JIA & Spondyloarthropathies Flashcards
Comparing 3 types of JIA: systemic, pauciarticular, and polyarticular How common? Age Joints Fever / rash / nodes / HSM Uveitis Destructive arthritis Leukocytosis / anemia Elevated ESR ANA RF
How common: Pauciarticular > polyarticular > systemic
Age: pauci is 2-3 years, poly has 2 peaks at 2-5 and 10-14, systemic is under age 17
Joints: Systemic and poly affects any, pauciarticular affects large joints but rarely hips
Fever / rash / nodes / HSM occurs in systemic only.
Uveitis occurs in pauci
Destructive arthritis occurs in systemic and poly
Leukocytosis / anemia occurs in systemic
Elevated ESR is highest in systemic
ANA is found in pauci
RF is sometimes found in poly
What percentage of back pain is inflammatory?
5%
Characteristics of spondyloarthropathy
- Hallmark is inflammatory low back pain / stiffness, usually >3 months and age under 45
- Sxs worsen over night and improve w/ activity.
- Pxs often have arthritis in lower extremities (RA / lupus usually involves upper extremities)
- Dactylitis
- Enthesopathy
Criteria for axial spondyloarthropathy
Sacroiliitis + 1 clinical feature or HLA-B27 + 2 clinical features.
Clinical features may include enthesitis, peripheral arthritis, dacytlitis, uveitis, family history, psoriasis, or IBD.
Physical exam for psondyloarthropathy (4)
SI tenderness, limited chest expansion, enthesopathy, Shober maneuver (spine should normally length from 10-15 cm)
Labs for spondyloarthropathy
Neg Abs to RF, CCP, and ANA.
HLA-B27 may be positive.
ESR / CRP may be high or normal
Imaging for spondyloarthropathy (3)
Sacroiliitis (may be symmetric or asymmetric), syndesmophytes (bony bridges b/w vertebral bodies), enhancing SI edema on contrasted MRI
Ankylosing spondylitis Gender / age Molecular marker Imaging (3) Early pathology Late pathology Sxs SI type Syndesmophytes Ocular conditions 4 complications Treatment
- 2% prevalence. 3x more common in males. Usually under 40 y/o.
- 90% of pxs are HLA B27 positive
- Imaging – symmetric sacroiliitis (no black line in SI joint seen on X-ray), erosions w/ irregular / serpiginous margins at the SI joint, and sclerosis of adjacent bone.
- Early pathology: synovitis and enthesitis may be absent on xray but show marrow edema on MRI
- Later pathology: bridging syndesmophytes (bamboo spine) and ankylosis
- Sxs: Synovitis, pannus formation, cartilage destruction, enthesitis, new bone formation, bony ankylosis.
- SI: 100% symmetric
- Syndesmophytes: delicate and marginal
- Ocular: anterior uveitis
- Complications: back fracture, restrictive lung disease, aortic aneurisms, CAD
- TNF treatment blocks edema, synovitis, and pain, but does NOT stop bone progression. NSAIDs reduce bone formation.
Psoriatic arthritis
Age
Joint
Extra-articular manifestations (4)
Age 35-45 Mainly affects DIPs Rash on scalp, umbilicus, and glutes Nail pits Dactylitis Arthritis mutilans (telescoping digits)
Reactive arthritis Age Gender ratio Pathogenesis / bugs Gonococcus SI Syndesmophytes Peripheral arthritis freq / distribution Enthesitis? Nails Prognosis
- Under 50 y/o
- 5x more common in males
- Pathogenesis: susceptible host w/ HLA-B27 allele gets an arthritogenic infection w/ GU or GI invasive species, including Klebsiella, Shigella, Salmonella, Yersinia, Campylobacter, Chlamydia, Mycoplasma, C diff, or Giardia.
- Gonococcus: can’t see (uveitis), can’t pee (urethritis), can’t climb a tree (Achilles tendonitis, keratoderma / blenorrhagica on bottom of feet)
- SI: 50% asymmetric
- Syndesmophytes: bulky, non-marginal
- Peripheral: common
- Enthesitis is very common
- Nails: onycholysis
- Rule of thirds: 1/3 get better, 1/3 come and go, 1/3 have progressive lifelong disease
What is enteropathic spondyloarthropathy associated with?
Associated w/ IBD (colitis > crohns)
Signs of Juvenile ankylosing spondylitis
- May have positive Schober maneuver, decreased chest expansion, tender SI joints.
- ESR / CRP are only elevated in 50% of pxs.
Extra-articular manifestations of spondyloarthropathies (7)
- Skin – psoriasis, nail pitting, onycholysis
- Keratoderma blenorrhagic and circinate blanitis occur in reactive arthritis
- Eyes – conjunctivitis / uveitis
- Mucus membranes – painful mouth sores
- GI – diarrhea / bowel inflammation occur in enteropathic and reactive arthritis
- GU – culture-neg urethritis / cervicitis w/ reactive arthritis
- Cardiac / pulmonary involvement is rare but serious. Occurs in AS. Risk for aortitis and heart block.
Treating spondyloarthritis (5)
- NSAIDs modify the disease by reducing bony formations.
- TNF inhibitors are used for axial SpA
- Mtx and Ssz used for peripheral SpA. Less effective than in RA.
- Psoriasis biologics may help psoriatic arthritis
- PT / exercise help pain, ROM, and function
