5. Seronegative Spondyloarthritis Flashcards
Generally, what is a seronegative spondyloarthritis?
Pathoma: group of joint disorders characterized by lack of rheumatic factor (–>seronegative), axial skel involvement (–>spondylo), and association with HLA-B27.
Lect: also involves asymmetric peripheral joints, enthesitis, occasional mucocutaneous, ocular, cardiac sx.
what is an enthesis?
site of insertion of a tendon, ligament, or joint capsule into bone. metabolically active site.
Clinical characteristics of spondyloarthritis?
asymmetric peripheral arthritis, sacroiliitis (may cause low back pain), enthesitis.
is there a genetic component to spondyloarthritis?
significant familial component due to association with HLA B27
general framework for thinking about the causes of spondyloarthritis?
genetic predisposition + environmental stimulus leads to inflammation, leads to ankylosis (bone formation)
what is a syndesmophyte?
Wiki: a bony growth originating inside a ligament, commonly seen in the ligaments of the spine, specifically the ligaments in the intervertebral joints leading to fusion of vertebrae. Syndesmophytes are pathologically similar to osteophytes.
what is the term for the ossification and other changes seen in the spines of patients with ankylosing spondyloarthritis? what is the cause?
“bamboo spine”
due to inflammation of the annulus fibros at its insertion site, resulting in its ossification and ultimate formation into a “syndesmophyte”, creating the appearance of a bamboo spine.
for pts with ankylosing spondyloarthritis, what is seen on imaging of the pelvis?
joint space narrowing, bony sclerosis around the SI joints.
Ankylosing Spondyloarthritis: pain is worst at what time of day?
morning, pain and stiffness, lasts over an hour
Ankylosing Spondyloarthritis: what can help the pain and stiffness?
exercise, naproxen (NSAID)
Ankylosing Spondyloarthritis: why are there different frequencies of this dz in different ethnic groups? what groups have high prev/low prev?
the prevalence generally mirrors the freq of HLA-B27 in the population –> low prev in africa, Japan; higher rates in Norway, arctic peoples
What % of pts with Ankylosing Spondyloarthritis have HLA B27?
85-95%
Sacroilitis in Ankylosing Spondyloarthritis: symmetric or asymmetric?
symmetric
other findings with Ankylosing Spondyloarthritis?
possible psoriasis, acute uveitis (eye), marginal syndesmophytes
what are the clinical criteria for diagnosing Ankylosing Spondyloarthritis?
- low back pain/stiffiness > 3 m
- limitation of lumbar flexion
- limited chest expansion
- Sacroiliitis on imaging (required, but may not appear for 7 yrs post dz onset)
Physical exams for Ankylosing Spondyloarthritis?
- occiput to wall distance
- chest expansion (nl 5 cm)
- Schober’s: lumbar spine lengthening with flexion
- FABER: hip movement, pain in contralat SI
What is a romanus lesion/erosion? what disease is it seen in?
Imaging finding: inflammation at the site of insertion of the annulus -> osteitis of the anterior vertebral margins. aka ‘shining corners’, aka syndesmophyte
seen in Ankylosing Spondyloarthritis
over time the syndesmophytes of Ankylosing Spondyloarthritis create what classic appearance?
‘bamboo spine’: ossification of the annulus
what will sacroiliitis in Ankylosing Spondyloarthritis look like on imaging?
early: joint space narrowing, sclerosis around SI joints
later: complete ankylosis/fusion of the SI joints
Progression of Ankylosing Spondyloarthritis will look like what over a few decades? what procedure may mitigate this progression?
lumbar lordosis (think old man very hunched over) hip replacement may relieve the forced flexion of this lordosis, allow pt to stand up more normally
patients with Ankylosing Spondyloarthritis are at incr risk of what complication (this reduces their survival compared to the overall population)?
incr risk of heart disease. Lecture says CVD, Pathoma says aortitis/aortic regurg
Ankylosing Spondyloarthritis: reason for restrictive lung disease?
Mechanical restriction due to limited ability to expand chest
what % of HLA-B27 individuals will develop Ankylosing Spondyloarthritis?
only 5%
Will rest make inflammatory back pain worse or better? what about Exercise? NSAIDs?
Rest –> Worse
Exercise –> Better
NSAIDs –> Better (80%)
Will rest make mechanical back pain worse or better? what about Exercise? NSAIDs?
Rest –> Better
Exercise –> Worse
NSAIDS –> Better (only 15%)
Treatment for ankylosing spondylitis?
- NSAIDs
- Sulfasalazine
- TNF-alpha antagonists
- Prednisone
- Physical Therapy
Possible treatments that do NOT work for ank spon?
- MTX
- DMARDs (don’t work for axial dz)
- Prednisone (effective only for uveitis complication)
Case: Pt is 19 yo woman with eye pain, redness, vision loss, photophobia. Treated for conjunctivitis twice in past. Eyes responded to steroids. Back pain since giving birth. Current chlamydia infection. MRI shows sacroiliitis. What kind of arthritis?
Reactive Arthritis
Definition of Reactive arthritis?
sterile synovitis, precipitated by extra-articular infection. occurs 2-4 weeks post-infection.
Reactive Arthritis: usually precipitated by what types of infections?
typically GI or GU
The saying “Can’t see, can’t pee, can’t climb a tree” describes the clinical presentation of what?
Reactive Arthritis
Clinical features of Reactive Arthritis?
Can’t see can’t pee can’t climb a tree.
- Typically affects lower extremeties
- Enthesitis
- Dactylitis
- Uveitis (eyes)
- Mucocutaneous sx: Oral ulcers, Keratoderma Blenorrhagicum (red pustules on soles of feet), Circinate Balinits (ulcers on penis. Think circumcised balls)
Reactive Arthritis: typical demographic?
Males 20-40y. remember this is the one that presents post-GU or GI infection
Reactive Arthritis: treatment?
- Abx to clear up that chlamydia!
- NSAIDs
- Sulfasalazine
- MTX
40 y man presents with 3y hx of psoriasis, swelling, stiffness, pain in wrist and thumb. Pitted fingernails. What does he have?
Psoriatic Arthritis
Can you have psoriatic arthritis without psoriasis?
yes: psoriatic arthritis sin psoriasis. Will still have nail pitting.
What are the patterns that Psoriatic Arthritis may present with?
- DIP arthritis
- asymmetric oligoarthritis
- symmetric polyarthritis
- arthritis mutilans
- spondyloarthritis
Psoriatic Arthritis: morning stiffness lasts how long?
> 30 min
Psoriatic Arthritis: classification criteria?
Inflammatory Joint/spine/enthesis PLUS at least 3:
- psoriasis of self or family
- psoriatic nail dystrophy
- RF negative
- dactylitis (at any time)
- xray with psoriatic arthritis
Psoriatic Arthritis: what is the classic finding on xray of the hand?
- Erosive arthritis (usually asymmetric)
- Pencil-in-cup deformity (distinctive!)
Psoriatic Arthritis: treatment?
- NSAIDs
- Sulfasalazine
- MTX
- anti-TNFa
32 yo woman, eval for ulcerative colitis. history of e. nodosum, knee/ankle pain, stiffness, swelling. Hx of back pain. What does she have?
Inflammatory Bowel Arthritis
Skin findings with Inflammatory Bowel Arthritis?
E nodosum, pyoderma gangrenosum
Inflammatory Bowel Arthritis: describe the arthritis?
- peripheral
- can be oligoarticular or polyarticular
- may be associated with skin disease
Inflammatory Bowel Arthritis: treatment?
- Tx for underlying dz
- NSAIDs contraindicated
- Sulfasalazine
- MTX
- Azathioprine/6 Mercaptopurine
- Corticosteroids
- TNF alpha antagonists
HLA-B27: why is it a double-edged sword to have this MHC?
Good: high rate of clearance of Hep C
Bad: molecular mimicry may lead to autoimmune dz
