like congregating on sidewalks. 'I've watched Black men all my life in this community being frisked and detained without probable cause,' she said. 'But I didn't see any rubber bullets that day. I didn't see anybody getting shot, like during Black Lives Matter protests. I didn't see gas. The calmness of the police overall, the way they were standing in front of them, it made us very upset.' Shya Smith, another Lincoln Heights resident who confronted the demonstrators after they called her an 'N-word b*tch,' told CNN her community believes President Donald Trump and his administration have given the White nationalists the confidence to show up without fear of being punished. 'It is so upsetting to see how a group of extremist people who promote hate can 'peacefully' protest while openly carrying rifles just 700 yards away from an elementary school,' she said. 'And it's a slap in the face to watch the police protect them while a predominantly African American neighborhood fears for their safety and well-being.' Despite the fear, anger and pain that has reverberated through the community in the wake of this reprehensible incident, it is unwavering love and unyielding unity that has emerged in response, sending a clear message to the hate-filled demonstrators: their behavior is not welcome here. Throughout the following morning and afternoon, local residents and neighbors from nearby towns gathered at the same overpass, this time holding signs and posters of solidarity, including one that read, 'My father fought Nazis, and so will I.' As they were doing so, three cars belonging to the peaceful demonstrators had their rear windshields shattered by unknown perpetrators, according to Kim Lachance, whose car was broken into. 'I came here because I couldn't just sit by and not do anything for any longer,' Lachance, who grew up in Lincoln Heights during desegregation, told CNN from the parking lot where her car had been vandalized. 'We have to fight back.' Lachance was holding a sign that said 'love' when two women drove by and stopped their cars to come out to give her a hug. 'They were crying because they said yesterday they were so heartbroken,' Lachance said. 'We have to take care of our communities, especially ones that have gone through things like this and continue to go through things like this.' The presence of White supremacist groups in Ohio is not new. In the early 20th century, the Ku Klux Klan bombed the University of Dayton, held rallies in the state and assembled in towns such as Westerville, where the group established a stronghold. 'When you have years and years of oppression and you have Nazi supporters in office, as police officers, judges, that is what's making these people feel confident to do something like that,' Talbert said. 'America needs to stand up and stop this madness, because it's only going to get worse and it's going to get dangerous.'
