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