02-20 Sero(-) Spondyloarthropathies Flashcards
1. Discuss the major types of spondyloarthropathies and their features 2. Review treatment options 3. Outline features of inflammatory back pain 4. Discuss the role of HLA-B27
ankylos
Gr: stiffening of a joint
athron
Gr: joint
Spondylos
Gr: vertebra
Axial
spine
peripheral joints
joints other than the spine
What is an enthesis?
- KEy lcations?
- Which ones are accessible for physical exam?
attachment of ligament, tendon or joint capsule to the bone
- Metabolically active site
- One of key differences between RA with synovial inflammation and spondyloarthropathies is that the inflammation starts at the enthesis.
- Key locations: SI joints, ligamentous structures in vertebrae, manubriosternal joints, symphysis pubis, iliac crests, trochanters, patellae, calcanei
- Some are easy to access area are the achilles tendon, plantar fascia insertion—others revealed only through imaging like along vertebral bodies.
What do we mean by “seronegative”?
Usually no RF –Also can imply no ANA and no ACPA
Define spondyloarthritis
group of inflammatory conditions characterized by:
- spinal and peripheral joint oligoarthritis,
- enthesitis and,
- occasionally mucocutaneous, ocular, and cardiac manifestations.
With what clinical characteristics does spondylarthritis present?
- Back Pain
- Low back pain, usually in the buttocks, insidious onset, chronic
- Worse (2-5AM) & early morning
- Morning stiffness >30 min
- Relieved w/ exercise, worse w/ rest
- improves with NSAIDs
- Extra-spinal sx
- Asymmetric peripheral arthritis
- enthesitis
- Absence of evidence of another rheumatic disease
- RF, ACPA, subQ nodules & other extra-articular features of RA
- Significant familial aggregation
- Associated with HLA B27
- Extra-articular involvement
- 30-40% Acute anterior uveitis
- aortitisi/dilated root
- IgA nephropathy/amyloidosis
- Psoraisis
- Arachnoiditis/Cauda equina syndrome
- Pulmonary Fibrosis/Restrictive lung disease
- Osteoporosis ->Vertebral fx and pseudo-fx
- Subclinical Colitis 20-50%; IBD 6%
- Radiographic evidence of sacroiliitis
Name this queen.
(Hint: She one Drag Race Season 1)
Bebe Zahara Benet, baby!
AS
- Sex
- Incidence
- Age at onset
- HLA B27
- Peripheral pattern
- Sacroilitis
- Skin
- Eye
- Syndesmophytes
- Sex: M:F 2-3:1
- Incidence*: 6-7/100,000
- Age at onset: 16-40
- HLA B27: 85-95%
- Peripheral pattern: Uncommon (oligo)
- Sacroilitis: Symmetric
- Skin: 20% have psoriasis
- Eye: 30-40% have acute anterior uveitis
- Syndesmophytes: marginal
*The incidence of AS ~mirrors the freq of HLA-B27 in population
- explains the virtual absence of dz in Sub-Saharan Africa, low rates in Japan and higher rates in Norway as compared with other European countries, and very high rates among native peoples of the circumpolar arctic.
Diagnostic Criteria: NY Modified vs. ASAS Criteria
Modified NY
- still most widely used
- Need 1 AS Sx + xray evidence of sacroiliitis
- problem: takes 6-8 yrs before xray positive
ASAS Criteria
- NY mod criteria OR HLA-B27+ plus 2+ A.S. s/sx
- better at catching earlier cases
Physical Exam Findings for AS
- Occiput to wall distance
- Chest Expansion
- Measured at the xiphisternum (normal 5cm)
- Schober’s*
- Measure 10cm from PSIS
- Touch toes, straight legs, <15cm abnormal (total-< 5cm change)
- F-A-B-E-R (flexion abduction external rotation)
- Pain in contra-lateral SI joint is +
- Pelvic compression
Xray ID?
Radiograph of the lumbar spine in a patient with ankylosing spondylitis. Inflammation at the site of insertion of the annulus fibrosus has resulted in osteitis of the anterior vertebral margins, also called “shining corners” This ossification, is called a syndesmophyte.
Over time, the inflammation and syndesmophytes formation leads to ossification of the annulus fibrosis creating the classic appearance of a bamboo spine.
advanced sacroiliitis as seen in late A.S.
The picture on this side of the card shows and earlier case with milder narrowing of SI joints bilaterally and pubic symphysis involvement.
Most Common Reason for Restrictive Lung Disease in Patients with AS?
1) Pulmonary Fibrosis
2) Susceptibility to COPD
3) Mechanical restriction
4) Interstitial lung disease
3) Mechanical restriction
Treatment of A.S.
- NSAIDs
- Show some delay of progression
- TNF antagonists
- quick improvement, esp w/ uveitis
- but unclear whether it delays progession
- sulfasalazine
- Helps in cases of high ESR, morning stiffness, & peripheral symptoms
- Physical Therapy
- Prednisone
- only helpful for uveitis
DMARDs,
Reactive Arthritis Dz Card
- Sex
- Incidence
- Age at onset
- HLA B27
- Peripheral pattern
- Sacroilitis
- Skin
- Eye
- Syndesmophytes
- Sex: 1:1 M:F
- Incidence: 8.5/100,000
- Age at onset: 20-40
- HLA B27: 30-80%
- Peripheral pattern: Asymmetric (mono/oligo)
- Sacroilitis: Asymmetric
- Skin: Keratoderma blenorrhagica, circinate balinitis
- Eye: Acute Anterior Uveitis/conjunctivitis
- Syndesmophytes: Non-marginal, bulky
Reactive Arthritis Dx & Tx
Presenting S/Sx/Hx
-
Sterile synovitis 2-4 wks s/p extra-articular infx (mostly GI or GU)
- Commonly: Chlamydia, Ureaplasma, Yersinia, Salmonella, Shigella, Campylobacter, E. coli, and more
- Arthritis sx
- Predominantly affecting the LE (mono to oligo)
- Enthesitis
- Dactylitis
- Spondylitis
- SI involved - up to 50%
- Occular sx: Conjunctivitis/Uveitis
- Mucocutaneous
- Keratoderma Blenorrhagicum
- Circinate Balinitis (ulcers and plaque-like lesions on the glans penis)
- Oral ulcers
- Urethritis: infectious /sterile
Treatment
- NSAIDs
- Sulfasalazine
- MTX
- Antibiotics
- only as Chlamydia treatment
- otherwise don’t Rx
What’s this? DDx?
Figure 5. Keratoderma blennorrhagica in a patient with Reactive arthritis.
DDx reactive arthritis vs. psoarisis
Interpret this xray
Figure 4. Radiograph of the heel in a patient with Reactive Arthritis syndrome. The radiograph shows a periosteal reaction at the plantar fascia insertion (black arrow) and early erosion at the achilles tendon insertion (white arrow) on the calcaneus.
Example “Enthesitis”
Psoriatic Arthritis Dz Card
- Sex
- Incidence
- Age at onset
- HLA B27
- Peripheral pattern
- Subtypes?
- Sacroilitis
- Skin
- Eye
- Syndesmophytes
Reactive Arthritis Dz Card
- Sex: M=F
- Incidence: 6/100,000
- Age at onset: 30-55
- HLA B27: 25-60%
- Peripheral pattern: varies (5 types)
- DIP arthritis
- Asymmetric oligoarthritis
- Symmetric polyarthritis
- Arthritis Mutilans
- Spondyloarthritis
- Sacroilitis: Asymmetric
- Skin: Psoriasis, nail involvement
- usu start before arthritis
- can have psoriatric arthritis sin psoriasis
- Eye: Uveitis (25%) +/- bilat
- Syndesmophytes: non-marginal, bulky
Psoriatic Arthritis Classification Criteria
- Include examples of which radiographic findings you’d have
Tx
Diagnosis:
—Classification of Psoriatic Arthritis (CASPAR 2006) 98 % sensitive and 91% specific
—Inflammatory Joint/spine/entheseal disease and >= 3 of:
- Current or h/o psoriasis/ FH of psoriasis
- Psoriatic nail dystrophy
- RF negative
- Dactylitis* at any point in time
- Xray c/w psoriatic arthritis
- Erosive arthritis (usually asymmetric)
- Pencil-in-cup deformity
- Arthritis mutilans
- Bony ankylosis
- Spurs/periosteal reaction
- Non-marginal asymmetric syndesmophytes
- Asymmetric sacroiliitis
*Dactylitis = sausage digit (i.e. inflam of an entire digit)
Treatment
- NSAIDs
- Sulfasalazine
- Methotrexate/leflunamide
- TNF alpha antagonists
- ?Prednisone
- Can help with pain, but can make psoriasis worse
- Other-IL12/IL23 (Ustekinumab in trials), abatacept?, JAK inhibitors
What is this called?
dactylitis (sausage digit)
ID this Xray
- common in?
A 32 year old woman presents for evaluation during a flare in her ulcerative colitis.
She has a history of e. nodosum and has left knee and right ankle pain, stiffness and swelling.
She has had back pain predating her most recent flare.
Which entity dose her syndrome complex likely represent?
1) Psoriatic Arthritis
2) Ankylosing Spondylitis
3) Inflammatory Bowel Arthritis
4) Reactive Arthritis
3) IBD arthritis
A 40 year old man with 3 year history of psoriasis presents with swelling stiffness and pain in the wrist and thumb .
He has pitting of the fingernails.
Which entity does his syndrome complex likely represent?
1) Psoriatic Arthritis
2) Ankylosing Spondylitis
3) Inflammatory Bowel Arthritis
4) Reactive Arthritis
1) Psoriatic Arthritis
21 year old man with a 3 year history of low back pain and stiffness that is worse in the morning and lasts over one hour. This started as alternating buttock pain when he was in high school. His posterior left heel is also painful. Exercise and naproxen help the pain and stiffness.
What type of presentation is this?
Which entity dose his syndrome complex likely represent?
1) Psoriatic Arthritis
2) Ankylosing Spondylitis
3) Inflammatory Bowel Arthritis
4) Reactive Arthritis
Presentation is inflammatory back pain
2 is correct Here are key clues from the case:
21 year old man with a 3 year history of low back pain and stiffness that is worse in the morning and _lasts over one hour. _ This started as alternating buttock pain when he was in high school. His posterior left heel is also painful. Exercise and naproxen help the pain and stiffness.
A call from ophthalmology
19 year old woman with:
- Eye pain
- Redness
- Loss of vision
- Photophobia
Treated for conjunctivitis x 2 prior to ER
What do you call these eye findings?
Case continues:
- Eye Responds to high dose steroids
- Past Medical History
- Back pain since birth of her child
- Chlamydia infection on routine testing
- Imaging shows sacroilitis on R side
Which entity dose her syndrome complex likely represent?
1) Psoriatic Arthritis
2) Ankylosing Spondylitis
3) Inflammatory Bowel Arthritis
4) Reactive Arthritis
- Eye findings: Anterior uveitis and synechiae (adhesion of the iris to the cornea as a result of inflammation).
- Dx = Reactive arthritis
What are the 4 seronegative spondyloarthritides we discussed in this lecture?
- Ankylosing Spondylitis
- Reactive Arthritis
- Psoriatic Arthritis
- Inflammatory Bowel Arthritis
IBD Arthritis Dz Card
- Sex
- Incidence w/in IBD pt population
- Age at onset
- HLA B27
- Peripheral pattern
- Sacroilitis
- Skin
- Eye
- Syndesmophytes
IBD Arthritis Dz Card
- Sex: M=F
- Incidence w/in IBD pt population: 5-26%
- Crohn’s>UC
- Age at onset: Any
- HLA B27: 7-70%
- Peripheral pattern: Asymmetric (oligo/poly)
- Sacroilitis: symmetric
- Skin: e. nodosum, pyoderma gangrenosum
- Eye: Acute Anterior Uveitis (11%)/chronic
- Syndesmophytes: Marginal, delicate
IBD Arthritis: Presentation and Tx
Presentation
- Crohn’s more common than ulcerative colitis
- Peripheral arthritis
- Frequently associated with skin disease
- E. nodosum and pyoderma gangrenosum
- Can be oligoarticular or polyarticular
- Spondylitis not associated with bowel disease activity
- Colectomy can induce remission in ulcerative colitis
Treatment
- Treat the underlying disease!
- NSAIDs – may help with the arthritis but are usually contraindicated
- Sulfasalazine
- MTX
- Azathioprine/6 Mercaptopurine
- Corticosteroids
- TNF alpha antagonists
- Adalimumb (Crohn’s)
- Infliximab (Crohn’s and UC)
