PRESENTATION AND MANAGEMENT

Louise is now 18 years old. She is white and developed erosive, polyarticular psoriatic arthritis with significant skin involvement when she was 10 years old . She was referred to the paediatric rheumatology team at the age of 13 having previously been treated with non-steroidal anti-inflammatory drugs, sulfasalazine and intra-articular corticosteroids. She was subsequently treated with further multiple intra-articular corticosteroid injections under general anaesthetic, oral methotrexate (maximum 20 mg/week) and naproxen (20 mg/kg/day).

Her disease failed to remit and oral methotrexate was replaced with weekly subcutaneous methotrexate (maximum 25 mg/week, given by Louise's mother) and continuous oral daily prednisolone (0.5 mg/kg/day). After three months of subcutaneous methotrexate treatment, Louise developed persistently abnormal liver function tests (maximum alanine transaminase (ALT) =286 IU/l, alkaline phosphatase (ALP) =718 IU/l). Methotrexate was subsequently omitted and re-introduced at a lower dose but to the detriment of the arthritis, which flared requiring increased prednisolone treatment. In view of the desire to continue methotrexate, a liver biopsy was performed that showed only sinusoidal dilatation with no chronic damage evident. The methotrexate was continued and a repeat liver biopsy a year later remained unchanged. The liver function tests gradually resolved with control of the disease and are currently as follows: ALT=17 IU/l, ALP= 339 IU/l.

When Louise was 15 years old, in view of the difficulty controlling her disease without concomitant oral corticosteroids, potential addition of cyclosporin was discussed. She adamantly refused this medication in view of the potential side effects, particularly the hirsuitism and gum hyperplasia. As a compromise, she agreed to take …