Seronegative Spondyloarthropathies

Question 1

What are Seronegative Spondyloarthropathies( Axial Arthropathies)?
lecture by Sterling West,MD,MACP

Answer 1

A cluster of interrelated chronic inflammatory diseases including:
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
Inflammatory bowel disease

Question 2

What is the hallmark of Seronegative Spondyloarthropathies?

Answer 2

They inflame the enthesis (not ligament, tendon or bone –> the insertion site)

Question 3

What are some features of seronegative spondyloarthropathies?

Answer 3

Sacroilliitis and spondylitis
Negative rheumatoid factor
Asymmetrical arthritis
Enthesitis
Extraarticular manifestations
Familial and racial aggregation 
HLA-B27

Question 4

Which race is most effected by seronegative spondyloarthropathies?

Answer 4

Caucasians

Question 5

What are symptoms of ankylosing spondylitis?

Answer 5

Men > women 3:1 - often starts in teens
Inflammatory back pain
Age 3 months
Morning (>60 min) and night time stiffness
Improves with activity
No neurologic symptoms

Question 6

What exam items should be looked at in someone with ankylosing spondylitis?

Answer 6

Global loss of spinal range of motion
Schobers maneuver 10 cm -15 cm normal
Occiput to wall
Chest expansion 4 cm
Patrick test - Fabere maneuver

Question 7

what clinical feature is in 100% of patients with ankylosing spondylitis?

Answer 7

Sacroiliitis

Question 8

What are some treatments for ankylosing spondylitis?

Answer 8

P.T. exercise (aerobic, strength, flexibility) and smoking cessation.
Indocin best of the NSAIDS in these illnesses
Sulfasalazine and Methotrexate good for peripheral arthritis
Anti-TNF agents good for axial arthritis

Question 9

What are poor prognostic signs for ankylosing spondylitis?

Answer 9

Hip disease or,
Three of the following:
Onset< age 16
Limitation of spine motion
Oligoarthritis
Sausage digit
High ESR or CRP
Poor efficacy of NSAIDs

Question 10

What is Reactive Arthritis?

Answer 10

Formerly called Reiters disease
Lower extremity joints – Asymmetrical
Sacroiliitis is asymetrical
Sausage digits
Enthesitis
Rash (keratoderma blennorragica, circinate balanitis, oral, nails)

Question 11

What are the demographics of Reactive Arthritis?

Answer 11

M>F 5-10:1

Caucasians> other races

Question 12

What is the symptom progression of reactive arthritis?

Answer 12

Starts with
G.I. infection with Shigella , Salmonella,yersinia or Campylobacter   OR
G.U. infection with Chylamdia
Followed by
Urethritis
Conjunctivitis
Arthritis (enthesitis)

Question 13

What is the treatment of reactive arthritis?

Answer 13

Treatment: PT, intraarticular steroids, NSAIDs, sulfasalazine, MTX, anti-TNF
Treat chlamydia-induced with doxycycline for 3 months. Antibiotics don’t work for diarrhea-induced organisms

Question 14

What is the course of Reactive Arthritis?

Answer 14

Duration 3-5 months
Often chronic mild symptoms for 1 year
Chronic arthritis with disability in 15%

Question 15

What are clinical features of PsA (Psoriatic arthritis)?

Answer 15

Arthritis, Dactylitis/sausage digits,Enthesitis,
Tenosynovitis, Sacroiliitis/spondylitis. Psoriasis, Nail pitting, Onycholysis, Conjunctivitis/iritis/uveitis, Aortitis- rare.

Question 16

Which condition may be difficult to distinguish from RA?

Answer 16

Symmetric Polyarticular Arthritis

Question 17

Not many diseases cause inflammation of the DIPs, what is this an indication of?

Answer 17

Psoriatic arthritis

Question 18

What is Arthritis Mutilans?

Answer 18

Findings of telescoping digits and flail joints associated with extensive osteolysis and joint instability describe the condition.

Question 19

How can you differentiate nail changes in dactylitis from a fungal infection?

Answer 19

dactylitis won’t affect all finger nails, a fungal infection usually will.

Question 20

What are features of Enteropathic Arthritis?

Answer 20

10-40 % of ulcerative colitis and Crohns have peripheral inflammatory arthritis
Peripheral arthritis correlates in 60% with activity of bowel disease
Peripheral arthritis tends to be large joint and recurrent. Not severly destructive.
Sacroiliitis and spondylitis in 10-15%. Looks like AS. Associated with HLA-B27(50%). Does not correlate with bowel disease.

Question 21

What is HLA-B27?

Answer 21

Class I MHC antigen on the surface of all cells
24 subtypes
Binds intracellular antigens in ER and presents them to CD8+ T cells

Question 22

What happened when they experimented with putting HLA-B27 in rats?

Answer 22

Put human HLA-B27 gene in rat, and then the rat got a lot of the same symptoms of A.S.
But when they raised the rat in a sterile environment, without bacteria in food, the signs and symptoms do not appear.
So it is a combination of the gene and a bacterial catalyst.