Rheumatology part I Flashcards
What are the types of spondyloarthritis/spondyloarthropathy?
Ankylosing spondylitis (MC) Axial spondyloarthritis Peripheral spondyloarthritis Reactive arthritis (formerly known as Reiter's syndrome) Psoriatic arthritis
What type of spondyloarthritis/spondyloarthropathy is associated with IBD?
Enteropathic arthritis/spondylitis
How does spondyloarthritis differ from other types of arthritis?
It involves the sites where ligaments and tendons attach to bones- enthesitis
What are the two main ways in which sx present in spondyloarthritis?
Inflammation causing pain and stiffness, most often of the spine. Some forms can affect the hands and feet or arms and legs
Bone destruction causing deformities of the spine and poor function of the shoulders and hips
What is the cause of ankylosing spondylitis?
Hereditary
Many genes cause it
The major gene involved is HLA-B27
Cause of enteropathic arthritis
Unclear
Ppl with HLA-B27 are more likely to have this form of arthritis than those without the gene
Predominant axial manifestations of spondyloarthritis
Inflammation of sacroiliac joints
Inflammation of the spine
Predominant peripheral involvement in spondyloarthritis
Peripheral arthritis
Enthesitis
Dactylitis
Enthesitis
Inflammation of the entheses, the sites where tendons or ligaments insert into the bone
Entheses:
-Where recurring stress or inflammatory autoimmune dz can cause infammation
-Or occasional fibrosis
-And calcification
What is the one of the primary entheses involved in inflammatory autoimmune dz
The heel, particularly the Achilles tendon
Sx of enthesitis
Multiple points of tenderness at the heel, tibial tuberosity, iliac crest and other tendon insertion sites
Diagnosis of spondyloarthritis
Pelvic X-ray looking for inflammatory changes in the sacroiliac joints X-ray changes of the sacroiliac joints, known as scoroiliitis, are a key sign of spondyloarthritis Spinal X-rays For more definitive assessment, order MRI CXR ANA ESR CBC CMP UA CRP HLA-B27 marker
HLA-B27
A specific type of protein that contributes to immune system dysfunction.
The presence of HLA-B27 on WBCs can cause the immune system to attack otherwise healthy cells
Tx of spondyloarthritis
PT and do joint-directed exercises
NSAIDs (naproxen, ibuprofen, meloxicam or indomethacin)
For joint swelling that is localized, injections of corticosteroids into joints or tendon sheaths can be effective quickly.
For pts who do not respond to the above lines of treatment, disease modifying antirheumatic drugs, such as sulfasalazine (Azulfidine) might be effective
Oral corticosteroids are not advised
DMARDs
Group of meds commonly used in pts with RA
Also used in treating other conditions, such as ankylosing spondylitis, psoriatic arthritis, and SLE
Work to decrease pain and inflammation, to reduce or prevent joint damage, and to preserve the structure and function of the joints
Work to suppress the body’s inflammatory systems
Take effect over weeks or mos
Epidemiology of ankylosing spondylitis
Chronic inflammatory disorder of the joints of the axial skeleton strongly associated with HLA-B27
Populations with higher incidence of HLA-B27 positive
Native Americans
Asian populations (except Japanese)
European and US Caucasian
Low prevalence HLA-B27 groups
South American Indians
Japanese
African Americans
Back pain in ankylosing spondylitis
Starts with dull low back radiating to gluteal area
Progresses up spine to ultimately involve neck
Accompanied with constitutional sx:
-Anorexia
-Malaise
-Low-grade fever
S/sx of ankylosing spondylitis
Onset before age 40
Insidious onset
Duration longer than 3 mos
Pain worse in morning
Morning stiffness lasts longer than 30 mins
Pain decreases with exercise or activity
Pain provoked by prolonged inactivity or lying down
Normal lumbar curve is flattened and thoracic curvature exaggerated
Other systemic signs of ankylosing spondylitis
Acute anterior uveitis (nongranulomatous) Microscopic colitis (often asymptomatic) Cardiac involvement rare -Aortic insufficiency -Aortitis -Conduction defects Arrhythmias
Pulmonary involvement in ankylosing spondylitis
Restrictive lung dz
Restricted costovertebral mobility
Apical lobe fibrosis
Neurologic involvement in ankylosing spondylitis
Spine fxs or dislocations
Cauda equina syndrome
Altantoaxial subluxation
PE of ankylosing spondylitis
Lumbar lordosis flattened
Thoracic kyphosis exaggerated
Cervical spine hyperextended
Test for ROM loss at lumbar spine
-Decreased lateral bending and lumbar extension
Enthesopathy- hallmark of spondyloarthopathies- can manifest as swelling of Achilles tendon or plantar fasciitis
X-ray findings in ankylosing spondylitis
Initially: bony sclerosis appears as squaring of vertebrae Next: osteitis of vertebral margins Late: annulus fibrosus ossifies Syndesmosphytes between vertebrae Classic bamboo spine apearance Progresses up spine
Special X-ray views in ankylosing spondylitis
Ferguson’s view (specialized sacroiliac view)
Bone scan
MRI spine
Labs in ankylosing spondylitis
HLA-B27- found in 90% of Caucasian pts CRP- usually elevated in 75% ESR- usually elevated in 75% ANA CBC CMP UA
1st line tx ankylosing spondylitis
NSAIDs
Indomethacin (up to max 50 mg PO TID)
Tolmetin 400 mg PO TID-QID
2nd line tx ankylosing spondylitis
TNF-alpha inhibitors- Etanercept (Enbrel)- helps best to reduce inflammatory activity of spinal dz and improve mobility
DMARDs
-Sulfasalazine
–Effective peripheral arthritis pain reduction
–Less effective for axial skeleton sx and not shown to improve mobility
-Inflixamab (Remicade)
–For ankylosing spondylitis plus IBD and iritis better than Enbrel
Meds to avoid in ankylosing spondylitis
Long-term systemic corticosteroids
Epidemiology of reactive arthritis
MC autoimmune inflammatory polyarthritis in young men
More commonly affect men by ratio of 9:1
Pathophysiology of reactive arthritis
Associated with HLA-B27 genotype in approximately 50-80% of pts
Oligoarthritis, conjunctivitis, urethritis, and mouth ulcers most common features
Usually follows dysentery (shigella, salmonella, campylobacter) or an STI, but could follow other infections such as strep A within 1-4 wks
Infectious agents in reactive arthritis diarrheal illness
Shigella C. difficile Salmonella Yersinia enterocolitica Campylobacter jejuni
Nonspecific urethritis in ankylosing spondylitis
C. trachomatis
Ureaplasma urealyticum
DDx of reactive arthritis
Ankylosing spondylitis Colitic arthritis Gonococcal arthritis SLE Lyme dz Psoriatic arthritis Rheumatic fever Rheumatoid Arthritis Juvenile rheumatoid arthritis Gouty arthritis
Clinical presentation of reactive arthritis
Constitutional
-Wt loss
-Fever up to 102
-Mild conjunctivitis in some pts/possible anterior uveitis
-Watch for carditis and aortic regurg
Arthritis onset 1-4 wks after GI or GU infection is cleared- can persist for mos
Classic clinical triad of reactive arthritis
Infrequently present-only 1/3 of the time
Arthritis
Conjunctivitis
Urethritis
Asymmetric oligoarticular arthritis in ankylosing spondylitis
2-4 joints
Affects lower extremities most commonly
Large knee effusion/ankle
Sausage-shaped fingers and toes
Enthesitis in ankylosing spondylitis
Achilles tendonitis
Plantar fasciitis
Patellofemoral syndrome
S/sx of reactive arthritis
Seronegative asymmetric arthritis following: -Urethritis or cervicitis -Infectious diarrhea Often associated with: -Inflammatory eye dz -Balanitis, oral ulceration or keratodermia -Enesthopathy -Sacroiliitis
Other musculoskeletal involvement in reactive arthritis
Anterolateral ribs
Pubic symphysis
Iliac crest
GI and reactive arthritis
Precedes arthritis by 1-4 wks
Acute diarrhea
GU and reactive arthritis
Precedes arthritis by 1-4 wks Urethritis Cervicitis Cystitis Hematuria Hydronephrosis
Circinate blanitis in reactive arthritis
Shallow painless gray-border ulcer of glans penis
Skin changes in reactive arthritis
Keratoderma blenorrhagica
Hyperkeratotic papules on plantar foot surface
Ulcers in reactive arthritis
Painless, shallow oral ulcers: Tongue Lip Pharyngeal Palate and buccal mucosa
Eye changes in reactive arthritis
Conjunctivitis
Acute anterior uveitis
CV changes in reactive arthritis
Aortitis
Aortic insufficiency
Conduction abnormality with potential heart block
Work up for reactive arthritis
CBC ESR is increased CRP is increased Joint fluid exam Consider HLA-B27 testing, but dx is generally made by clinical findings
Joint fluid exam in reactive arthritis
Synovial fluid WBC: 15-30K per mm cubed
Neutrophils predominant on differential (>66%)
Nl joint fluid glucose
No synovial fluid crystals on polarized microscopy
X-ray of sacro-iliac joint: pos in only 40-70%
Management of reactive arthritis
NSAIDs: Indomethacin SR
Consider DMARDs if not responding to NSAIDs
Doxycycline for 3-6 mos
-Indicated for suspected chlamydia etiology
Topical corticosteroid cream for keratoderma blenorrhagica
NO systemic corticosteroids
Prognosis of reactive arthritis
Self-limited: resolves over 3-12 mos usually
Chronic arthritis may develop in up to 30% of cases
Epidemiology of psoriatic arthritis
No gender predominance
Onset is usually 2 yrs after the 1st psoriatic skin lesions
Pathophysiology of psoriatic arthritis
Spondyloarthropay- sacroiliac joint involved commonly
Seronegative inflammatory arthritis (only ESR may be elevated)
Distal interphalangeal arthritis in psoriatic arthritis
Adjacent nails may show psoriatic change
Progressive bony erosions occur
Arthritis mutilans- psoriatic arthritis
Severe ostolysis
Phalanges
Metatarsals
Metacarpals
Types of psoriatic arthritis
Symmetric polyarthritis
-RA similarities: prominent metacarpal dz, prominent proximal interphalangeal joint dz
Monoarticular with DIP joints mainly affected and nail pitting
Differences between psoriatic and rheumatoid arthritis
Milder course than RA No extra-articular RA signs No subcutaneous nodules No vasculitis No pulmonary involvement RF seronegative
Oligoarthritis in psoriatic arthritis
> 50-70% of cases
Asymmetric joint involvement (<4 joints)
Often presents as arthritis in one knee
Arthritis mutilans in psoriatic arthritis
Severe deforming arthritis in which osteolysis is marked
Psoriatic spondylitis
Anklyosing spondylitis type spine involvement 50% associated with HLA-B27 Atypical axial skeleton involvement Lumbar spine most commonly affected Sacroiliitis (30%)
Asymmetric oligoarthritis in psoriatic arthritis
Involves the knee or any large joint with a few small joints in the fingers and toes
Metarsophalangeal
Proximal and distal interphalangeal
Dactylitis
Clinical presentation of psoriatic arthritis
Inflammatory arthritis -Asymmetrical distal joint involvement often -Joint pain and tenderness to palpation -Peripheral joint and spine stiffness --Occurs >30 mins in morning and after inactivity Classic psoriatic plaques -Look at typical sites on extensor knee and elbow -Examine scalp, ears, trunk Nail pitting or onycholysis Dactylitis Enthesitis Other MS involvement: -Sternoclavicular joint involvement -Tempromandibular joint involvement
DDx of psoriatic arthritis
Reactive arthritis Ankylosing spondylitis RA Septic arthritis Gouty arthritis HIV infection
Classification criteria for psoriatic arthritis (CASPAR)
Established inflammatory articular dz with at least 3 points from the following features:
Current psoriasis- 2
Hx of psoriasis (in the absence of current psoriasis)- 1
FHx of psoriasis (in the absence of current psoriasis and hx of psoriasis)-1
Dactylitis- 1
Juxta-articular new-bone formation- 1
RF negativity- 1
Nail dystrophy- 1
Labs for psoriatic arthritis
RF neg ESR increased CBC -Mild normocytic normochromic anemia Uric acid elevated (hyperuricemia) in severe psoriasis but gout risk is not increased
X-ray of involved joints in psoriatic arthritis
Bony erosions
Pencil-in-a-cup deformity at DIP joints
-Whittling of proximal phalanx
-Expanded base of distal phalanx
Spine X-ray (cervical, thoracic, lumbar) in psoriatic arthritis
Bamboo spine of ankylosing spondylitis rarely occurs
Asymmetric sacroiliitis
Asymmetric paravertebral ossification
Management of psoriatic arthritis
Treat underlying psoriasis PT -Learn to protect affected joints -Perform strengthening and ROM exercises NSAIDs in mild cases
EULAR recommendations for psoriatic arthritis tx
NSAIDs for relief of MS s/sx
Tx with DMARDs should be considered at an early stage for pts with active dz
Adjunctive tx with local corticosteroids should be considered
Cautious use of systemic steroids, if administered at the lowest effective dose, can also be considered
If active psoriatic arthritis fails to adequately respond to DMARDs, TNF-inhibitor therapy should be employed
Examples of DMARDs
Sulfasalazine (Azulfidine)
Methotrexate (avoid in HIV infection)
Cyclosporine (avoid in HIV infection)
Leflunomide (Arava)- benefits some specifically with psoriatic arthritis
Example of TNF-a inhibitors
Adalimumab (Humira)
Etanercept (Enbrel)
Infliximab (Remicade)
Ustekinumabe (Stelara)- marketed specifically for psoriatic arthritis
Example of PDE-4 inhibitor
Apremilast (Otezia)
General characteristics of OA
Most common arthropathy among adults, particularly the elderly
Progressive loss of articular cartilage with reactive changes in the bone
90% of ppl 40 yoa and older will have X-ray evidence of dz process
What the bone will look like in OA
Bone and cartilage fragments Cartilage breaking down Eroded cartilage Joint fluid with low concentration of hyaluronan Osteophytes
RFs of OA
Obesity- risk for OA in knee, hand, and hip
Competitive contact sports (but not recreational running)
Jobs with frequent bending and carrying can lead to knee osteoarthritis
Primary OA
DIP, PIP joints CMC joint of thumb Hip Knee MTP joint of the big toe Cervical and lumbar spine
Secondary OA
ANY JOINT, as an outcome of articular injury resulting from dzs such as RA or
-Extra-articular causes: acute injury, or chronic overuse of joint
Sx of OA
Insidious, with initial stiffness- lasting <15 mins
Later develops pain on motion of affected joint and worse by activity or weight bearing and relieved by rest
Flexion contracture or varus deformity, bony enlargements of DIP and PIP are prominent
Clinical features of OA
Decreased ROM, joint crepitus and pain worsening throughout the day The fingers at the DIP joints with latter stage development of Heberden's nodes and the PIP joints with with Bouchard's nodes Hips, knees, and spine are commonly affected MCP joints (except the thumb) are spared as well as the ankles and elbows Joints can become unstable during the late stages of the dz
Dx of OA
Lab tests are nonspecific-ESR is nl
X-rays show asymmetric narrowing, subchrondral sclerosis, cysts and marginal osteophytes (bone spurs)- in mid to late stages
Tx of OA
1st line- APAP
2nd line- NSAIDs (chronic use should be paired with PPI)
3rd line: intra-articular injections- can be repeated four times a year (not for use in hand)
4th line: surgical joint replacement
NSAID risk in OA
Ultimately inhibit prostaglandins that will relieve inflammation and pain
-Prostaglandins also help maintain homeostasis in several organs, esp the stomach where prostaglandin is needed for gastric mucosal cell protection
Prostaglandin maintains homeostasis by regulation of COX-1. COX-2 is generally only expressed in inflammatory tissues. Most NSAIDs block both COX-1 and COX-2.
-COX-2 inhibitors have been found to be less likely to cause GI events but still can produce renal toxicity in some pts and increase risk of CV events the same as NSAIDs
