A 55-year-old man with a history of open-angle glaucoma, urolithiasis, sinusitis, and asthma presented with bilateral conjunctival hyperemia accompanied by pain, photophobia, and decreased visual acuity. He presented for consultation with a diagnosis of idiopathic bilateral uveitis made in another center, where infectious and autoimmune diseases were ruled out through laboratory and imaging investigations (Table 1a).

Table 1 Ancillary investigations to determine the etiology of uveitis

In the first ophthalmological center, he was initially treated with 17.5 mg/week of methotrexate (MTX), which was suspended for 3 weeks due to bacterial sinusitis. Consequently, the uveitis relapsed 3 months later with bilateral grade II pigment dispersion in the anterior chamber (AC), mild inflammation in the AC (0.5 + cells) of the right eye (OD), and moderate inflammation in the AC (1 + cells) of the left eye (OS). Therefore, 20 mg/day of prednisolone and topical prednisolone were added to the treatment regimen alongside 17.5 mg per week of MTX administered orally. Two months later, ocular inflammation worsened, and treatment failure was considered.

Subsequently, the patient was referred to our center for a second opinion. During the physical examination, attention was brought to the nails because the patient showed characteristic lesions of nail psoriasis, including pitting, onycholysis, crumbling, and sub-ungual hyperkeratosis along the second, third, and fifth fingers on the right hand and the first finger of the left hand (Fig. 1). Appropriate anamnesis and physical examination were performed to exclude any skin involvement suggestive of psoriasis and any signs or symptoms concordant with PsA.

Fig. 1
figure 1

Macroscopic findings on the nails. a Third finger of the right hand showing sub-ungual hyperkeratosis, crumbling, leukonychia, distal onycholysis, and pitting. b First finger of the right hand showing distal onycholysis. c Fifth finger of the right hand with sub-ungual hyperkeratosis, crumbling, and distal onycholysis. d Second finger of the left hand showing distal onycholysis and pitting

On ophthalmological examination, the best-corrected visual acuity was 20/20 in both eyes (OU). Positive findings at slit-lamp examination were Meibomian gland dysfunction, moderate conjunctival hyperemia, gerontoxon, and AC inflammation with 1 + cells according to the SUN grading OD (Fig. 2) similar findings with the only difference being AC cells graded as 0.5 + OS. Nuclear lens opacity was evidenced OU. The intraocular pressure was 20/20 mmHg. A cup-to-disk ratio of 0.9 OU was observed with nasalization of the vessels, and the rest of the posterior segment evaluation was unremarkable.

Fig. 2
figure 2

Slit-lamp findings OD. The image shows 1 + cells in the anterior chamber according to SUN grading

In this patient with non-granulomatous anterior uveitis with apparent autoimmune/autoinflammatory etiology with nail findings suggestive of psoriasis, PsA had to be excluded alongside any other possible uveitis etiologies not discarded by the previous ophthalmologist. Even though the patient only presented with findings suggestive of nail psoriasis, comparative radiographs of the hands and the axial skeleton did not show positive results. In addition, nail psoriasis was confirmed by nail ultrasonography performed by a radiologist specialized in psoriasis (Fig. 3), and several ancillary tests were performed to rule out other systemic diseases, including anti-nuclear antibodies, anti-cyclic citrullinated peptide, differential blood count, and HLA-B27 typing, and all were normal (Table 1b).

Fig. 3
figure 3

Nail ultrasonography. a Grayscale longitudinal plane ultrasonography and Doppler ultrasonography of the nail apparatus of the right hand fifth finger characteristic of phase III psoriatic onychopathy. The image shows wavy appearance with thickening of the nail plates, the nail bed shows focal hyperechoic involvement and thickening. The matrix does not have any changes. The nail vascularization is normal, as shown in the Doppler exploration. b Grayscale longitudinal plane ultrasonography and Doppler ultrasonography of the nail apparatus of the left hand fifth finger showing signs of early-stage phase I psoriatic onychopathy. The nail plates have normal morphology with hyperechogenic foci below the distal third of the ventral plate (****). The nail bed, matrix, and distal interphalangeal joint are normal

After confirming the diagnosis of HLA-B27-negative anterior non-infectious uveitis, the patient continued the treatment regimen ordered by the previous physician for 6 months before consulting to our center, consisting of 12.5 mg per day of oral prednisolone, topical prednisolone acetate 1%, topical tacrolimus 0.03%, and 17.5 mg per week of oral MTX alongside topical hypotensive treatment for open-angle glaucoma composed of timolol 0.5%, brimonidine tartrate 0.2% and brinzolamide 1%. However, satisfactory inflammation was not achieved 2 weeks after the first consultation in our center showing 1 + cell grading OU. Therefore, dual immunomodulatory therapy with a single dose of 80 mg followed by 40 mg every 15 days of adalimumab was ordered, accompanied by 20 mg per week of subcutaneous MTX, tapering doses of topical and oral prednisone, topical anti-inflammatory therapy with ketorolac tromethamine 0.5%, and topical treatment for glaucoma described previously, achieving overall satisfactory inflammatory response without further relapses (within 6 months). During the 24 months of follow-up, the patient has not referred any PsA symptom.

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