Patient is 10 years old with psoriasis polyarthritis. Received Methotrexate, and Enbrel for three years. As in medical remission, it was decided ten months ago to stop Methotrexate and continue only with Enbrel. Three months later started having infections and paradoxical reaction to Enbrel (psoriasis), therefore stopped Enbrel and started again with Methotrexate. One ankle is swollen for six months. Steroid injection in ankle did not help. Currently on weekly Methotrexate 17.5 mg for three months and daily steroid tablets 20 mg, and Monovas but still there is no improvement in the ankle.
My questions are additionally to Methotrexate, steroid injections and oral steroids is there anything else that can help in this case? How long will a joint swelling take to cause permanent joint damage?
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I have gone through your history. Well, it seems like you developed a reaction to Enbrel which is quite common as it does flare psoriasis in some patients. Pertaining to your queries:
Since you have mentioned only one ankle is swollen, it is not justified taking such a high dose of steroids. Considering the patient is 10-year-old, it will hamper the growth and height of the patient. Firstly, one needs to see, if there is an effusion left or there is synovial thickening due to prolonged inflammation. The thickening will not respond to the injections or the steroids. Also, if only ankle is the problem then, consult an orthopedic and you may want some synovectomy done to relieve the inflammation if the other methods have failed. If 20 mg is not working, it is very less likely higher doses will work. My suggestion is to get orthopedic advice.
It is hard to say but normally one year of the swelling can damage the joint. If the disease is too aggressive, may be two months are enough. Always a tough thing to call for.
US (ultrasound) of the ankle.Treatment plan:
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