65: Psoriatic Arthritis and Reactive Arthritis Flashcards
What are the classification criteria for Psoriatic Arthritis (PsA) according to CASPAR?
The CASPAR criteria include:
1. Psoriasis (must be current) - 2 points
2. Personal history of psoriasis - 1 point
3. Family history (first- or second-degree relative) - 1 point
4. Nail dystrophy typical of psoriasis (onycholysis, pitting, hyperkeratosis) - 1 point
5. Negative rheumatoid factor (any method except latex) - 1 point
6. Dactylitis (current or historical) - 1 point
7. Juxtaarticular new bone formation (defined ossification near joint margins excluding osteophytes) - 1 point
A total score of 3 or more points is required for diagnosis.
What is the prevalence of Psoriatic Arthritis (PsA) in the general population?
PsA prevalence is highly variable, estimated to be between 0.02% to 0.25% in the general population. It occurs most frequently in individuals with psoriasis, with a prevalence of 3.2% to 41% in that population.
What are the clinical predictors of Psoriatic Arthritis (PsA)?
Clinical predictors of PsA include:
- Nail psoriasis
- Severe psoriasis
- Scalp psoriasis
- Intergluteal or perianal psoriasis
- Presence of uveitis
These factors are associated with a higher risk of developing PsA.
What are the cutaneous findings associated with Psoriatic Arthritis (PsA)?
Cutaneous findings associated with PsA include:
- Scalp and intergluteal psoriasis are more likely to be associated with PsA risk.
- Nail disease has a prevalence of 40% in psoriasis and is a known risk factor for PsA, with an overall prevalence of 80%.
- Both nail plate and nail matrix are affected, with nail pitting being the most common finding.
- There is an association between nail psoriasis and distal interphalangeal joint arthritis.
What are the key clinical predictors of Psoriatic Arthritis (PsA) and their significance?
Key clinical predictors of PsA include:
- Nail Psoriasis: Indicates a higher risk of developing PsA.
- Severe Psoriasis: Associated with increased risk.
- Scalp, Intergluteal, or Perianal Psoriasis: These areas are linked to higher PsA risk.
- Presence of Uveitis: Also a significant predictor.
These predictors help in early diagnosis and treatment, which are crucial for preventing damage and improving long-term outcomes.
How does the prevalence of nail disease relate to Psoriatic Arthritis in patients with psoriasis?
Nail disease prevalence in psoriasis patients is significant:
- Prevalence of Nail Disease: 40% in psoriasis patients.
- Known Risk Factor for PsA: Nail disease is a recognized risk factor for developing PsA.
- Overall Prevalence of PsA: 80% of patients with nail disease may develop PsA.
This relationship highlights the importance of monitoring nail health in psoriasis patients for early intervention.
What is the estimated prevalence of Psoriatic Arthritis in the general population and among those with psoriasis?
The estimated prevalence of Psoriatic Arthritis (PsA) is:
- General Population: 0.02% to 0.25%.
- Among People with Psoriasis: 3.2% to 41%.
This variability underscores the need for awareness and screening in populations at risk, particularly those with psoriasis.
What are the implications of early diagnosis and treatment of Psoriatic Arthritis?
Early diagnosis and treatment of Psoriatic Arthritis (PsA) are crucial for:
1. Preventing Damage: Early intervention can prevent joint and tissue damage.
2. Improving Function: Timely treatment helps maintain mobility and quality of life.
3. Long-term Outcomes: Effective management can lead to better long-term health outcomes for patients.
These factors highlight the importance of recognizing symptoms and risk factors early in the disease process.
A patient with psoriasis presents with nail pitting and distal interphalangeal joint arthritis. What is the significance of these findings in the context of Psoriatic Arthritis (PsA)?
Nail pitting and distal interphalangeal joint arthritis are significant as they are strongly associated with PsA. Nail psoriasis is a known risk factor for PsA, with a prevalence of 80% in PsA patients.
A patient with PsA has a history of scalp psoriasis and severe nail disease. How do these factors influence the risk of developing PsA?
Scalp psoriasis and severe nail disease are significant risk factors for PsA. Nail disease has a prevalence of 80% in PsA patients and is strongly associated with distal interphalangeal joint arthritis.
What are the common noncutaneous findings preceding the diagnosis of Psoriatic Arthritis (PsA)?
PsA is preceded by nonspecific musculoskeletal and systemic symptoms such as:
- Joint pain
- Fatigue
- Stiffness
These symptoms typically occur in the year prior to diagnosis.
What is the prevalence of dactylitis in Psoriatic Arthritis and what does it indicate?
Dactylitis has a prevalence of 20% to 59% in PsA and is a sign of disease severity associated with radiographic damage. It involves full-thickness inflammation of a digit (finger or toe) and affects the joints, entheses, and subcutaneous tissues of the digits.
What is enthesitis and its clinical significance in Psoriatic Arthritis?
Enthesitis refers to the tenderness at the insertion sites of tendons, ligaments, and joint capsules on bone. It occurs clinically in 35% of people with PsA, with an annual incidence of 0.9%. The most common sites of involvement include:
- Achilles tendons
- Plantar fascia
- Lateral epicondyles at the elbows.
What are the risk factors associated with axial Psoriatic Arthritis?
Risk factors for axial PsA include:
- Presence of onycholysis
- Inflammatory back pain symptoms
- PsA duration or young age at onset
- Positive HLA-B27
- Inflammatory bowel disease
Axial PsA with isolated spondylitis is about 4 times more likely to be asymptomatic than axial PsA with sacroiliitis.
What are the eye diseases associated with Psoriatic Arthritis?
Eye diseases in PsA include:
- Blepharitis
- Dry eye
- Conjunctivitis
- Uveitis
- Episcleritis
- Scleritis
- Keratoconjunctivitis sicca
- Keratitis
Uveitis occurs in 7% to 25% of people with PsA, which is less than in ankylosing spondylitis (AS) but higher than in psoriasis.
What is the prevalence of dactylitis in patients with Psoriatic Arthritis and its significance?
Dactylitis has a prevalence of 20% to 59% in PsA and is a sign of disease severity associated with radiographic damage, affecting joints, entheses, and subcutaneous tissues of the digits.
How is enthesitis clinically diagnosed in patients with Psoriatic Arthritis?
Enthesitis is clinically diagnosed as tenderness to pressure at entheseal insertion sites, occurring in 35% of people with PsA, with an annual incidence of 0.9%.
What are the risk factors associated with axial Psoriatic Arthritis?
Risk factors for axial PsA include the presence of onycholysis, inflammatory back pain symptoms, PsA duration/young age at onset, positive HLA-B27, and inflammatory bowel disease.
What is the estimated prevalence of eye disease in patients with Psoriatic Arthritis compared to those with psoriasis?
A third of people with PsA experience eye disease, while only 10% of people with psoriasis do. Uveitis is estimated at 7% to 25% in PsA, which is higher than in psoriasis but lower than in ankylosing spondylitis (AS).
A patient with PsA has axial involvement. What are the clinical and genetic risk factors for this subtype?
Risk factors include inflammatory back pain symptoms, onycholysis, young age at onset, positive HLA-B27, and inflammatory bowel disease.
A patient with PsA reports inflammatory back pain and has a history of onycholysis. What is the likely subtype of PsA, and what are the risk factors?
The likely subtype is axial PsA. Risk factors include onycholysis, inflammatory back pain symptoms, PsA duration, young age at onset, positive HLA-B27, and inflammatory bowel disease.
A patient with PsA presents with dactylitis. What imaging findings would support this diagnosis?
Imaging findings supporting dactylitis include diffuse extracapsular soft tissue edema, diffuse or focal increased bone marrow edema, enthesitis at the collateral ligament and extensor tendon insertions, flexor tenosynovitis, and synovitis.
What is the relationship between psoriasis, PsA, and inflammatory bowel disease in terms of genetic determinants?
Psoriasis, PsA, and inflammatory bowel disease partially overlap in their genetic determinants, immune effectors, and therapeutics.
What are some medical risk factors and comorbidities associated with PsA?
Medical risk factors and comorbidities associated with PsA include:
- Cardiovascular risk (myocardial infarction, congestive heart failure)
- Cerebrovascular events
- Obesity, type 2 diabetes mellitus, non-alcoholic fatty liver disease, and metabolic syndrome.
What is the prevalence of PsA in first-degree relatives and the significance of HLA-B27?
The prevalence of PsA in first-degree relatives is 5.5%, which is around 100 times higher than in the general population. HLA-B27 has the strongest evidence for being a genetic risk factor for PsA, with a prevalence in PsA ranging from 19% to 35%.
What are the key components of the adaptive immune system responses in PsA?
The adaptive immune system responses in PsA are characterized by:
- Selective transcription of mediators favoring Th1 and Th17 cells.
- IL12/Tbet signaling leading to Th1 cell differentiation and proliferation.
- RORγt signaling in the presence of IL23 leading to Th17 cell differentiation and proliferation.
What are the implications of delayed diagnosis in early PsA?
Studies indicate that a delay in diagnosis of 6 months or more is linked to significantly more disability in people with PsA. Early diagnosis is crucial to manage associated manifestations such as lower extremity arthritis, uveitis, and enthesitis, as well as health risk factors like cardiovascular disease and metabolic syndrome.
What criteria are used for the classification of PsA?
The CASPAR criteria are used for the classification of PsA and for participant inclusion in PsA clinical trials. Additionally, laboratory tests for rheumatoid factor and anticyclic citrullinated peptides are also utilized.
What are the implications of delaying the diagnosis of PsA for more than 6 months?
Delaying the diagnosis of PsA for more than 6 months is linked to significantly more disability in affected individuals. This delay can lead to worsening symptoms and complications, including associated manifestations such as lower extremity arthritis, uveitis, sacroiliitis, and enthesitis, as well as increased health risk factors like cardiovascular disease and metabolic syndrome.
How do genetic factors contribute to the risk of developing PsA?
Genetic factors contribute to the risk of developing PsA through several mechanisms:
1. HLA-B27: This allele has the strongest evidence as a genetic risk factor, with a prevalence of 19% to 35% in PsA patients.
2. Family History: The prevalence of PsA is significantly higher (around 100 times) in first-degree relatives, with a baseline risk of 5.5%.
3. Other Genetic Factors: Factors encoding immune system functions, including antigen presentation and processing, also play a role in the pathogenesis of PsA.
What role does the adaptive immune system play in PsA?
The adaptive immune system in PsA is characterized by selective transcription of mediators that favor the differentiation and proliferation of specific T cell subsets:
- Th1 Cells: Mediated by IL12/Tbet signaling, leading to Th1 cell differentiation.
- Th17 Cells: Mediated by RORγt signaling in the presence of IL23, leading to Th17 cell differentiation.
These responses are crucial for the inflammatory processes observed in PsA.
What are the CASPAR criteria and their significance in PsA?
The CASPAR criteria are a set of classification criteria used for diagnosing PsA and determining participant inclusion in clinical trials. These criteria help ensure that individuals diagnosed with PsA meet specific clinical and laboratory parameters, facilitating more accurate research and treatment approaches.
A patient with PsA has severe enthesitis. What genetic and immune factors contribute to this condition?
Genetic factors include HLA-B27. Immune factors involve TNF-induced NF-kB signaling and adaptive immune responses favoring Th1 and Th17 cells, mediated by IL12/Tbet and RORγt signaling.
A patient with PsA has metabolic syndrome. What comorbidities are commonly associated with PsA, and how do they impact management?
Comorbidities include cardiovascular risk (myocardial infarction, congestive heart failure), cerebrovascular events, obesity, type 2 diabetes mellitus, and non-alcoholic fatty liver disease. These comorbidities necessitate a multidisciplinary approach to management.
A patient with PsA has a family history of the disease. What is the prevalence of PsA in first-degree relatives, and what genetic marker is most strongly associated?
The prevalence of PsA in first-degree relatives is 5.5%, with a 100-fold increased risk. The genetic marker most strongly associated is HLA-B27.
A patient with PsA has been diagnosed with inflammatory bowel disease (IBD). What is the relationship between PsA and IBD, and how does it influence treatment?
PsA and IBD partially overlap in genetic determinants, immune effectors, and therapeutics. Treatment may involve TNF inhibitors like adalimumab and infliximab, which are effective for both conditions.
What is the significance of genotyping for HLA-B27 in patients with psoriasis?
Genotyping for HLA-B27 has clinical and prognostic value because HLA-B27-positive individuals are at higher risk for early PsA, axial PsA, severe enthesitis, and uveitis.
What are the common differential diagnoses to consider in patients with psoriasis?
Common differential diagnoses include:
1. Rheumatoid arthritis - usually positive for rheumatoid factor or anti-CCP.
What is the significance of genotyping for HLA-B27 in patients with psoriasis?
Genotyping for HLA-B27 has clinical and prognostic value because HLA-B27-positive individuals are at higher risk for early PsA, axial PsA, severe enthesitis, and uveitis.
What are the common differential diagnoses to consider in patients with psoriasis?
Common differential diagnoses include:
- Rheumatoid arthritis - usually positive for rheumatoid factor or anti-CCP.
- Reactive arthritis - more likely to occur after a GI or sexually transmitted infection.
- Gout - more common in people with psoriasis due to increased skin turnover and cardiovascular comorbidities.
- Osteoarthritis (OA) - high prevalence and overlapping comorbidities, usually less inflammatory than PsA, and lacks PsA-specific manifestations like dactylitis, enthesitis, and/or spondylitis.
What is the clinical significance of delayed PsA diagnosis and treatment?
Delayed PsA diagnosis and effective treatment are associated with disability and radiographic damage. There is a critical window of opportunity of about 6 months to initiate therapy to maximize chances of minimal disease damage.
What are the current treatment recommendations for PsA?
Current treatment recommendations for PsA include:
- Begin treatment according to the clinical phenotype.
- Assess disease activity every 3 months at least in the beginning or until the treatment target is achieved.
- The goal of therapy is to achieve minimal or low disease activity and escalate therapy until this goal is achieved.
- Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, and leflunomide are recommended as standard of care.
What is the window of opportunity for initiating therapy in PsA to minimize disease damage?
There is a window of opportunity of about 6 months to initiate therapy in PsA to maximize the chances of achieving minimal disease damage.
What genetic marker is associated with uveitis in PsA?
The genetic marker HLA-B27 is associated with uveitis in PsA. HLA-B27-positive individuals are at higher risk for early PsA, axial PsA, severe enthesitis, and uveitis.
What are the potential consequences of delayed diagnosis in PsA?
Delayed diagnosis can lead to increased disability, radiographic damage, and missed opportunities to initiate therapy during the critical six-month window to minimize disease damage.
What is the preferred DMARD for peripheral spondyloarthritis in the treatment of psoriatic arthritis?
Sulfasalazine has been shown to improve psoriatic joint swelling with no effect on psoriasis or enthesitis, making it the preferred DMARD in peripheral spondyloarthritis.
Which class of medications is generally considered first-line biologic agents for psoriatic arthritis?
TNF inhibitors (adalimumab, certolizumab, golimumab, etanercept, infliximab) are generally the first-line biologic agents and have been used for PsA for almost 2 decades.
What are the effects of Apremilast in the treatment of psoriatic arthritis?
Apremilast is a selective inhibitor of the enzyme phosphodiesterase 4 (PDE4) and is a targeted synthetic disease-modifying medication with moderate effects for PsA affecting skin, nails, arthritis, enthesitis, and dactylitis.
What is the role of IL17 inhibitors in the treatment of psoriasis and psoriatic arthritis?
IL17 inhibitors are the most efficacious medication class approved for psoriasis. Secukinumab and ixekizumab are both IL17 inhibitors, with Secukinumab labeled for PsA and AS, in addition to psoriasis.
What is the significance of Tofacitinib in the treatment of psoriatic arthritis?
Tofacitinib, a jak/stat inhibitor, was recently labeled for psoriatic arthritis and ulcerative colitis, indicating its role in managing these conditions.
Which medications are effective for PsA-associated manifestations of uveitis and inflammatory bowel disease?
Adalimumab and infliximab are effective for PsA-associated manifestations of uveitis and inflammatory bowel disease.
What is the role of sulfasalazine in the treatment of peripheral spondyloarthritis?
Sulfasalazine has been shown to improve psoriatic joint swelling with no effect on psoriasis or enthesitis. It is considered the preferred DMARD in peripheral spondyloarthritis.
How do TNF inhibitors compare to other treatment options for PsA?
TNF inhibitors (adalimumab, certolizumab, golimumab, etanercept, infliximab) are generally the first-line biologic agents for PsA and have been used for almost 2 decades. They are effective for both PsA and associated conditions like uveitis and inflammatory bowel disease.
What are the clinical implications of using IL17 inhibitors for psoriasis and psoriatic arthritis?
IL17 inhibitors, such as secukinumab and ixekizumab, are the most efficacious medication class approved for psoriasis. Secukinumab is labeled for both PsA and AS, while ixekizumab is approved for psoriasis and psoriatic arthritis and is being evaluated in phase III clinical trials for AS.
What is the significance of apremilast in the management of PsA?
Apremilast is a selective inhibitor of the enzyme phosphodiesterase 4 (PDE4), and it is a targeted synthetic disease-modifying medication with moderate effects for PsA, particularly for skin, nails, arthritis, enthesitis, and dactylitis.
What are the potential risks associated with using antimalarials like hydroxychloroquine in patients with PsA?
Antimalarials, such as hydroxychloroquine, are not used in PsA due to the potential for worsening or precipitating the development of psoriasis.
What alternative treatment options are recommended for a patient with PsA showing no improvement with methotrexate?
Alternative treatments include TNF inhibitors (e.g., adalimumab, certolizumab) and IL17 inhibitors (e.g., secukinumab, ixekizumab), which are effective for enthesitis.
What are the first-line biologic agents for a patient with PsA being considered for biologic therapy?
First-line biologic agents include TNF inhibitors (e.g., adalimumab, infliximab). These agents are also effective for PsA-associated uveitis and inflammatory bowel disease.
What are the limitations of sulfasalazine in the treatment of PsA?
Sulfasalazine improves psoriatic joint swelling but has no effect on psoriasis or enthesitis. It is the preferred DMARD for peripheral spondyloarthritis.
What is the mechanism of action of apremilast, and what symptoms does it target?
Apremilast is a selective inhibitor of the enzyme phosphodiesterase 4 (PDE4). It targets symptoms of PsA, including skin, nails, arthritis, enthesitis, and dactylitis.
What are the approved drugs in the IL17 inhibitor class, and what conditions do they treat?
Approved IL17 inhibitors include secukinumab and ixekizumab. They treat psoriasis, PsA, and ankylosing spondylitis (AS).
What is the mechanism of action of ustekinumab, and what conditions does it treat?
Ustekinumab inhibits the common p40 subunit of IL12 and IL23. It is approved for the treatment of psoriasis and PsA.
What is the mechanism of action of tofacitinib, and what conditions does it treat?
Tofacitinib is a JAK/STAT inhibitor. It is labeled for the treatment of psoriatic arthritis and ulcerative colitis.
What is the mechanism of action of abatacept, and what condition is it labeled for?
Abatacept is an anti-T cell therapy/CTLA4 inhibitor. It is labeled for the treatment of psoriatic arthritis.
What are the benefits and limitations of methotrexate in the treatment of PsA?
Methotrexate is a first-line DMARD effective for joint symptoms but has limited efficacy for enthesitis and dactylitis.
What is the mechanism of action of secukinumab, and what conditions does it treat?
Secukinumab is an IL17 inhibitor. It is labeled for the treatment of psoriasis, PsA, and ankylosing spondylitis.
What are the benefits and limitations of leflunomide in the treatment of PsA?
Leflunomide is effective for both psoriasis and PsA, providing mild to moderate improvements.
What is reactive arthritis and how is it classified?
Reactive arthritis (ReA) is an oligoarthritis that develops 1 to 4 weeks following an enteric or urethral infection. It is classified as a type of spondyloarthritis (SpA) and is associated with conditions like PsA, AS, and inflammatory bowel disease.
What are the common infectious agents implicated in reactive arthritis?
The infectious agents most commonly implicated in reactive arthritis include:
- GI pathogens: Yersinia, Shigella, Salmonella, Campylobacter, Clostridium difficile
- Venereal infections: Chlamydia trachomatis (urogenital infection)
What are the clinical features of reactive arthritis?
The clinical features of reactive arthritis include:
- Development of oligoarthritis (2 to 4 joints) that is asymmetric within 1 to 4 weeks after infection.
- Predominant symptoms:
- Bloody diarrhea in enteric infections.
- Dysuria with purulent urethral discharge in urogenital infections.
- The classic triad of urethral, ocular, and articular inflammation is rarely present together.
- The condition may be self-limited or may extend beyond six months (chronic ReA).
What are the cutaneous manifestations associated with reactive arthritis?
Cutaneous manifestations of reactive arthritis include:
- Circinate balanitis: Develops on the shaft or glans penis, moist and generally painless.
- In circumcised patients, lesions may harden to a hyperkeratotic dry crust resembling a psoriatic plaque, which can be painful and lead to scarring.
- Rarely, female patients may develop erythematous vulvar ulcerative lesions.
What is the epidemiology of reactive arthritis in relation to chlamydial infections?
The epidemiology of reactive arthritis shows that:
- The post-venereal urogenital type typically presents in younger adults in their third to fifth decade of life, with a male predominance.
- Up to 8% of patients with chlamydial infections may develop reactive arthritis.
- The overall prevalence is estimated at 20 to 40 per 100,000, with a yearly incidence of 25 per 100,000.
What is the typical time frame for the development of oligoarthritis following the triggering infection in reactive arthritis patients?
Oligoarthritis typically develops 1 to 4 weeks following the triggering infection.
What is the classic triad of symptoms in reactive arthritis, and how often does it present together?
The classic triad of symptoms includes urethral, ocular, and articular inflammation, but it is rarely present together in the majority of patients.
What is the male predominance in the epidemiology of post-venereal urogenital reactive arthritis?
The post-venereal urogenital type typically presents in younger adults in their third to fifth decade of life, with a male predominance.
What are the cutaneous manifestations associated with reactive arthritis?
Cutaneous manifestations include keratoderma blenorrhagicum, circinate balanitis, aphthous ulcers, and nail changes.
What is Keratoderma blenorrhagicum and where is it typically found?
Keratoderma blenorrhagicum resembles a pustular psoriasis and is generally found on the palms and soles. These skin lesions occur in 10% to 30% of cases.
What are the characteristics of stomatitis associated with Psoriatic Arthritis?
A typically self-limited stomatitis may rarely develop, characterized by superficial ulcerations or erythematous grayish plaques involving the buccal mucosa, palate, and tongue. It is painless but may bleed.
What is the typical pattern of joint involvement in Psoriatic Arthritis?
The typical pattern of joint involvement is an asymmetric peripheral oligoarthritis that may also involve the axial skeleton, presenting with inflammatory back and buttock pain. Oligoarthritis in the lower extremities is the most common pattern of peripheral joint involvement.
What is enthesitis and how does it manifest in Psoriatic Arthritis?
Enthesitis includes inflammation of tendons, fascia, and ligaments with a predilection for insertions onto bone. It can lead to swelling and discomfort of the heel, known as Lover’s heel, resulting from Achilles tendon involvement.
What is dactylitis and what causes it in Psoriatic Arthritis?
Dactylitis is the result of enthesitis involving the toes and fingers, leading to a diffuse swelling.
What is dactylitis and what causes it in Psoriatic Arthritis?
Dactylitis is the result of enthesitis involving the toes and fingers, leading to a diffuse swelling of the entire digit, commonly referred to as sausage digit.
What ocular symptoms are associated with Psoriatic Arthritis?
Ocular symptoms include conjunctivitis and inflammatory eye diseases such as keratitis, scleritis, episcleritis, and iritis. Presenting symptoms may include photophobia and visual clouding, with potential relapse leading to chronic uveitis and visual loss.
What cardiac complications can arise from Psoriatic Arthritis?
Cardiac complications can include aortic insufficiency and heart block, which may develop if there is involvement of the atrioventricular node or conducting pathway.
What genetic factor is associated with an increased risk of Reactive Arthritis?
HLA-B27 is seen as a risk factor in 30% to 40% of patients with Reactive Arthritis (ReA).
What infectious agents are commonly implicated in Reactive Arthritis?
Infectious agents most commonly implicated are the GI pathogens such as Yersinia, Shigella, Salmonella, Campylobacter, and C. difficile, as well as venereal urogenital infections with C. trachomatis. Other agents include Chlamydia pneumoniae, Ureaplasma urealyticum, and intravascular Bacille Calmette-Guérin.
What are the clinical features of Keratoderma blenorrhagicum and its prevalence in cases?
Keratoderma blenorrhagicum resembles pustular psoriasis and is generally found on the palms and soles. These skin lesions occur in 10% to 30% of cases.
Describe the typical pattern of joint involvement in patients with asymmetric peripheral oligoarthritis.
The typical pattern of joint involvement in asymmetric peripheral oligoarthritis may also involve the axial skeleton with symptoms of inflammatory back and buttock pain. The lumbar spine is more frequently involved than the cervical and thoracic spine, and oligoarthritis in the lower extremities is the most common pattern of peripheral joint involvement.
What are the criteria for diagnosing arthritis that predominantly involves the lower limb?
The criteria include: 1. The arthritis should predominantly involve the lower limb, involve one or only a few joints, and not equally involve both sides of the body (asymmetric). 2. There should be evidence or a history of preceding infection, with laboratory confirmation not required if the patient has documented diarrhea or urethritis in the prior 4 weeks. 3. The patient should not have evidence that the joint itself is infected (i.e., septic arthritis), and other causes of monoarthritis or oligoarthritis should be ruled out.
What laboratory findings are associated with the diagnosis of Reactive Arthritis?
Laboratory findings include: - No definitive laboratory test. - Nonspecific acute-phase reactants (e.g., erythrocyte sedimentation rate, C-reactive protein, platelet count) may be elevated. - No association with known autoantibodies such as rheumatoid factor or antinuclear antibody. - HLA-B27 haplotype can be seen in up to half of the patients who develop sacroiliitis. - Synovial fluid analysis typically shows evidence of sterile inflammation. - Cultures should be obtained for C. trachomatis in cases of urethritis and for Shigella, Salmonella, Yersinia, Campylobacter, and C. difficile for gastroenteritis.
What imaging findings are characteristic of Reactive Arthritis?
Imaging findings include: - Axial imaging can demonstrate sacroiliac erosions that are frequently unilateral. - Formation of syndesmophytes where the longitudinal spinal ligaments calcify, leading to ankyloses and the development of a ‘bamboo spine.’
What are some differential diagnoses for Reactive Arthritis?
Differential diagnoses include: - Disseminated gonococcal infection, Lyme disease, and subacute bacterial endocarditis, which present with oligoarthritis and different skin manifestations. - Viral infections such as HIV and parvovirus B19, which present as polyarthritis. - Septic arthritis, which is generally a monoarthritis where the infectious agent can be cultured directly from the joint. - Microcrystalline diseases like gout or pseudogout, which generally present with severe monoarthritis or oligoarthritis. - Systemic lupus erythematosus and rheumatoid arthritis, which usually present with symmetric and progressive small joint polyarthritis.
What is the initial treatment approach for acute Reactive Arthritis (ReA)?
The initial treatment for acute ReA involves a symptomatic approach with nonsteroidal antiinflammatory drugs (NSAIDs), as many symptoms are self-limiting.
What role do corticosteroids play in the treatment of Reactive Arthritis?
Corticosteroids can be used for short-term relief of joint inflammation through intraarticular injections. They are also used topically for treating extrarheumatic features of ReA, such as inflammatory eye disease and keratoderma blenorrhagicum.
What is the prognosis for patients with Reactive Arthritis?
The majority of patients with Reactive Arthritis have a self-limited course. However, relapses can occur, leading to complications such as recurrent uveitis, urethritis, or erosive arthritis.
What is the significance of disease-modifying antirheumatic drugs in chronic Reactive Arthritis?
In chronic Reactive Arthritis, sulfasalazine has shown some benefit in clinical trials, while there have been no trials for methotrexate, azathioprine, and cyclosporine.
What is the initial treatment approach for acute Reactive Arthritis (ReA) when the infectious agent is identified?
The initial treatment approach for acute ReA, when the infectious agent is identified, is to treat it aggressively with antibiotics.
What role do nonsteroidal antiinflammatory drugs (NSAIDs) play in the treatment of acute Reactive Arthritis (ReA)?
NSAIDs are used as a symptomatic approach for initial therapy in acute ReA, as many symptoms are self-limiting.
How are corticosteroids utilized in the management of Reactive Arthritis (ReA)?
Corticosteroids are used through intraarticular injections for short-term relief of joint inflammation and topically for treating extraarticular features of ReA, such as inflammatory eye disease and keratoderma.
What is the significance of sulfasalazine in the treatment of chronic Reactive Arthritis (ReA)?
Sulfasalazine has been shown in clinical trials to provide marginal benefit in overall response for chronic ReA.
A patient with chronic ReA has recurrent uveitis and erosive arthritis. What should be monitored?
Recurrent uveitis and erosive arthritis should be monitored in patients with chronic ReA.
What is the significance of sulfasalazine in the treatment of chronic Reactive Arthritis (ReA)?
Sulfasalazine has been shown in clinical trials to provide marginal benefit in overall response for chronic ReA.
What is the prognosis for patients with Reactive Arthritis (ReA)?
The prognosis for the majority of patients with ReA is that it has a self-limited course, although relapses can occur, leading to recurrent uveitis, urethritis, or erosive arthritis.
What treatment options are available for managing recurrent uveitis and erosive arthritis in chronic ReA?
Treatment options include sulfasalazine for chronic ReA, corticosteroids for short-term relief of joint inflammation, and topical corticosteroids for inflammatory eye disease.
What are the common infectious agents in urethritis for patients with ReA, and how is it managed?
Common infectious agents include Chlamydia trachomatis. Management involves aggressive antibiotic treatment of the inciting infectious agent.
