SM_228a: Spondyloarthropathies Flashcards
Describe spondyloarthritis
Spondyloarthritis: group of related disorders with common clinical, biological, and genetic characteristics
- Genetic markers (e.g. HLA B27)
- Spine involvement, namely sacroiliitis
- Asymmetric joint involvement
- Enthesitis
- Iritis
- Absence of female predominance
- Negative rheumatoid factor
Two main classes of spondyloarthritis are ____ and ____
Two main classes of spondyloarthritis are axial and peripheral
- Axial spondyloarthritis / ankylosing spondylitis: mainly axial
- IBD arthritis: mainly axial
- Psoriatic arthritis: mainly peripheral
- Reactive arthritis: mainly peripheral
Describe reactive arthritis
Reactive arthritis
- Acute inflammatory arthritis following GI or GU infection
- Affects men > women
- Usually self-limited, may be recurrent or chronic
- Can’t see, can’t pee, can’t climb a tree
Reactive arthritis is acute inflammatory arthritis following a ____ or ____ infection and is characterized by symptoms “____”
Reactive arthritis is acute inflammatory arthritis following a GI or GU infection and is characterized by the symptoms “can’t see, can’t pee, can’t climb a tree”
(affects men more than women)
Describe the articular features of reactive arthritis
Articular features of reactive arthritis
- Additive, asymmetric mono- or oligo- arthritis involving more commonly large lower extremity joints
- Dactylitis: diffusely swollen digits, “sausage toe” or finger
- Enthesitis: heel pain at tendon insertion
- Inflammatory low back pain: sacroiliitis
Inflammatory enthesopathy in reactive arthritis involves _____ and _____
Inflammatory enthesopathy in reactive arthritis involves subchondral bone inflammation and resorption and periosteal new bone formation
Describe the extra-articular features of reactive arthritis
Extra-articular features of reactive arthritis
- Skin: keratoderma blennorhagicum (histology like psoriasis): keratotic conical lesions on lateral and palmoplantar aspects of hands and feet
- Mucosal lesions: oral ulcers (painless), circinate balanitis (annular erythematous lesions on glans pens)
- Nails: thickened, opacified (like psoriasis)
- Eyes: conjunctivitis, acute anterior uveitis
This is _____ from _____
This is keratoderma blennorrhagicum from reactive arthritis
Describe pathogenesis of spondyloarthritis, especially reactive arthritis
Pathogenesis of spondyloarthritis, specifically reactive arthritis
- Genetic predisposition (HLA-B27+ and others)
- Environmental triggers: enteric infections, urogenitcal infection (urethritis)
- Causatove agent may be asymptomatic
HLA-B27 is an ______
HLA-B27 is an antigen-presenting protein
Pathogenesis of spondyloarthritis involves ____, which involves immune system confusion due to ____ between ____ and ____
Pathogenesis of spondyloarthritis involves molecular mimicry, which involves immune system confusion due to sequence homology between HLA-B27 “self” and bacteria “non-self”
Presence of HLA-B27 ____ disease but is predictive of disease in the ____
Presence of HLA-B27 does not mean presence of disease but is predictive of disease in the spine
Describe treatment of reactive arthritis
Treatment of reactive arthritis
- NSAIDs
- Physical therapy
- If NSAIDs fail: corticosteroids, disease modifying agents (DMARDS), biologics (peripheral and axial)
- Do NOT use antibiotics
Describe psoriatic arthritis
Psoriatic arthritis
- 5-39% of people with psoriasis
- Equal in males and females
- Peak onset in late 20s to 30s
Describe clinical features of psoriatic arthritis
Clinical features of psoriatic arthritis
- Cutaneous disease: psoriatic plaques, oncholysis/fingernail pitting, guttate/pustular/erythrodermic variants
- Inflammatory arthritis: asymmetric, symmetric, axial
- Dactylitis
- Enthesitis
- Rheumatoid factor negative
- Productive erosions (pencil in cup)
_____ is pathognomonic for psoriatic arthritis
Pencil in cup (productive erosions) is pathognomonic for psoriatic arthritis
Describe the presentation of psoriatic arthritis
Psoriatic arthritis presentation
- Skin disease usually precedes joint disease
- No correlation between severity of skin and joint disease but presence of joint disease is more likely with severe skin disease
- Nail findings associated with joint disease
- Enthesitis or tendonitis is a common finding
Describe treatment for psoriatic arthritis
Psoriatic arthritis therapy
- Traditional: NSAIDs, corticosteroids, DMARDs (sulfasalazine, methotrexate)
- Next generation: phosphodiesterase-4 inhibitor, JAK inhibitor, biologics
Etancercept is less effective for treating _____ but equally effective for treating _____ in psoriatic arthritis compared to the other TNF-alpha inhibitors
Etancercept is less effective for treating psoriasis but equally effective for treating arthritis in psoriatic arthritis compared to the other TNF-alpha inhibitors
Ustekinumab binds to ____ subunit of ____ and ____, blocking them from binding to receptors
Ustekinumab binds to p40 subunit of IL-12 and IL-23, blocking them from binding to receptors
(want to block IL-23, blocking IL-2 makes it less effective
Describe mechanisms of action of IL-17 inhibitors in treating psoriatic arthritis
IL-17 inhibitors to treat psoriatic arthritis
- Secukinumab, Ixekizumab bind to IL-17A
- Brodalumab blocks IL-17 receptor
Describe presentation of axial spondyloarthritis
Axial spondyloarthritis presentation
- Late diagnosis but symptoms begin in 20s
- Inflammatory back pain and stiffness - bone bridging across vertebrae
- Sacroilitis
- Oligoarthritis
- Enthesitis
- Systemic symptoms (fatigue, impaired sleep)
- Extra-articular disease (uveitis, IBD, aortitis)
Axial spondyloarthritis is ____ that picks up more ____
Axial spondyloarthritis is a systemic disease that has all features of ankylosing spondylitis without some of the bone changes and picks up more women
Describe treatment for axial spondyloarthritis
Axial spondyloarthritis treatment
- Exercise / physical therapy
- NSAIDs
- Corticosteroids
- Sulfasalazine
- Methotrexate
- TNF inhibitors
- IL-17 inhibitors
Describe the effect of biologics on progress of axial spondyloarthritis
Effect of biologics on progress of axial spondyloarthritis
- No controolled trials of disease progression with TNF or IL-17 inhibitor therapies
- All available therapies reduce MRI evidence of inflammation
- Structural progression of radiographic changes may be reduced
Describe presentation of IBD related arthritis
IBD related arthritis
- Inflammatory back pain and stiffness
- Sacroiliitis
- Oligoarthritis
- Enthesitis
- Dactylitis
- Systemic symptoms (fatigue, impaired sleep)
- Change in bowel habits
Spondyloarthritis treatment involves a shared approach to therapy driven by _____ more than _____
Spondyloarthritis treatment involves a shared approach to therapy driven by disease manifestations more than specific diagnosis
