Seronegative spondyloarthropathies - Postlethwaite Flashcards by Jacob McMillan

List group of disorders associated with Spondyloarthropathies

PAIR + 2

Psoriatic arthritis

Ankylosing spondylitis

Inflammatory bowel disease

Reactive arthritis (Reiter Syndrome)

Undifferentiated Spondyloarthropathies

Juvenile chronic arthritis and Juvenile-Onset Ankylosing Spondylitis

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Spondyloarthropathies

Rheumatoid factor (+ or -) ?

negative ghostrider

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Spondyloarthropathies

High Association with what gene?

HLA - B27

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Spondyloarthropathies

More often in males or females?

Males

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Spondyloarthropathies

Axial or appendicular skeleton involvement?

Axial skeletal involvement with sacroiliitis and spondylitis

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Spondyloarthropathies large joint features

Poly or oligoarthritis?

Symmetric or asymmetric?

Upper or lower extremities?

Large joint asymmetric oligoarthritis predominantly in lower extremites

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Spondyloarthropathies

Familial involvement?

Yes, Significantly

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Spondyloarthropathies

Absence of what (that are commonly seen in RA)

Absence of subcutaneous nodules and other extra-artiular manifestations of RA

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HLA-B27 is what MHC class?

MHC Class I, binds antigenic peptides and presents them to CD8+ T cells

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HLA-B27 is found in over 90% of patients with what disorder?

General population frequency?

Ankylosing Spondylitis

8% of general population has HLA-B27. means that just b/c you have it, doesn’t mean you have disorder

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HLA-B27 is found in 75% of which patients?

Pts with Reactive Arthritis (Reiter’s)

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Frequency of HLA-B27 in Psoriatic Arthritis?

50%

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Ankylosing Spondylitis Epidemiology

Age?

Gender preference? Ratio?

Etiology?

Age: Adolescence to 35

Gender: Male:Female 3:1

Etiology: Unknown

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Ankylosing Spondylitis has what pathologic findings (3)?

Inflammatory cell infiltrates

Synovial inflammation similar to RA

TNF alpha excess

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Clinical features of Ankylosing Spondylitis?

Rapid vs insiduous onset?

Insidous onset

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Clinical features of Ankylosing Spondylitis?

Pt pain usually begins where in body?

Overtime where does pain go? What does this cause?

Pain usually begins in lower back, vertebral bodies eventually involved, causing fusion of the vertebrae “bamboo spine”

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Bamboo spine refers to what pathology of which disorder?

Vertebral fusion, seen in Ankylosing spondylitis

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What extra-articular manifestation are seen in Ankylosing spondylitis? Which is most common?

Eye: Anterior Uveitis (25-30%) = MOST COMMON

Cardiac: Aortitis (leading to aortic regurgitation), heart block, pericarditis, Increased risk for MI

Lungs: Apical lung fibrosis, thoracic cage restriction

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If AS patient has peripheral joint involvement, what extra-articular symptoms are more common?

Aortic regurg and heart block 2x more common

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Describe spine of Ankylosing Spondylitis patient?

Fusion of spine causes limited ROM in all directions
Loss of lumbar lordosis & development of thoracic and cervical kyphosis

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Ankylosing Spondylitis Exam findings (3) ?

Abnormal Schober’s test (< 3 cm)
Reduced chest expansion (<2.5 cm) measured at 4th Intercostal space
Increased occiput to wall distance

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Spine probs in Ankylosing Spondylitis lead to what feature?

generalized osteopenia, increased risk for fractures

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Drug of choice for AS? If pt cant take this type of drugs, next best drug of choice?

TNF blockers = BEST choice (Infliximab, adalimumab)

Indomethacin = next best if needed

Cant see, Cant pee, Cant climb a tree. What am I talking about?

Reactive Arthritis (Reiter syndrome)

Triad of: Arthritis, Urethritis, and Conjunctivitis

Urethritis might not be present for long

Reactive Arthritis Epidemiology. Male or Female? What gene is it most associated with? More common in what subset of patients? Prognosis?

M/F ratio 5:1 (Goljian says 10:1) 75% pts have HLA-B27 ReA most common in HIV/AIDS (much more severe and resistant to therapy). Also a feature seen in Psoriatic Arthritis

Reactive Arthritis usually caused by?

Arises after infectious process

Urethritis in Reiter's most commonly due to what bacterial infection?

Chlamydia trachomatis

Arthritis in Reiter's most commonly associated with what bacterial infections?

Shigella, Salmonella, Campylobacter, Yersinia

Made you look. But seriously, what the hell is going on here?

**Circinate balanitis**. Feature of Reactive Arthritis. Rash on the distal shaft and glans penis that appears as vesicles, shallow ulcerations, or both

What is this called? Which spondyloarthropathy is it most associated with?

Enthesitis, most commonly seen in Reactive Arthritis

What is this? What disease is it associated with?

**Keratoderma blennorrhagica**, feature of Reactive arthritis

What lab tests does Dr. P get on all reactive arthritis patients?

HIV test, HLA-B27. Also check ESR, CRP, blood culture (usually +), Serology

How long does reactive arthritis last? Will it ever recur?

Mean duration 2-3 months, Recurrence common, 20-50% demonstrate chronic course

Actual name of sausage shaped DIP joints? Associated with what disorder?

Dactylitis. Primarly associated with Psoriatic arthritis. Also enteropathic (IBS), reactive, and AS

What is going on here? What disease is it associated with?

Etensive nail pitting seen in Psoriatic Arthritis

Psoriatic Arthritis Immunopathology compared to RA Synovial cytokines that are greater? Synovial cytokines that are less than RA?

More TNF-alpha, IL-1 beta, IL-2, IL-10, and IFN Gamma as compared to RA Less IL-4, IL-5 as compared to RA

Besides the cytokines mentioned in comparison to RA, what other synovial cytokine is present in psoriatic arthritis? Features of this cytokine?

IL-18. Member of IL-1 Superfamily stimulates angiogenesis, upregulates chemokine expression on synovial fibroblasts, increases mononuclear cell recruitment

How many types of Psoriatic Arthritis? Name them

5 Types 1. Polyarticular pattern 2. Oligoarticular pattern 3. DIP involvement pattern 4. Arthritis Mutilans 5. Axial involvement

Which type of PsA involves \>4 joints? What disorder is it similar to?

Polyarticular pattern. Similar to RA

Which type of PsA involves ≤ 4 joints? Symmetrical or Assymetrical involvement seen in this type?

Oligoarticular pattern. Assymetric involvement

Which type of PsA involves only a specific joint? which joint is this?

DIP involvement pattern

Which type of Psoriatic Arthritis is severe and destructive?

Arthritis Mutilans

If PsA patient is B27+, what type of bone involvement is seen? Similar to what disease?

Axial involvement type (similar to sacroilitis and sponydlitis)

What is being shown here? What disease?

"pencil in cup" deformity seen in Psoriatic Arthritis

Another name for Enteropathic arthritis? Helps you to remember its association?

Inflammatory bowel disease associated arthritis

Enteropathic arthritis is associated with what other disorders?

Crohn's, Ulcerative colitis, Whipple's (rare)

Epidemiology. Enteropathic Arthritis gender association?

M = F

Enteropathic arthritis types? Which is associated with HLA-B27?

Axial, Peripheral - axial associated with HLA-B27

Which comes first, the GI disease or enteropathic arthritis?

GI disease usually comes first

Axial vs Peripheral enteropathic arthritis. Which is clinically and radiographically identical to idopathic Ankylosing spondylitis?

Axial

Axial vs Peripheral Enteropathic Arthritis. Which often parallels GI disease (meaning the arthritis worsens when GI disease worsens)

Peripheral ----- Axial does not parallel. Can do what it wants.

Peripheral enteropathic arthritis is similar to what other form of spondyloarthropathy?

Reactive arthritis - oligoarticular, generally asymmetric; lower extremity joint involvement; Dactylitis and enthesitis; parallels GI inflammation

Which arthritis is associated with IgA deficiency?

Arthritis of Celiac Disease

In Arthritis of Celiac Disease, which comes first?

Arthritis can present prior to development of Celiac Diseaes. Can help distinguish this from enteropathic arthritis.

In DISH (diffuse idiopathic skeletal hyperostosis), calcification and ossification is most common on which side of the spine?

Right

DISH is inflammatory or non-inflammatory?

non inflammatory