Case study | diagnosing unspecific back pain in a 67-year-old patient with psoriasis and PsA

Patients with psoriasis and psoriatic arthritis (PsA) may present with unspecific back and spinal pain, which may be related to their psoriatic disease.¹ Here, we summarize a case study originally presented by Vladimirova at the European Alliance of Associations for Rheumatology (EULAR) 2023 Congress.¹ This case highlights the importance of imaging for the differential diagnosis of patients with psoriasis.

Figure 1. Patient history* 

NSAID, non-steroidal anti-inflammatory drug.
*Data from Vladimirova.¹

The patient was diagnosed with psoriasis in their early 20's.¹ They developed PsA during their first pregnancy and then, during their second pregnancy, developed pelvic pain which did not resolve after delivery. During their thirties, this patient also developed cervical spine pain, nail psoriasis, and non-radiographic axial PsA. The patient timeline and treatments given are shown in Figure 2.¹

Figure 2. Patient timeline, with diagnoses and treatments* 

NSAID, non-steroidal anti-inflammatory drug; PsA, psoriatic arthritis, UV, ultraviolet radiation.
*Data from Vladimirova.¹ 

After experiencing lower back and buttock pain, especially in the left hip, an MRI of sacroiliac joint revealed sacroiliitis and bilateral bone marrow oedema with T1 structural changes.¹ No radiographic changes were found in the sacroiliac joint. The patient was diagnosed with non-radiographic axial PsA at age 43, and treatment was changed to an interleukin-17 inhibitor (secukinumab) to cover all affected domains.¹

Hypothetically, a proposed flare of symptoms has affected the patient at age 67. The problems that the patient is experiencing are shown in Figure 3 and a treatment plan is outlined in Figure 4.

Figure 3. Patient symptoms* 

CT, computed tomography; MRI, magnetic resonance imaging; NSAID, non-steroidal anti-inflammatory drug.
*Data from Vladimirova.¹

Figure 4.  Treatment plan* 

*Data from Vladimirova.¹

Degenerative vs inflammatory disease: How can imaging help?²

In this case study, imaging was informative when diagnosing the causes of back pain. Imaging can also help clinicians to identify whether psoriatic disease is degenerative or inflammatory. Figure 5 illustrates which imaging techniques can be applied to each indication, but does not take into account the specificity of each technique.

Figure 5. Effectiveness of imaging techniques*

CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasound.
*Adapted from Østergaard.²