This is Not a Named Syndrome
The coexistence of rheumatoid arthritis, psoriasis, and gastritis in an adult patient does not represent a recognized clinical syndrome. These are three distinct conditions that may occasionally occur together, but their co-occurrence is not sufficiently common or pathophysiologically linked to constitute a defined syndrome.
Understanding the Clinical Scenario
Psoriatic Arthritis vs. Rheumatoid Arthritis
The most critical diagnostic consideration here is whether this patient truly has both rheumatoid arthritis and psoriasis, or whether they have psoriatic arthritis (PsA) that is being misdiagnosed as rheumatoid arthritis 1, 2.
- Inflammatory arthritis in a patient with psoriasis should first raise suspicion for psoriatic arthritis, not rheumatoid arthritis 2.
- PsA can present with polyarticular symmetric arthritis that mimics rheumatoid arthritis, making differentiation challenging 1, 3.
- The diagnosis of PsA is made by exclusion of other inflammatory arthritides and based on immunologic, radiologic, and clinical features 2.
Key Distinguishing Features
Clinical patterns that favor PsA over RA include:
- Distal interphalangeal (DIP) joint involvement 1, 4
- Dactylitis ("sausage digits") 1
- Enthesitis (inflammation at tendon/ligament insertion sites) 1
- Asymmetric joint involvement 1, 4
- Nail disease (pitting, onycholysis, oil drop sign) 1
- Axial/spinal involvement 1
Radiographic features that distinguish PsA:
- Erosions with accompanying bone proliferation (not seen in RA) 4
- Pencil-in-cup deformities 4
- Periostitis and juxta-articular new bone formation 4
- Ankylosis of joints 4
Gastrointestinal Associations
Gastritis specifically is not a recognized association with either psoriasis or psoriatic arthritis. However, there are important gastrointestinal considerations:
- Inflammatory bowel disease (IBD) is genuinely associated with psoriasis and PsA, with Crohn's disease occurring in 7-11% of psoriasis patients versus 1-2% of controls 1, 5, 6.
- Psoriasis and PsA are associated with numerous gastrointestinal conditions including celiac disease, autoimmune hepatitis, and non-alcoholic fatty liver disease 6.
- Drug-induced gastritis or autoimmune hepatitis may occur as complications of treatment with TNF-alpha inhibitors (infliximab, adalimumab, etanercept) used for PsA 1, 7.
Clinical Approach
Establish the Correct Diagnosis
Use CASPAR criteria to diagnose PsA (requires inflammatory articular disease plus ≥3 points from specific features including current psoriasis, psoriatic nail dystrophy, negative rheumatoid factor, dactylitis, or juxta-articular new bone formation) 1, 5.
Evaluate the Gastritis
- Determine if gastritis is medication-related (NSAIDs, DMARDs, biologics) 1
- Screen for Helicobacter pylori infection 1
- Consider immunosuppression-related infections if patient is on biologics (phlegmonous gastritis has been reported in PsA patients on infliximab) 7
- Evaluate for autoimmune gastritis or other autoimmune gastrointestinal conditions 6
Coordinate Multidisciplinary Care
Management of musculoskeletal and extra-articular manifestations should be coordinated between rheumatology and gastroenterology 1, 8.
Important Caveats
- True coexistence of RA and psoriasis is rare but possible 2. However, this diagnosis should only be made after careful exclusion of PsA.
- The severity of skin disease and arthritis do not correlate in PsA, so mild psoriasis does not exclude severe arthritis 1.
- Gastritis is not part of any recognized syndrome with these rheumatologic conditions and should be evaluated as a separate entity or potential treatment complication 1, 7.