Eosinophilic fasciitis presenting as psoriatic arthropathy.

CASE HISTORY. A 19-year-old student nurse presented with a four month history of pain and stiffness in her knees, ankles and elbows following a brief 'flu-like illness. Wrist and elbow movements were limited, with bilateral knee effusions and flexion deformities of approximately 100. Evidence of psoriasis was limited to areas of hyperkeratosis on the elbows, and a few nail pits; there was a positive history in her maternal grandmother. Rheumatoid factor test was negative, serum C-reactive protein 19-5 mg/I (normal <6), and erythrocyte sedimentation rate 39 mm/hr. X -rays of hands, elbows and knees were normal. A provisional diagnosis of psoriatic arthropathy was made and she was treated with the nonsteroidal anti-inflammatory drug nabumetone 1 gm daily, with improvement. Five months later her condition deteriorated, her skin felt "very tight", and she had to walk on her toes because of tightness at the ankle. She described occasional difficulty with swallowing but gave no history of Raynaud's phenomenon. She now had thickened, shiny skin on the limbs and flexion deformity of her knees, wrists, and the small joints in her hands. Systemic sclerosis was considered to be the likely diagnosis, and she was commenced on d penicillamine 100 mg/day and nifedipine 10 mg/tid. Investigations showed eosinophilia of 8%; ESR 32 mm; C-reactive protein < 6 mg/I; serum IgM 2-72 g/l. Relevant autoantibody tests were negative (including antinuclear factor, anti-centromere antibody, anti SCL-70 and antineutrophil cytoplasmic antibody); complement components were normal and