Seronegative Spondyloarthropathies: AS and EA

Question 1

All seronegative spondyloarthropathies will present with what?

Answer 1

Negative RF
Sacroiliitis
HLA-B-27
Uvetis

Question 2

T/F: AS and EA are virtually identical radiographically

Answer 2

True

Question 3

What are some characteristics of AS (formerly known as: Von Bechterew disease, Marie-Strumpell disease)

Answer 3

• RF neg, ESR, CRP = +
• Affects SI and “root” joints (hips, shoulders)
• 3-9:1 M:F
• HLA-B-27 Ag (>92%)
• 15-40 y/o

Question 4

What are the clinical signs of AS?

Answer 4

LBP > 3 months
Fatigue > 65%
LBP is worse supine, relieved with activity
Limited chest expansion (1" and less)
Peripheral enthesitis

Question 5

What is the age of onset?

Answer 5

< 40 y/o

Question 6

What are the extra-articular manifestations of AS?

Answer 6

Anterior Uveitis
Pulmonary Fibrosis (upper lobes)
Aortitis

Question 7

What is a key radiographic feature of AS that can be seen in an AP pelvis x-ray?

Answer 7

Symmetrical sacroiliitis

Question 8

What are 3 other things aside from symmetrical sacroiliitis that one would see on an x-ray?

Answer 8

1. Pseudo-widening
2. Subchondral sclerosis of iliac side
3. Leads to ankylosis (ghost joints, star sign)

Question 9

What are the “root joints” dr. korvatko likes for AS?

Answer 9

Hip and shoulder

Question 10

What is the key pathophysiological process for AS?

Answer 10

CD4 and CD8 T-cell activation –> inflammatory cytokines –> Enthesitis –> initial osseous erosion –> Fibrosis and ossification

Question 11

T/F: AS begins with the joints of the chest and progresses inferiorly until it reaches the SI joint.

Answer 11

FALSE: it begins with the SI joint progresses to lumbrosacral region gradually and ascends all the way to the cervical region and then will start to affect the costovertebral joints of the chest

Question 12

What are the two major signs we talked about in class that have to do with AS.

Answer 12

Romanus lesion and shiny corner

Question 13

Defined as Osteitis and enthesitis @ annular fiber attachments

Answer 13

Romanus lesion

Question 14

Reactive zone of sclerosis

Answer 14

Shiny corner

Question 15

What is an important thing in AS that radiographically sets it apart from other types of bone diseases?

Answer 15

Marginal syndesmophytes

Question 16

If looking at an AP spine x-ray of AS, what will one see when looking at the vertebral column?

Answer 16

Bamboo spine

Question 17

What is Bamboo sign commonly accompanied by in relation to the SP?

Answer 17

Dagger sign

Question 18

What is another sign that can be clearly identified on an x-ray that would help with Dx of AS?

Answer 18

Squaring of the vertebral body

Question 19

In AS, a sign called trolley track sign is present, what is this a representation of structurally?

Answer 19

Ossification of posterior ligaments and facet capsules

Question 20

What is the 2nd site to the hip in AS?

Answer 20

Shoulder (GHJ) - erosion and enthesitis at greater humeral tuberosity, insertion of the rotator cuff muscles and shoulder ligaments

Question 21

Where would instability develop in a patient with AS in the cervical region?

Answer 21

C1-C2

Note: MANIP IS STRONGLY CONTRAINDICATED

Question 22

What test is performed to evaluate loss of flexion in the lumbar spine?

Answer 22

Schober test (norm is an increase of 5cm)

Question 23

There is a certain discovertebral abnormality in AS known as _____ that may progress to re-fracturing phenomenon through end-plate.

Answer 23

Anderson lesion

Question 24

What are 4 spinal complications for AS?

Answer 24

Ankylosis
Fractures
Canal Stenosis
Dural ectasia (widening of dura)

Question 25

There is a certain type of fracture that can occur with AS, it has been mentioned before in the DJD lecture as well…

Answer 25

Chalk-stick fracture

Question 26

What is the treatment for AS?

Answer 26

NSAID, sulfasalazine
TNF-a antagonists have been used
Exercise and physiotherapy to maintain mobility and prevent ankylosis progression

Question 27

What are some etiologies for enteropathic arthritis?

Answer 27

IBD
Ulcerative colitis
Crohn's disease
Post shigella, salmonella, yersenia arthritis
WHipple's disease
GI by-pass

Question 28

T/F: EnA is radiographically very different from AS

Answer 28

FALSE EnA is radiographically almost identical to AS

Question 29

Is EnA less severe that AS or vice versa?

Answer 29

Less severe

Question 30

T/F: The Sacroiliitis that is present in EnA is different than that of AS

Answer 30

FALSE the sacroiliitis is identical to AS

Question 31

What is another feature of EnA?

Answer 31

Hypertrophic osteoarthropathy (HOA)

Question 32

What are the clinical presentations of EnA?

Answer 32

Morning pain and stiffness (especially after periods of inactivity)
Enthesitis in LE (foot, heel)
Skin: myoderma gangrenosum and erythema nodosum
Uveitis

Question 33

If there was a periosteal reaction from EnA along the shaft and metastasis of the femur, what would the Dx be?

Answer 33

Hypertrophic osteoarthropathy

Slide: 54 for picture, got a feeling on this one, in the nugs

Question 34

On a radiograph if you are looking for EnA, what would lead you to this Dx?

Answer 34

SI fusion and ankylosis
Colonic spasm, narrowing and lause of haustra in UC
(Note: got a feeling for this on lab exam, slide 56)

Question 35

What markers would be elevated in EnA?

Answer 35

HLA-B-27, ESR, CRP

Question 36

What would CMP and CBC be helpful for in Dx?

Answer 36

anemia of chronic disease
IDA - malabsorption of iron
B12 deficiency

Question 37

What would be treatment for this disease?

Answer 37

Treat the primary disease (Crohns, IBD, etc)

Immune modulatory drugs (TNF-a inhibitors)