3- Seronegative Spondyloarthropathy Flashcards
Q1: What features in the history and physical examination are helpful in differentiating inflammatory low back pain in AS from mechanical low back pain?
Q2: What are the evidence(s) of inflammatory back pain?
(1) morning stiffness of at least 30 minutes
(2) improvement of back pain with exercise but not rest
(3) awakening because of back pain during the second half of the night only;
(4) alternating buttock pain.
How do you differentiate inflammatory vs mechanical joint pain? 🔑🔑 Leak 21
Rheumatology Secrets 3rd & 4th Edition Chapter 34 Table 34-1
Braddom 6th Edition Chapter 31 Table 31.4
List 4 Seronegative arthritis 🔑🔑
💡 Majority are HLA-B27 (+) and RF (–).
- Ankylosing spondylitis
- Reactive arthritis (also known as Reiter’s syndrome)
- Psoriatic arthritis—HLA Cw6
- Arthritis of inflammatory bowel disease (IBD)
- Pauciarticular JIA
Cuccurollo 4th Edition Chapter 3 Rheumatology pg121
Ankylosing spondylitis: Definition, Presentation, 2 Hallmarks & Labs 🔑
Ankylosing spondylitis
- Chronic, inflammatory rheumatic disorder of the axial skeleton affecting the sacroiliac (SI) joint and the spine
Presentation
- Back pain and significant stiffness, notably in the morning and at night.
- Symptoms worsen with rest and improve with activity (inflammatory back pain)
Hallmark
- Bilateral sacroiliitis
- (+) HLA-B27 approximately 90%
Labs (CBC - Inflammatory - Rheumatoid workup)
- Anemia—normochromic/normocytic
- Elevated ESR and CRP
- RF (–) and ANA (–)
- HLA-B27 (+) in 90% of patients
Cuccurollo 4th Edition Chapter 3 Rheumatology pg121-122
Ankylosing Spondylitis vs. Rheumatoid Arthritis. 2 Marks 🔑🔑
💡 Ankylosing Spondylitis is Seronegative and Nodule-negative
- Absence of rheumatoid nodules
- RF (–)
Cuccurollo 4th Edition Chapter 3 Rheumatology pg122
List 3 findings yield high suspicion of Ankylosing spondylitis (clinical, lab, radiology)
-
Bilateral Sacroiliitis
- Diagnostic SI joint injection
- MRI (21% positive)
- Early: Bone marrow edema
- Late: Fatty marrow deposition, erosions, and sclerosis
-
Serology
- HLA-B27 positive (90% positive)
-
Acute iritis
- Most common extraskeletal manifestation of AS)
List 3 findings yield high suspicion of Ankylosing spondylitis (clinical, lab, radiology)
-
Bilateral Sacroiliitis
- Diagnostic SI joint injection
- MRI (21% positive)
- Early: Bone marrow edema
- Late: Fatty marrow deposition, erosions, and sclerosis
-
Serology
- HLA-B27 positive (90% positive)
-
Acute iritis
- Most common extraskeletal manifestation of AS)
List 4 common sites/locations of enthesitis in patients with spondyloarthropathies. 🔑🔑
MORE COMMON
- Iliac crest
- Superior and inferior poles of the patella
- Tibial tuberosity
- Achilles tendon insertion
- Insertion of the plantar fascia on the calcaneus or the metatarsal heads
- Base of the fifth metatarsal head
LESS COMMON
- Greater trochanter
- Ischial tuberosity
- Costochondral junctions
- Distal scapula
- Lateral epicondyle
- Distal ulna
ASAS Criteria for Ankylosing spondylitis 🔑🔑
Articular & Extra-Articular Manifestations 🔑🔑
ARTICULAR
- Decreased lumbar lordosis and increased thoracic kyphosis
- Respiratory restriction with limited chest expansion → diaphragmatic breathing
- Insidious onset of back/gluteal pain
- Pain for at least 3 months
- Lumbar morning stiffness that improves with activity and worsens with rest/inactivity
- Enthesitis
EXTRA-ARTICULAR
- Acute iritis/iridocyclitis → Pain, photophobia, blurred vision (most common)
- C1 to C2 subluxation
- Apical pulmonary fibrosis → dyspnea and cough
- Cardiac → Conduction defects and aortitis
- Amyloidosis
- Cauda equina syndrome
- Systemic effects—fatigue, weight loss, low-grade fever (systemic inflammation)
Cuccurollo 4th Edition Chapter 3 Rheumatology pg122-123
Radiological Findings in Ankylosing spondylitis 🔑🔑
SI JOINT
Findings
- Pseudo-widening of the joint space due to erosion & subchondral bone resorption
- SI joint narrowing: sclerosis → ankylosis
- Calcification leading to ankylosis
- Enthesopathy: “whiskering” of the iliac crest, greater tuberosities of the humerus, ischial tuberosities, femoral trochanters, calcaneus, and vertebral spinous processes
Grading
- Normal
- Suspicious changes
- Minimal changes: erosion or sclerosis (no change in joint space)
- Moderate changes: erosion (widening) or sclerosis (narrow) or partial ankylosing
- Total ankylosing
SPINE
- Loss of cervical lordosis (straightening of the C-spine)
- Bamboo spine: Ossification of the annulus fibrosis, resulting in bridging syndesmophytes that completely bridge adjacent vertebral bodies
- Dagger sign: Interspinous ligament ossification
- Squaring of lumbar vertebrae’s anterior concavity
- Ankylosis of the facet joints
- Romanus lesions of the spine (shiny corner sign): Small erosions at the corners of vertebral bodies with reactive sclerosis
- Associated osteopenia/osteoporosis (bone washout)
Cuccurollo 4th Edition Chapter 3 Rheumatology pg123
What is Osteitis condensans ilii?
Osteitis condensans ilii
- From it’s name “condence ilium”, affecting iliac side.
- DDx of sacroiliitis.
- Benign sclerosis of the ILIAC SIDE of the sacroiliac joints.
CLINICAL
- Back/SI joint pain, Positive SI joint stress tests, stiffness
RADIOLOGY
- Triangular sclerosis involving only the iliac side of the SI joint, intact SI joint space, well defined margins of sclerosis, bilateral symmetric sclerosis if the iliac joint. No/minimal changes on the sacral sclerosis. Absent of subchondral cysts or moth ball appearance.
LABS
- Usually negative HLAB27 antigen.
TREATMENT
- Physiotherapy, NSAID, injections into SI joint, surgical resection.
Ref: Rheumatology international [0172-8172] Mitra, Raj yr:2010 vol:30 iss:3 pg:293 -296
When comparing sacroiliitis in ankylosing spondylitis and osteitis condensus ilii What key radiological feature distinguishes these two?
Anyklosing spondylitis: sacroiliitis is SYMMETRICAL, affecting both sacral and iliac bones
Osteitis condensus ilii: sacroiliitis is ASYMMETRICAL – affects iliac bone only.
Ref: Am Fam Physician 2004;69:2853-60
Rheumatology international [0172-8172] Mitra, Raj yr:2010 vol:30 iss:3 pg:293 -296
List 6 Physical examination tests used to assess the severity of
sacroiliac and spinal joint involvement in axSpA. 🔑🔑 MOCK & Leak 21
- Occiput-to-wall test: Occiput should also touch the wall, and it represents the magnitude of thoracic and cervical involvement
- Chest expansion: abnormal if <2.5 cm and normal if ≥5 cm.
- Schober test (modified) increase less than 5 cm is considered a restriction
- Pelviccompression
- Gaenslen’stest: Hip flexion contracture
- Patrick’s test or FABER Test (SI Joint)
Rheumatology Secrets 4th Edition Chapter 34 Axial Spondylarthrtitis
Treatment of Ankylosing spondylitis
EDUCATION “Bent Stiff Vertebra Affecting Lungs”
- Good posture
- Prevent spine flexion contractures
- Firm mattress, prone sleep position to keep spine straight/prevent spine flexion
- Lie prone for 15-20min twice a day
- Discourage flexion based activities
- Deep breathing exercises
- Cigarette smoking should be avoided
- Smoking diminishes response to therapy
- Accelerates radiographic progression.
PROTECTION & ORTHOSIS
- Joint protection
OPTIMAL LAODING OF BENT VERTEBRA
- Spine mobility
- Extension-based exercises
- Twice daily stretches for shoulder and hips
MEDICATION
- NSAIDs—indomethacin
- Corticosteroids—tapering dose, PO, and injections
- Muscle relaxants
- Bisphosphonates
- Calcium/vitamin D replacement
- DMARDs
- Topical corticosteroid drops—uveitis
SURGERY
- Total hip replacement is indicated in the setting of severe pain and limitation of motion.
- Bisphosphonates and NSAIDs may be used for 3 months after surgery to prevent postoperative calcifications around the prosthesis.
Cuccurollo 4th Edition Chapter 3 Rheumatology pg123-124
How to prevent heterotopic ossification after total hip replacement?
Bisphosphonates and NSAIDs may be used for 3 months after surgery to prevent postoperative calcifications around the prosthesis.
Cuccurollo 4th Edition Chapter 3 Rheumatology pg123-124
Diffuse idiopathic skeletal hyperostosis (DISH) distinguishes from ankylosing spondylitis? 🔑🔑
DISH
- Primary OA degenerative arthritis typically characterized by ossification of spinal ligaments (syndesmophytes) in the anterior spine leading to spinal fusion
- Most commonly affects the thoracic spine but can also affect the lumbar and cervical spines
- Ossification of the anterior longitudinal ligament, separated from vertebral body by radiolucent line
Hallmark
- Syndesmophytes extending to the length of anterior longitudinal ligament (ALL)
- Ossification spanning four contiguous vertebral bodies (three or more inter vertebral discs)
Patient
- DM, obesity, hypertension, coronary artery disease, males aged greater than 50 years.
DISH is NOT associated with
- Sacroiliitis
- HLA-B27 positivity
- Apophyseal / Zygapophyseal / Facet joint ankylosis
Presentation
- Stiffness in the morning or evening
- Dysphagia with cervical involvement
Cuccurollo 4th Edition Chapter 3 Rheumatology pg114
List 5 SI joint examination
Triad of Reactive Arthritis & Treatment 🔑🔑
“Can’t see, can’t pee, can’t climb a tree”
- Conjunctivitis
- Nongonoccal urethritis
- Arthritis
History
- Typically follows GI or genitourinary (GU) infection
- Up to 10% of patients with reactive arthritis progress to AS
Treatment
- NSAIDs such as indomethacin
- Antibiotics: Typically tetracycline or erythromycin-based account
- Corticosteroids
- DMARDs
Cuccurollo 4th Edition Chapter 3 Rheumatology pg124
Clinical presentation of reactive arthritis 🔑🔑
OCULAR
- Conjunctivitis, iritis, uveitis, episcleritis, corneal ulceration
GENITOURINARY
- Urethritis
- Balanitis circinata, small painless ulcers on the glans penis or urethritis
SKIN AND NAILS
- Keratoderma blennorrhagica
- Reiter’s nails
ARTHRITIS
- Arthritis appears 2 to 4 weeks after initiating infectious event—GU or GI.
- Oligoarticular
- Lower extremity (LE) involvement >> upper extremity (UE)
- LE → knees, ankles, and small joints of the feet
- UE → wrist, elbows, and small joints of the hand
- Sausage digits (dactylitis): Swollen, tender digits with a dusk-like blue discoloration
- Enthesopathies—Achilles tendon
- Low back pain—sacroiliitis
CARDIAC
- Conduction defects
SYSTEMIC
- Weight loss, fever
- Amyloidosis
Cuccurollo 4th Edition Chapter 3 Rheumatology pg124
Lab investigations for reactive arthritis 🔑
💡 GIU infection → CBC, Inflammatory markers & Rheumatology workup
- Positive evidence of GI or GU infection
- Anemia—normochromic/normocytic
- Increased ESR
- RF (–) and ANA (–)
- HLA-B27 (+)
Inflammatory Synovial Fluid
- Turbid
- Poor viscosity
- WBC 5,000–50,000 PMNs
- Increased protein, normal glucose
Cuccurollo 4th Edition Chapter 3 Rheumatology pg
Radiographic Findings for reactive arthritis
- Asymmetric SI joint involvement
- “Lover’s heel”—erosion at the insertion of the plantar fascia and Achilles tendons
- Pencil-in-cup deformities of the hands and feet (more common in psoriatic arthritis)
- Syndesmophytes: Annulus fibrous and Ligamentous ossification
Cuccurollo 4th Edition Chapter 3 Rheumatology pg124
List 2 skin changed in reactive arthritis 🔑
- Keratoderma blennorhagia (ie. Can’t climb tree – feet hurt).
- Reiter’s nails
- Dactylitis
- Circinate balanitis (ie. ‘Can’t pee’).
- Erythema nodosum
Ref: Am Fam Physician 2004;69:2853-60.
Cuccurollo 4th Edition Chapter 3 Rheumatology pg124
Clinical Manifestations & Treatment of psoriatic arthritis 🔑🔑 CASPER Criteria
CASPER
- Psoriatic Arthritis is Seronegative with Fluff
- Psoriatic → Hand lesion
- Arthritis → Inflammation in MSK
- Seronegative → RF (-)
- Fluff → Juxtra-articular bone
Psoriasis
- Nail pitting
- Psoriatic skin lesions—erythematous, silvery scales
- Auspitz’s sign—gentle scraping of the lesions results in pinpoint bleeding
- DIP: Arthritis mutilans → “telescoping of the finger”
Seronegative Arthropathy
- Conjunctivitis
- Aortic insufficiency
- Spondylitis
- Sacroiliitis
- Stiffness of the spine lasting approximately 30 minutes
- Enthesopathy
Treatment
- ROM to all joints
- Do not abuse an inflamed joint → exacerbation
- Meds—similar to RA, psoralen plus ultraviolet A (PUVA; long wave ultraviolet Å light)
- Steroids—oral steroids not proven, injection may help
- Biologicals: Anti-TNF antibodies (adalimumab, infliximab) work best
Cuccurollo 4th Edition Chapter 3 Rheumatology pg126
List 5 Nail Changes of Psoriatic Arthritis 🔑🔑
- Leukonychia (white lines or dots)
- Onycholysis (nail separates from its nail bed)
- Nail plate crumbling
- Oil spots
- Pitting nails
- Transverse ridges
- Splinter hemorrhages (lines of blood under the nails)
- Hyperkeratosis (increased thickness of the stratum corneum, the outer layer of the skin)
Ref: Current dx tx rheumatology pg 296.
Answer
- “Pencil-in-cup” appearance of the DIP
- “Fluffy periostitis”—hands, feet, spine, and SI joint
- Bone erosion
- Asymmetric sacroiliitis → fusion
- Syndesmophytes—see “AS Radiology” section
Cuccurollo 4th Edition Chapter 3 Rheumatology pg126
What is the most common arthritic change with psoriasis. 🔑🔑
Pencil in a Cup: most often the DIP joints.
Ref: Current dx and tx in rheumatology pg 301.
Match
- Psoriatic arthritis: Pencil in cup.
- Rheumatoid arthritis: No DIP involvement.
- Ankylosing spondylitis: Bamboo spine.
- Reiter’s (Reactive) arthritis: Keratoderma blennorrhagica.
- Inflammatory bowel disease: Migratory arthropathy.
Primer on Rheumatic Diseases, 11th edition
Name two extra-articular features of ankylosing spondylitis that affect the CV system.
- Aortitis
- Conduction abnormalities
Name two extra-articular features of ankylosing spondylitis that affect the CNS system.
- C1 to C2 subluxation
- Cauda equina syndrome
List 4 arthritides that lead to sacroilitis. Which cause is usually unilateral?
- Ankylosing spondylitis
- Reactive arthritis (Reiter’s syndrome) – UNILATERAL.
- Inflammatory bowel disease (enteropathic arthritis).
- Psoriatic arthritis.
Ref: Current dx tx in rheumatology textbook pg 276.
Provide 2 differential diagnoses for patient with dactylitis, polyarthropathy, enthesopathy
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Arthritis of inflammatory bowel disease
Ref: basic principles.
Describe Patrick Test 🔑🔑 Leak 21
Also named FABER-E Test:
Passive Flexion & ABduction & Externally Rotate of the hip passively while patient in supine position
Extension of the leg is achieved with a downward force by the examiner.
Anterior hip/groin pain → intra-articular or periarticular hip pathology
Posterior hip pain → SI joint disorder
Cuccurollo 4th Edition Chapter 4 MSK pg210
What are the Red & Yellow Flags of Back Pain? 🔑🔑 Leak 21
RED FLAGS
Age:
- Children <18 years or > 50 years
Infection:
- Fevers/chills/Night sweats
- Drug abuse
Tumor:
- Night pain/Unintentional weight loss
- History of cancer
Myelopathy
- History of violent trauma
- Systemic steroid use
- Progressive motor weakness or gait disturbance
- Nonmechanical nature of pain (i.e., constant pain)
- Persisting severe restriction of motion or intense pain with minimal motion
Cauda Equina
- Difficulty with micturition
- Loss of anal sphincter tone or fecal incontinence, saddle anesthesia
YELLOW FLAGS
- Presence of catastrophic thinking
- Emotions such as stress and anxiety
- Poor sleep
- Avoidance of normal activity and extended rest
- Expectations that the pain will only worsen with work or activity
- Compensation issues
- Work issues, such as poor job satisfaction and poor relationship with supervisors
- Extended time off work
Braddom Chapter 33 Low Back Disorders pg659 Box 33.2
