9. Conf 2: Spondyloarth, Migratory Polyarth

Question 1

What are the characteristics of inflammatory back pain? (age of occurrence, duration, response to activity/rest)

Answer 1

• usually occurs before age 40
• insidious onset, lasts > 3m
• better with activity, worse with rest

Question 2

Inflammatory back pain: at what point during the day is the pain worst? what is another unusual pain pattern with this type of back pain?

Answer 2

• pain at night, esp second half of the night
• alternating buttock pain

Question 3

Mechanical/degenerative back pain: acute or chronic presentation? age of onset? response to activity/rest?

Answer 3

• more abrupt in onset than inflammatory back pain
• worst with activity, better with rest
• usually occurs at older age than inflammatory back pain

Question 4

list the 5 types of (seronegative) spondyloarthropathies?

Answer 4

PAIR:

• Psoriatic Arthritis
• Ankylosing Spondylitis
• Associated Arthritis
• IBD
• Reactive Arthritis
• (Undifferentiated Spondyloarthropathy)

Question 5

Aside from inflammatory back pain, what are other features of spondyloarthropathy? other body parts than can be involved?

Answer 5

• large joint arthritis of the lower extremeties
• enthesitis
• dactylitis
• uveitis
• bowel inflammation
• hx of psoraisis
• preceding infection
• family hx

Question 6

Spondyloarthropathy: ESR? CRP?

Answer 6

Elevations in both ESR and CRP may be present but are non-specific.

Question 7

Spondyloarthropathy: what plain film imaging should I obtain? what will be seen on imaging (early v laste stage)?

Answer 7

Order plain films of sacroiliac joints, lumbar and thoracic spine.

Early on: may be normal

Later: erosions or sclerosis of the SI joints, enthesitis at the vertebral bodies or syndesmophytes

Question 8

Spondyloarthropathy: if xrays are negative but I still suspect spondylo, what imaging should I order? What might I see?

Answer 8

MRI: may show early inflammation and bone marrow edema

Question 9

HLAB27 testing: is it helpful? in what clinical context can it help support a dx?

Answer 9

• Debatable: positive in 8% of caucasians
• If clinical picture suggests spondylo but imaging does not support, HLAB27 can help tip the balance towards dx.

Question 10

HLAB27: positive in what % of patients with spondyloarthropathy?

Answer 10

positive in 90%

Question 11

HLAB27: in what scenario do I definitely NOT need to do this test?

Answer 11

If a patient has sacroiliitis on imaging (don’t need further confirmation in that case)

Question 12

Inflammatory back pain: responds to NSAIDs?

Answer 12

Yes. (70-80% of patients)

Question 13

mechanical back pain: responds to NSAIDs?

Answer 13

Only 15% of patients

Question 14

what are the only med treatments for ankylosing spondyloarthropathy?

Answer 14

• NSAIDs
• sulfa-something? (Sulfasalazine)
• anti-TNF alpha
• Physical Tx
• Hip replacement

Note: MTX and DMARDs DO NOT WORK in SpA

Question 15

what is seen on this image?

Answer 15

ankylosing spondylitis: specifically, ossification of the annular ligaments that are on the lateral sides of the spinal cord

(in other words, syndesmophytes bridging the intervertebral disc spaces)

Question 16

what is seen on this image? what do we call it?

Answer 16

ankylosing spondylitis: “Bamboo spine”

syndesmophytes bridging the interverterbral disc spaces

Question 17

What is this?

Answer 17

This is an image Jen found on the internet that claims to be of ankylosing spondylitis. Pretty sure it is. Kinda helpful.

this s awesome/really helpful!!

Question 18

Describe? What disease process?

Answer 18

ankylosing spondylitis again.

Widening of the SI joint. initially in this dz, the joint space will widen due to sclerosis/erosion. Eventually the joint space will narrow and fuse.

Question 19

Shows what? part of what disease?

Answer 19

Ankylosing spondylitis: advanced sacroiliitis

Complege ankylosis/fusion of the SI joints

Question 20

patient with 2 week hx of joint pain. High fever, pain and swelling in the 2nd and 3rd MCP and PIP joints of her left hand and the 2nd, 3rd and 4th MCP joints of her right hand which lasted for 3 days. Pain and swelling in her hands abated; Pain then went to wrist, then knee.

She has mild sore throat, some bumps on her arms. what label would you give this patient’s symptoms? Chronic/acute? poly or mono? migratory or intermittent?

Answer 20

Acute migratory polyarthritis

Question 21

patients with disseminated gonococcal infection can present with what triad of symptoms?

Answer 21

• MIGRATORY polyathralgia
• Tenosynovitis
• Dermatitis

(they may also present without this triad but rather with prurulent arthritis and NO skin lesions)

think of this: neisseria gonorrhoeae is MADE TO DELIVER cause it’s an STD - it will deliver!! haha

Question 22

what infections can present with a clinical picture of acute migratory polyarthritis and systemic symptoms of fever, sore throat, skin lestions? (three main ones, all with points of distinction)

Answer 22

• disseminated gonococcal infection (triad: tenosynovitis, dermatitis, polyarthralgia)
• meningococcal infection (will be severely ill, may be septic)
• Hep B (fever, polyarthritis, tenosynovitis, rash)
• similar: Acute HIV, secondary syphilis, parvovirus, acute rheumatic fever, bacterial endocarditis

Question 23

If patient has acute migratory arthritis, but NO fever, what is on your differential? What tests or symptoms could confirm each possibility?

Answer 23

• Rheumatoid Arthritis (esp palindromic rheumatoid arthritis. Most will be ACPA +)
• Reactive Arthritis (may also have conjunctivitis or keratoderma blennorhagicum)
• Lupus can initially present as inflammatory arthritis (will also have malar rash, photosensitivity, oral ulcers, Raynauds)

Question 24

These lesions are accompanied by acute migratory polyarthritis. They are consistent with what diagnosis?

Answer 24

Disseminated neisseria gonorrhea

Due to bacterial embolization to the skin -> microabscess formation

May only have 40-100 on whole body; not hundreds as with secondary syphilis

From conference answers: “Patients intially develop pinpoint macules that go on to become papules, pustules, vesicles or bullae which may become hemorrhagic or necrotic.”

Question 25

This rash shows what?

Answer 25

Erythema Chronica Migrans: Lyme disease

Conference answers document calls it a Bullous rash.

Question 26

This rash is characteristic of what?

Answer 26

secondary syphilis: generalized pustular lesions on palms and soles

With secondary syph, you’d have HUNDREDS of these pustules

Question 27

How would I confirm the diagnosis of disseminated gonoccal infection?

Answer 27

culture synovial fluid, skin, urethra/cervix, rectum. Hard to catch the actual organism but hopefully will find it at one of the mucosal sites.

also draw blood cultures

Question 28

when screening for possible disseminated gonococcal infection (DGI), what other STDs should I screen for?

Answer 28

• HIV, syphilis - these frequently coexist with DGI
• also chlamydia: epidemiologically, 46% of pts with gonorrhea have chlamydia also

Question 29

How should I go about treating disseminated gonorrhea?

Answer 29

Ceftriaxone is first line. (IV, IM every 24h: then can decrease to oral/daily)

Duration of antibiotics depends on the clinical situation (next slide)

Try to find and treat the sexual partners!

Question 30

There are 2 presentation patterns of disseminated gonococcal infection: what are they? How is each one treated?

Answer 30

Jen has been ignoring this distinction and hoping it’s not important. But it keeps coming up, damn it. So here it is:

• Some patients present with tenosynovitis, dermatitis, polyarthralgia (the triad). treat with ceftriaxone for 7d.
• Others present with prurulent arthritis and no skin involvement. may require ceftriaxone for 14d, plus drainage of joints.