Seronegative Spondyloarthropathies Flashcards
what conditions are classified as seronegative spondyloarthropathies
what does this class of conditions mean
- ankylosing spondylitis
- reactive arthritis
- enteropathic arthritis
- psoriatric arthritis
seronegative: no postive RH (can have postive other rhum. labs)
spondy: spine
arthropathy: arthritis
seronegative spondyloarthropathies
- multisystem inflammatory diseases which affect the spine, peripheral joints and periarticualar structures
- due to the inflammation, erosive lesions heal over with new bone formation
- extraarticualr manifestations: uveitis, psoriasis in skin/nails and aoritc inflammation
- no postivie ab. of RH, anti-CCP or other antibodies
- these are ALL associted with HLA-B27
what are some features of all the seronegative spondyloarthropathies
- seronegative for RF
- individuals with a + HLA-B27 gene are at an increased risk (not necessary for dx. but increase risk)
- axial skeleton involvement: the lumbosacral spine & sacroiliac joint
- Enthesitis : inflammation which distruptes the connection between the bone and the joint : like achilles
- asymmertical arthritis in the peripheary
- involved with the Eye: uveitis and conjuctivitis
- Dactylitis: sausage digits: the entire digit is inflammed
left untreated
- aoritis: inflammation of the aorta
- heart blocks and aortic insufficiency
-apical pulmonary fiberosis
what the deal with HLA-B27 and seroneg. spondy.
HLA B27 is a serotype
- HLA B27 is seen most commonly in caucasian individuals
- not everyone with the serotype will have a spondy. but 97% of those with spondy. have the HLAb-27 serotype
- (06 & 08 see to be protective)
relations with the HLAB27 also with
- IBD (and specifically enteropathic arthritis)
- psoriasis (psoriatric arthritis)
- anky. spondy. (specifically those with uveitis)
- reactive arthritis (to a GI/GU infection trigger)
increases risk of getting these conditions of seroneg. spondy. with the HLAB-27 gene
- close relation with a family member having it and twins both having it
Ankylosing Spondylitis
etiology
charactisitcs of symptoms your pt. will complain of
Anky. Spondy. (AS)
Etiology
- an inflammatory arthropathy of the axial skeleton with a variety of extra-articualr manifestations
- effects men > women
Symptoms
Inflammaotry arthritis pain
- pain worst with rest, better with moving
- pain awaking at night
- no active inflammation (red, warmth or tender)
- arthritis in the lower back and the SI joint most commonly
- hips, shoulders, TMJ and AC joints can also be affected
Enthesitis: AP has inflammation at the connection between ligament and bone more than iwthin the joint synovum itself, differentiating it from RA in that way
- the site where the tendon, ligamenet or fascia attach to the bone
- seen as edema of adjacent bone marrow & erosive lesions that eventually ossify and create more pain
Ankylosing Spondylitis
Diagnosis
HLAb gene?
Diagnosis
- inflammatory back paind for 3+ months in someone younger thatn 45
- limited lumbar spine motion (Schober Test)
- elevated inflammtory markers (not needed)
- evidence of bilateral saroillitis on imaging (fusion of the joint)
the presence of the HLA-B27 gene is not necessary for teh dx. or any other Rhum. makrer!!! can point int he direction but not needed for dx. (can be helpful)
how to test spine flexibiltiy for AS
Spine Flexibility
- testing with the Schobers and occiput to wall test can be done prior to imaging
Schober Test: pt. bends and the distance between the PSIS and 10 cm higher up shoud grow by 5cm compared to standing = if this distance is less than 5 cm = decreased flex.
Occipt Test
- test c-spine involvement: if its limiited they wont be able to put back of teh head to the wall
- shows a forward, progressive swoop of the neck & the dsitance can be measured
can see
- flattening chest wall
- lost lumbar curve
- and thoracic kyphosis
- forward protrusion of the head cuasing a characteristic upward gaze
- inability to get remootely close to touching the floor
Radiographic Findings of Ankylosing Spondylitis
Spine Pathology on Imaging
Lumbar spine straightens
- the syndesmophytes eventually change the shape of the spine creating a bambooing of the spine
- these fit snug with the contour of the spine, curvy!
- squaring of vertebrae bodies causing shiny corners seen on imaging
Syndesmophytes (new bone formation)
- vertical ossifications bridging two adjacent vertebral bodies together: severing limiting ROM
- these come from the sharpes fibers & become part of the vertebral bodies overtime
- eventual ossification of the longitudianl ligament
SI joint pathology on Imaging
- sacrolitis: erosions at first effecting the iliac side of the joint
- psuedowidening of the SI joint
- ankylosing of the joint = fusion of the entire SI joint
ADditional Radiographic (outside the spine and SI joint) pathology for AS
Lung
Calcaneous
Calcaneous
- calcaneal erosins and spurs (enthesitis leading to spurr formation)
- loos fuzzy early on then develops a sharp spur and the normal enthesitits symptoms
Lungs: Apical Fibrosis
- seen on CXR: crackels hear on PE
- linear and pathcy infiltrates with caviteis in the apical aspects of the lungs
Offical Modified New York Criteria for diagonsis of Ankylosing Spondylitis
Diagnosis Criteris used to day (imaging and HLAB27)
Clinical
- low back pain 3+ months, improved with exercise and worse with rest
- limitation in the spine in sagital and frontal planes
- limitiaion of chest expansion
Radiolgical
- bilateral sacroilitis
- unilateral sacroilitis
graded 0 (normal) to grade 4 (complete)
___________________________________________________
Criteris for Diagnosis used today
chronic back pain 3+ months with age < 45
HLA-b27 gene
PLUSE
2+ of the features
OR
Sacroilitis on imaging: showing actue/active inflammation OR definiative radiographic evidence via the NY criteria
PLUS
1+ of the following features
Features
- inflammatory back pain
- arthritis
- enthesitis in achilles
- uveitis
- dactalyitis
- psoriasis
- chrons/UC
- respons to NSIAD
- fam hx.
- HLAB27
- elevated CRP
Treatment of Ankylosing Spondylitis
Start with non-pharm (education and exercise) and NSAIDS
then
Axial AS
- try analgeics, opioids and local steroids
- then go to anti-TNFs
Perihperhal AS
- try anagesics, opiods, local steroids
- then go to Sulfasalzine (DMARD)
- then go to anti-TNFS
in sum
- NSAIDS should be used continuously and are FIRST ling treatment
- then TNF inhibitors (infliximab, adalimumab, etanercept) (slow bone growth!)
- sulfazaline can be used in peripheral AS
Reactive Arthritis (Reiter’s Syndrome)
etiology
organisms
Etiology
- a reactive arthritis; descrbing an acute, sterile synovitis following local infection elsewehre in the body
- commonly a GU or GI illness
- Reiter’s Syndrome: cant pee, cant see, cant climb a tree; a reactive arthritis following a nongonoccoal urethritis
- Poncet’s disease: reactive arthritis from TB and erythema nodosum
- Post-strep arthritis also possible
- develop 2-4 weeks after infection in the GU/GI
- seroneg. for RF and ANA, +/- HLAb27
Organisims
GI: shigella, camplyobacter, salmonella, yersnia
- diarrheal illness
GU: chlamydia trachomatis (NOT GONNORRHEA)
- any type of GU infection by these: can even be asymptomatic
Reactive Arthritis: symptoms
nongonococcal urethritis can be the first manifestaion and occurs from BOTh post-GI and post-GU infections!!!
urethritis: stingin, buring pain with urination
Arthritis
- inflammation: warmth, pain, swelling
- this is ADDITIVE in nature, asymmetric and oligoarticular (1-4 joints) average = 4 joints
- lower limb joints:knees, ankles and feet
- rare to be upper limb involvement
Occular
- conjunctivitis: within a few days or the joints: red eyes; mild burning and exudative sensation
- acute anterior uveitis: iritis: erythema, pain and photopobia
Reactive Arthritis: Additional symptoms
(besides arthritis, urethritis, and eye)
Dactylitis
- sausage digits of fingers or toes
- entire digits!!!!
Enthesopathy
- inflammation at the tendon attachmen tto th ebone
- in reactive THE HEEL IS MOST COMMONLY AFFECTED
- called “Lovers heel: due to achilles invovlement
Back Pain
- as a result of SI pathology, enthetitis or prostatitis
- some can progress to ankylosing pondylitis
Diagnosis of Reactive Arthritis
diagnosis and idetification of the organsim causing teh GU/GI infection
- the most commony bug is chalymida
- the urethritis: wont have as much discharge as gonnorhea
with the proper symptoms present
Dermatologic involvment of reactive arthritis
Keratoderma blennorrhagicum
- a papulosquamous rahs on the palms and soles but can be anywhere
- raised waxy andd papular
- overtype can become hyperkeratotic and scaly & look like psoriasis
Nails
- thickened, obaque, and crumble
Treatment of Reactice Arthritis
Treatment
Treat the STI & any coexisting gonorrhea
- doxycycline for chamylmida
- +/- adding abx. for 6 months might help (dox + rifamiin or azithrmyocin+ rifamiin)
Arthritis = NSAIDS initailly
Chronic Symptoms
- Sulfsalazine
differentiate gonoccoccoal infection dissemminated
the cultures from the joint, urethral, cervical etc. will be POSTIVE
(in reactive= these are sterile)
GC has tenosynovitis, rash, and effects upper nad lower limbgs equally
Enteropathic arthritis
etiology
symptoms
radiography
treatment
Etiology
- those with IBD have peripheral arthritis
- can have the HLAb27 gene
Symptoms
- acute, in relation to flairs of the IBD and can be self-limiting
- they are early in the course of the IBD and do not cause destruction to the joints
- symmetric, migratory polyarthritis affecting the large joints of the lower extremities
Spondylitis (back pain)
- less common, but if it happens it preceeds the IBD
- it will be inflammatory back pain
Radiography
- wont cause destruction in teh arthtiris
- if its spondylitis: show typical bilateral sacroilitis
- can have asymptomatic bilateral sacroilitis in those with IBD
Treatment
- TNF inhibits:
- adalimumab
- infliximab
- golinimab
Psoriatic Arthritis (pSa)
etiology
symptoms
Etiology
- a chronic inflammatory arthritis that affects a good chunk (up to 42%) of those with psoriasis
- this can preceeed or follow the normal skin presentation and dx. of psoriasis (sometimes the skin lesions are so small they just dont know about them untl the arthritis)
Symptoms
Skin & Nails
- flexural psorisais in the natal ceft! (hidden)
- plaque formation at the flexor surfaces of the body, scalp, etc.
- dactalyisis
- oncyodystrophy: ridging, pitting of the nails
Arthritis
- the arthrtis: can be asymmetric inflammtory arthristis (can be symmetric)
- swelling at the DIP, PIP, MCP (DIP involved here!!)
- red, swollen joints
Severe Arthritic Findings of psoriatic arthrisits
Arthritis mutilans
- rare: but shortening of the digits due to telescoping of the bones and joints
- imaging: pencil in a cup appearance
Psoriatric Arthritis: Xray findings
Imaging
- “Pencil in a Cup” soft tissue swelling, lost cartilage, erosins, bony ankylosis and subluxation
- DIP arthritis
- bone proliferation and periositis: periotsisits is inflmmation around the digits : looks soft and fluffy around the joint: NOT demineralized
- the whiskering of the bone around the joint, on the shaft
- telescoping of the bone into the other, creating”opera glass”
- asymmetric sacrolillitis
- syndesmophytes: but not on the joint margins: in the middle “Chunky syndesophytes
Diagnosis of Psoriatic Arthritis
CASPAR Criteria
> 3 points from any of teh 5 categories
- evidence of psoriasis: personal or family hx.
- nail dystrophy
- negative RF
- dactalysis: personal hx. or current
- radiographic of involvement
Treatment of Psoriatic Arthritis
methotrexate is first line
- NSAIDS and local GC can help but ^^
- if those dont work you move on to TNF inhibits, etc. and other IL inhibitots
- IL-23 and IL-17 are the targets to stop
ORDER for Peripheral invovlement
- NSAIDS and local steroid injections
- first line med: methotrexate
- then: IL-17/IL-23 inhibitors and TNFs
ORDER for Entheseal Invovlement
- NSAIDS and local steroid injections
- then IL-17 & IL 23
- then PDE 4 inhibitors
ORDER for Axial INvovlement
- NSAIDS
- THEN IL-17 or IL-23
