AS, EA, PsA, Reiter's Syndrome

Question 1

What is Ankylosing Spondylitis (AS)?

Answer 1

A chronic, progressive immune-mediated inflammatory disorder that results in ankylosis of the vertebral column and the sacroiliac joints
A seronegative spondyloarthropathy

Epidemiology:
- typically affects young patients aged 18 – 30 years old
- men > women (3:1 ratio)

Location:
- Most commonly affects the spine and the sacroiliac joints
- May affect large joints
Usual progression: SIT/LL/ST-spineC-spine

Question 2

What are the causes of Ankylosing Spondylitis?

Answer 2

• Unknown
• May be genetic

Question 3

What are the pathological features of Ankylosing Spondylitis?

Answer 3

Chronic spinal inflammation (spondylitis) can lead to fusion of vertebrae (Ankylosis)

Question 4

What are the signs and symptoms of Ankylosing Spondylitis?

Answer 4

• mild to severe back and buttock pain
  - pain may be unilateral or intermittent at first; but within a few months it generally becomes stiff & painful
  - pain worse in the early morning hours (Morning stiffness) or after prolonged periods of inactivity
  - pain usually gets better with activity or by a hot shower or exercise
  - may simulate ‘sciatica’ although neuro exam normal
  - inflammation: ligaments, tendons, joint capsules and spine
  - reduced ROM due to fusion (ankylosis)
  - sleep disturbance
  - generalised fatigue
  - Anorexia
  - Malaise
  - Low grade fever
  - weight loss

Question 5

What are the radiological features of Ankylosing Spondylitis?

Answer 5

• SI Joints - Sacroiliitis
  - Spine- Stages:
  Normal Spine > Inflammation > Syndesmophytes Formation >Fusion (Ankylosis)
  - Romanus Lesion (Shiny Corner sign)
  - Vertebral Body Squaring
  - Bamboo Spine - fusion of the spine
  - Dagger Spine
  - Osteoporosis

Question 6

What is squared vertebra?

Answer 6

Caused by a combination of corner erosions with resorption at the enthesis.

Best seen in the lumbar region, loss of anterior vertebral concavity and straightening of the anterior vertebral margin.

Question 7

What is Dagger sign?

Answer 7

Posterior interspinous ligament ossification
Solid midline vertical density simulating a dagger
Preceded by the formation of syndesmophytes.

Question 8

What is trolley track sign?

Answer 8

2 lines:
- central vertical line: ossification of supraspinous and interspinous ligaments
- two lateral vertical lines: ossification of the apophyseal joint capsules

Question 9

What are the treatment options for Ankylosing Spondylitis?

Answer 9

• Medication: help manage symptoms of pain and stiffness
• Physiotherapy
• Surgical intervention

Question 10

What are complications of Ankylosing Spondylitis?

Answer 10

-Carrot stick” Fx
- through ankylosed segment
- MC in lower C-spine and T/L junction
- may follow trivial trauma
- “Anderson Lesion”
- non union of Fx, forming pseudoarthrosis through the IVD
Carrot stick Fxs and Anderson lesions are highly unstable and can sever the spinal cord
- Atlantoaxial instability (2-15%)
- spinal stenosis & cauda equina syndrome

Question 11

What is Enteropathic Arthritis (EA)?

Answer 11

A form of chronic, inflammatory arthritis associated with the occurrence of inflammatory bowel disease (IBD)
Classified as a form of seronegative spondyloarthropathy
Approximately 20% of people with Crohn disease or ulcerative colitis may develop EA
At least three forms of joint abnormalities are recognised in patients with IBD according to locations:
- peripheral joint arthritis
- sacroiliitis
- spondylitis identical to AS

Question 12

What is Psoriatic Arthritis (PsA)?

Answer 12

A seronegative arthritis is patients with psoriasis
A Chronic disease characterized by a form of inflammation of the skin (psoriasis) and joints (inflammatory arthritis)
Affects both men and women equally

Question 13

What ages are the onset of Psoriatic Arthritis (PsA)?

Answer 13

Between 20-50 yoa

Question 14

What are the causes of Psoriatic Arthritis (PsA)?

Answer 14

Unknown
- genetics (HLA-B27 found in >50% of PsA patients)
- immune factors (stressors or changes in the immune system may affect the development or progression of the disease)
- environmental factors

Question 15

What are the signs and symptoms of Psoriatic Arthritis (PsA)?

Answer 15

• Swollen, painful, hot, red joints - frequently in the knees, ankles and feet
• Swollen fingers or toes – “Sausage digits”
• Joint stiffness – worse in the morning
• Pitted nails, or nails separating from the nail bed
• Lower back pain
• Inflammation of the tendons

Question 16

What are the clinical findings of Psoriatic Arthritis (PsA)?

Answer 16

• Confined to DIPS of hands and feet (Hands > Feet)
  - Painful, hot, red joints
  - Swollen fingers or toes – “Sausage digits”
  - Joint stiffness – worse in the morning
  - Almost always accompanies skin disease (e.g. psoriasis) and nail changes (e.g. pitted nails, or nails separating from the nail bed)
  - Lower back pain
  - Inflammation of the tendons

PSORIASIS: An immune-mediated skin disorder, causing skin cells to multiply up to 10 times faster than normal. This causes build-up of irregular red patches covered with white scales on the scalp, elbows, knees, and lower back.

Question 17

What are the radiological findings of Psoriatic Arthritis (PsA)?

Answer 17

• Asymmetrical distribution
  - Soft tissue Swelling
  - the earliest and only radiographic sign
  - fusiform
  - may involve a single joint (spindle digit) or whole digit (Sausage digit)
  - Bone density
  - Normal - helpful in the DDX from RA
  - Joint Space
  - narrow or widened d/t fibrous tissue deposition
  - ankylosis – later stage
  - Erosions
  - prominent finding
  - starts at marginal bare areas of joints, progressing to the central areas
  - May be extensive
  - bones may appear gnawed away (“pencil in cup”)
  - Tuftal resorption (tip of terminal phalanx)
  - common finding
  - DDX: Scleroderma, Hyperparathyroidism (HPTH), thermal injury

Question 18

What is Reactive Arthritis (Reiters Syndrome)?

Answer 18

A painful form of inflammatory arthritis that develops in reaction to a bacterial or viral infection (e.g., genitourinary or gastrointestinal infections)
A Seronegative Spondyloarthropathy
CLINICAL TRIAD:
- Urethritis
- Arthritis
- Conjunctivitis

18 - 40 yrs
- Men>woman (50:1)

Question 19

What causes Reactive Arthritis (Reiters Syndrome)?

Answer 19

• Bacterial or viral infection
• glandular fever
• food poisoning
• sexually acquired

Question 20

What are the clinical findings of Reactive Arthritis (Reiters Syndrome)?

Answer 20

• Mild Anemia
• Markedly elevated ESR in most cases of acute reactive arthritis
• Elevated CRP at onset of disease
• Negative for RA factor
• May persist for years

Question 21

What are the signs and symptoms of Reactive Arthritis (Reiters Syndrome)?

Answer 21

Urethritis - usually first complaint
- Dysuria (burning pain on urination) or increased frequency of urination - may be the only symptoms
- Fever, conjunctivitis & arthritis develop over few weeks
- Painful effusion
- Pain and swelling in large joints e.g., knees
- Heel pain and tenderness (“lover’s heels”)- common manifestation and should suggest DX in young male patients

Question 22

What are the radiological findings of Reactive Arthritis (Reiters Syndrome)?

Answer 22

• Articular and periarticular soft tissue swelling
• Uniform loss of joint space
• Marginal erosions

Question 23

What are the complications of Reactive Arthritis (Reiters Syndrome)?

Answer 23

Urinary tract obstruction
- Iritis, retrobulbar neuritis, corneal ulceration
- Initial illness typically resolves in 3-4 months
- 50% of patients experience transient recurrences of arthritis over a period of several years