Ch 3 - Rheumatology: Spondyloarthropathies Flashcards by Chris Garrison

What are types of Juvenile spondyloarthropathies?

Juvenile AS
Reiter’s syndrome
Psoriatic arthritis
Arthritis of Inflammatory bowel disease/Enteropathic arthropathy

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How do seronegative enthesopathy and athropathy (SEA syndrome) present?

– RF (−)
– ANA (−)
– Enthesitis/arthritis/ arthralgia
– May have uveitis (painful and acute)

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How does inflammatory arthritis present?

Inc WBC and ESR
Acute painful onset
Erythema, warmth, and tenderness

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What are types of inflammatory arthritis?

CTD—SLE, polymyositis, dermatomyositis, PSS, RA
Crystal—gout and pseudogout
Infectious
Seronegative spondyloarthropathies

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What are types of noninflammatory arthritis?

OA, AVN
Traumatic
Joint tumors
Hemophilia
Metabolic: hemochromatosis, alkaptonuria, rheumatic fever, Wilson’s disease

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What diseases are HLA-B27 positive?

AS
Reactive arthritis (Reiter’s syndrome)
Psoriatic arthritis—HLA Cw6
Enteropathic arthropathy
Pauciarticular JRA

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What is Ankylosing spondylitis?

Chronic, inflammatory rheumatic disorder of the axial skeleton affecting the sacroiliac joint and the spine

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What is the hallmark finding of Ankylosing spondylitis?

Bilateral sacroiliitis

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Who is affected by Ankylosing spondylitis?

Males&raquo_space; females

* More common in whites

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What is the onset of Ankylosing spondylitis?

Late adolescent and early adulthood

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What are the skeletal sites of involvement in Ankylosing spondylitis?

SI joint
Lumbar vertebrae
Thoracic vertebrae
Cervical vertebrae

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What is the clinical presentation of Ankylosing spondylitis?

• Insidious onset, back pain, or tenderness in the bilateral SI joints
– Initially asymmetric then bilateral
• Sx for least 3 mo
• Lumbar morning stiffness that improves with exercise
• Dec lumbar lordosis and inc thoracic kyphosi

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Which patients will develop cervical ankylosis?

Develops in 75% of the patients who have AS for 16 years or longer

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What is the MC site of fracture in Ankylosing spondylitis?

Lumbar or lower cervical spine

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What is enthesitis?

Inflammatory process occurring at the tendon insertion site onto bone

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Where does enthesitis occur in AS?

Ischial tuberosity
Greater trochanter
ASIS
Iliac crests

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Which joints are MC involved in juvenile AS?

Hip

Shoulder

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What pulmonary condition can develop in AS?

Restrictive lung disease l/t dec chest expansion and diagphragmatic breathing

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What is the MC extraskeletal manifestion of AS?

Acute iritis/iridocyclitis

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What are extraskeletal manifestions of AS?

Fever/fatigue/wt loss
Aortitis l/t fibrosis
Conduction defects
Apical plumonary fibrosis
Amyloidosis
Cauda equina syndrome
C1 to C2 subluxation

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What are lab findings in AS?

HLA-B27 (+) in 90%
RF (–) and ANA (–)
Elevated ESR and CRP
Normochromic normocytic anemia

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Describe SI joint narrowing on radiographs in AS.

Symmetric

Erosions and sclerosis may lead to fusion

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Describe pseudo-widening of the joint space on radiographs in AS.

– Subchondral bone resorption (blurring of joint line)
– Erosion sclerosis
– Calcification leading to ankylosis

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What causes bamboo spine?

Ossification of the spinal ligaments, syndesmophyte formation, and ankylosis of the facet joints lead to complete fusion

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Describe the appearance of syndesmophyte formation

Squaring of lumbar vertebrae’s anterior concavity

What causes syndesmophyte formation?

Ossification of the outer annulus fibrosis at the dorsolumbar and lumbosacral area and reactive bone sclerosis

Describe bone density in AS.

Associated osteopenia/ osteoporosis (bone washout)

What is Schober's test used to detect?

Limitation of forward flexion and hyperextension of the lumbar spine

Describe how to perform a Schober's test.

While standing erect, place a landmark midline at a point 5 cm below the iliac crest line and 10 cm above the illiac crest on a spinous processes. On forward flexion, the line should increase by > 5 cm to a total of 20 cm or more (from 15 cm).

What is considered a restriction on a Schobers test.

Inc <5 cm on forward spine flexion

How should patients with AS sleep?

Firm mattress | Sleep in prone position to keep spine straight/prevent spine flexion deformity

What type of PT should be used for AS patients?

– Spine extension-based exercises – Swimming is ideal – Joint protection

Which DMARDs can be used for AS?

Sulfasalazine Methotrexate | TNF inhibitors

What should be used to treat uveitis in AS?

Topical corticosteroid drops

What is the triad of Reactive arthritis?

1. Conjunctivitis 2. Arthritis 3. Nongonoccal urethritis (“Can’t see, can’t pee, can’t climb a tree”)

Who is typically affected by Reactive arthritis?

Males >> females | More common in Caucasian population

Which organisms cause Reactive arthritis?

– STDs: Chlamydia – GI: Campylobacter, Yersinia, Shigella, Salmonella – Also assoc w/ HIV

What can patients with reactive arthritis progress to?

3% to 10% of patients progress to AS

What is the onset of arthritis in reactive arthriits?

2-4 weeks after infectious event

Describe the feautre of arthritis in Reactive arthritis.

``` Asymmetric Oligoarticular (<4 joints) Dactylitis Enthesopathies Low back pain: sacroiliitis ```

What are the MC joints involved in Reactive arthritis?

LE > UE joints LE: knees, ankles, and small joints of the feet UE: wrist, elbows, and small joints of the hand.

What can Reactive arthritis be confused with?

Plantar fasciitis

Describe the appearance of dactylitis.

Swollen, tender digits with a dusk-like blue discoloration

Which tendon is MC involved with enthesopoathy in reactive arthritis?

Achilles tendon

What are ocular disorders of reactive arthritis?

``` Conjunctivitis Iritis Uveitis Episcleritis Corneal ulceration ```

What is Balanitis circinata?

Small painless ulcers on the glans penis or urethritis in reactive arthritis

What is Keratoderma blennorrhagica?

Hypertrophic skin lesions on palms and soles of feet in reactive arthritis

What are Reiter's nails?

Thickened and opacified, crumbling, nonpitting

What is seen in synovial fluid of reactive arthritis?

* Turbid * Poor viscosity * WBC 5,000 to 50,000 PMNs * Inc protein * Normal glucose

What is seen on labwork in reactive arthritis?

* Inc ESR * RF (–) and ANA (–) * normochromic normocytic anemia * HLA-B27 (+)

What is seen on radiographs in reactive arthritis?

* “Lover’s heel” * Ischial tuberosities and greater trochanter * Asymmetric SI joint involvement * Syndesmophytes * Pencil-in-cup deformities of the hands and fee

What is a "Lover's heel"?

Erosion and periosteal changes at the insertion of the plantar fascia and Achilles tendons

What is the treatment of reactive arthritis?

* NSAIDs (indomethacin) * Abx: tetracycline or erythromycin * Corticosteroids * DMARDs

What % of patients with psoriasis develop psoriatic arthritis?

5-7%

Who is affected by psoriatic arthritis?

* Male=female * 30 to 55 yo * MC in white

What is associated with psoriatic arthritis?

HIV

Which joints are involved in psoriatic arthritis associated with HIV?

Foot and ankle MC and severe

What is the treatment of psoriatic arthritis associated with HIV?

– First-line NSAIDs – No oral corticosteroids – No methotrexate

Describe the skin and nail findings of psoriatic arthritis.

Erythematous, silvery scales over extensor surfaces | Nail pitting

What is Auspitz's sign?

Gentle scraping of psoriatic lesions results in pinpoint bleeding

Describe the arthritis of psoriatic arthritis.

* Asymmetric monoarticular or oligoarticular * Enthesopathy * Spondylitis, sacroiliitis

Which joints are MC involved in psoriatic arthritis?

– Large joints: knee | – DIP involvement

What is Arthritis mutilans?

Osteolysis of the phalanges and metacarpals of the hand resulting in “telescoping of the finger”

What are lab findings of psoriatic arthritis?

HLA-B27 (+)

What is seen on radiographs in psoriatic arthritis?

* “Pencil-in-cup” DIP * Asymmetric sacroiliitis l/t fusion * “Fluffy periostitis”—hands, feet, spine, and SI joint * Syndesmophytes * Bone erosion

Describe rehab for psoriatic arthritis.

* ROM to all joints | * Do not abuse an inflamed joint as can l/t exacerbation

What is treatment for psoriatic arthritis?

* PUVA (long wave ultraviolet Å light) * Steroids—oral steroids not proven, injection may help * Anti-TNF antibodies (adalimumab, infliximab)

Which joints are affected in enteropathic athropathy?

Large joints—knees, ankles, feet

When will enteropathic arthropathy typically resolve?

With bowel disease remission

What are extra-articular manifestations of enteropathic arthropathy?

* Erythema nodosa—Crohn’s * Pyoderma gangrenosa—ulcerative colitis * Painful deep oral ulcers * Uveitis * Fever and weight loss during bowel episodes

What is seen on lab work in enteropathic arthropathy?

* Anemia * Inc ESR, CRP * RF (–), ANA (–) * HLA-B27 (+) * (+) antineutrophil cytoplasmic antibodies (ANCAs) ~60% (antimyeloperoxidase)