seronegative spondyloarthropathies Flashcards
7 shared features of these disorders
- seronegative; no rheumatoid nodules
- HLA-B27 association
- familial aggregation
- inflammatory axial arthritis (SI and spondylitis)
- oligoarthritis w/ asymmetric presentation
- enthesis
- extraarticular features
inflammation of place where tendons or ligaments insert into bone
enthesitis (plantar fasciitis, achilles tendonitis, costochondritis)
fine delicate calcifications/osteophytes
syndesmophytes
digital tendon inflammation (sausage digits)
dactylitis
- dull achy, insidious lower back/gluteal pain/discomfort before age 40 lasting over 3 months
- associated w/ morning stiffness & improves w/ exercise
- initial presentation in the SI joint first then other joints
- peripheral joint involvement usually asymmetric
- neck pain & stiffness as late manifestations
ankylosing spondylitis (AS)
inflammatory d/o of unknown cause; affects axial skeleton, peripheral joints & extra-articular structures
AS
- loss of lumbar lordosis on flexion
- chest expansion
- peripheral involvement: achilles tendinitis, plantar fasciitis, tibial tuberosity, superior & inferior poles of patella, iliac crests
- schoeber’s test/index to monitor treatment
AS
3 areas of extra-articular involvement with AS
- Uveitis is most common; acute, unilateral & non granulomatous
- CV– aortitis of ascending causing aortic valve insufficiency, MV insufficiency, AV block
- Pulm– restrictive lung disease, bilateral apical pulm fibrosis
if a patient w/ known AS falls and has backpain, what imaging must you get to evaluate for fractures?
MRI!
- radiograph shows straightening of spine + squaring & fusion of vertebrae (bamboo sign)
- shiny end of vertebral bodies from where tendons pull (shiny corner/romanus sign)
AS
erosions, sclerosis, joint space widening, narrowing & eventually bony anklyosis on radiograph
sacroilitis
tx of uveitis from AS
steroids & cycloplegics
immunosuppressants if recurrent
- asymmetric inflammatory oligoarthritis of hands (often DIP joint) w/ axial involvement
- dactylitis/sausage digits
- nail changes
- erythematous plaques w/ thick silvery-white scales on skin
psoriatic arthritis
for each feature, which one happens in PsA vs RA?
- peripheral involvement
- axial involvement
- symmetry
- DIP joint
- enthesitis, dactylitis, bony erosions or new bone
- skin?
- peripheral– all
- axial– mostly PsA; RA is C1-2 only
- symmetry– RA, sometimes OA
- DIP joint– PsA (& OA)
- Enthesis, dactylitis, erosions, skin– PsA only
very fast resorption of bone/digits causing telescoped/collapsed “opera glass hand”
PsA– arthritis mutilans
“pencil in a cup” deformity on radiogaph
Psoriatic arthritis
radiograph is best initial test
inflammatory arthritis in response to an infection or inflammation in another part of the body
- Reiters triad-
- venereal (post chlamydia/ureaplasma) or dysentry (post shigella, salmonella, campylobacter, yersinia) causes
reactive arthritis– think hot swollen knee after having diarrhea wks before
what is the reactive arthritis traid
arthritis
uRETHRitis
conjuctivitis
is this conjuctivitis or uvitis?
erythema & exudate on bulbar & palpebral conjunctivae; sterile weeping pus bc infection has passed
conjuctivitis– uveitis typically does not have palpebral involvement
- asymmetric synoyitis in knees, achilles tenditis/ethesitis, sacrilitis
- keratoderma blennorrhagicum– hyperkeratotic lesions on palms & soles
- circinate balanitis– painless erythematous lesions w/ small shallow ulcers on glans penis & urethral meatus
reactive arthritis
first line tx of reactive arthritis
1st line: NSAIDs– high dose Indomethacin
- UC or Crohns
- axial w/ thin syndesmosphytes and peripheral pauciarticular disease
enteropathic arthritis
axial or peripheral– which disease type correlates with GI activity in enteropathic arthritis?
peripheral
tx for peripheral vs axial enteropathic arthritis (2)
- peripheral: RA pathway (SSZ, MTX, TNF inhibitors, IL-17 inhibitors)
- axial: TNF or IL-17 inihibitors
- nonsteroidals or biologics does NOT stop extra bone formation
class of medications that are approved as AS therapy after NSAID therapy has failed; medication is also used with enteropathic arthritis
TNF inhibitors– etanercept (SC), infliximab (IV), adalimumab (SC), golimumab, certolizumab
medication approved for psoriatic arthritis and AS; also used in enteropathic arthritis but can CAUSE IBD
IL-17 inhibitors (cosentyx/taltz)
oral PPD4 inhibitor that causes depression & diarrhea; new and expensive
otezla
class that can be used for PsA, AS, UC but has increased risk of zoster and a BBW for CV events, clots & cancer
JAK inhibitors
sx suggestive of spondyloarthritis/AS but no radiographic findings (complaints of back pain but no SI involvementon xray)
MRI maybe helpful or confusing (bone edema); can have false positives if you fell recently or postpartum
non-radiographic axial spA
