spondylarthropathy/septic arthritis Flashcards by Jacqui Joseph

what are Spondyloarthropathies? what another name for it?

Group of conditions manifested by inflammatory arthritis of back
Also called seronegative arthritis

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ANA and RF are negative or positive for spondyloarthropathies?

both negative

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what are entheses? ethesitis?

The enthesis (plural entheses) is the connective tissue between tendon or ligament and bone. There are two types of entheses: Fibrous entheses and fibrocartilaginous entheses
inflammation of these tendon/ligament connection

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4 kinds of spondyloarthropathies that we talked about?

Ankylosing Spondylitis (AS – prototype)
Reiter’s/reactive arthritis
Psoriatic arthritis
Arthritis of inflammatory bowel disease

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7 clinical features shared (to varying degrees) by the spondyloarthropathies? (kinda weeds)

Axial joint involvement (spinal and SI joint)
Asymmetric peripheral arthritis
Enthesitis (inflammation of tendon insertion
Eye and bowel inflammation
Preceding or ongoing infectious disorders
HLA-B27 association
Genital and skin lesions

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what is included in the axial involvement?

Inflammatory back pain
Prolonged am stiffness in back >30 minutes
Better with exercise
Usually slow onset,

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what is dactylitis?

inflammation of tendon along entire digit- looks like sausage digit

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genital + skin lesions involve what?

Superficial oral ulcers, transient, painless and unnoticed
Nonspecific urethritis (urethra inflamed)

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what is Ankylosing Spondylitis (AS)?

Chronic, inflammatory disease of axial skeleton, progresses over decades
Involves spine, sacroiliac joints and pelvic joints

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what happens eventually with AS?

Eventual fusion of spinal vertebrae - eventually lose all spinal mobility
Hip flexion contractures
hyperkyphosis

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who get AS?

More in men

Starts in 20s and 30s

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likely pathophys of AS?

Likely autoimmune - b/c immmune suppression makes it better

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PE and onset of AS ?

Inflammatory back pain and symmetrical SI pain and stiffness (morning stiffness)
Insidious onset > 3 months duration

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what are the limitations in for AS?

Limitation of spinal rotation and lumbar flexion ( can’t touch toes)

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3 things to look for in Dx of AS?

Look for evidence of inflammation with blood tests (ESR, CRP, seronegative - ANA and RF negative)
Look for sacroiliitis (inflammation in SI joint)
Look for inflammation in vertebrae

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imaging AS: what bones are first involved? is this as sign of early disease? why/why not?

SI joints: not an early sign for the disease

Inflammation of lining of joint –> once you see bony changes, a lot of damage is already done,

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3 types of imaging studies for SI?

X-ray - easy, cheap, show bony changes
MRI - most sensitive
Bone Scan

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what is one characteristic sign of imaging of back for AS?

“bamboo spine” - vertebrae fuse at points around the disc

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Diffuse idiopathic skeletal hyperostosis (DISH) (kinda weeds) - how does it compare to AS?

Usually fewer/less severe symptoms of spinal stiffness
Looks like AS on X ray
No S-I involvement
ESR and CRP are nl

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non-pharm txt for AS? (2)

PT- make sure spine fuses (b/c it eventually will) - into the correct position
surgery stabilization- may need if they fracture b/c can’t heal on their own

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AS: why should we not use toxic meds unless severe disease?

b/c AS doesnt increase morbidity or mortality

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3 options for pharm txt of AS

Non-steroidal anti-inflammatory to control pain and inflammation
Steroid injections for single joint flares
Severe disease: Biologic agents (TNF-α)

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txt for acute uveitis (very common!) with AS?

topical corticosteroids and mydriatics are usually adequate.

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what is reiter’s syndrome

reiter’s a reactive arthritis : Triad of eye inflammation (Uveitis or conjunctivitis), urethritis, and oligoarthritis after infection

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what is "Reactive arthritis" that doesn't qualify as "reiter's"

Incomplete triad: | Oligoarthritis of lower extremities within 6 weeks of infection

reiter's and reactive arthritis ; more men or women?

men

clinical presentation of reactive arthritis/reiter's? (what prompts it, where is the arthritis and pain? )

``` After STD (chlamydia) or gastroenteritis (Salmonella, Shigella, Campylobacter) Oligoarthritis Few, asymmetrical large joints Back pain not common Enthesopathy Ulcers ```

dx of reactive arthritis/reiters:

ESR and CRP increased

pharm txt options for reactive arthritis/reiters? (4 options)

1 .NSAID:control pain, and do it well, don’t prevent progression 2. Sulfasalazine: if NSAIDs don’t work 3. Methotrexate:Only for severe disease 4. steroid injections

what is the "rule of thirds" for reiter's?

1/3 self limited (< 6 months) 1/3 goes into remission and recurs intermittently 1/3 never subsides, waxing and waning

psoriatic arthritis (PsA) occurs in ___% of those with psoriasis

10% | MUST have psoriasis for it to be called PsA

other than psoriasis skin, what are two other physical presentations of PsA?

``` Dactylitis (sausage digits) Nail changes (Pitting and ridging) ```

join distribution for PsA?

Pretty much any joint or pattern- just have to have the skin rash Often involves DIPs, spine and sacroiliac joints

Dx lab tests for PsA

elevated ESR and CRP Elevated uric acid (tested only when NOT an active flare --B/c of skin turnover from rash --Sometimes mistaken for gout

non-pharm txt of PsA

PT | Surgery if needed once arthritis progressed

pharm txt for PsA? (what to use and what to avoid? )

THINK about DMARDS- don’t just txt the symptoms. no steroids- b/c will cause pustular psoriasis that can become systemic and kill you - injection is ok just not oral

what is "the most severe PsA"?

"arthritis mutilans" - joint is destroyed within months

arthritis assoc. with inflamm bowel: what two types of inflamm. bowel? what is it like?

Ulcerative Colitis and Crohn’s | Nonerosive and non-deforming

clinical presentation of "arthritis assoc. with inflamm. bowel

symptoms of inflammatory bowel and arthritis - Arthritis tends to be less active than bowel - Few peripheral joints and/or axial involvement

txt of arthritis w/ inflamm bowel

Treat inflammatory bowel disease and usually arthritis gets better

how do you know someone has spondyloarthropathy? (where is the pain? what are the "common features")?

- Inflammatory back pain/ few peripheral joints | - other common features: Enthesopathy- uveitis, skin ulcers, IBD

which type of spondyloarthropathy?...If primarily back symptoms and losing motion in back

which type of spondyloarthropathy?..psoriasis

PsA

which type of spondyloarthropathy?...History of inflammatory bowel

arthritis of inflamm bowel

which type of spondyloarthropathy?...History of previous infection (GU or GI) and now triad or part of triad

reactive arthritis or Reiter’s syndrome

two types of septic arthritis

gonoccocal and non-gonoccocal

nongonoccocal arthritis: where does it come from ? is it dangerous?

Results from persistent bacteremia in synovial fluid plus joint w/ history of damage (e.g. arthritic, prosthetic joints) Urgent: destruction of joint very quickly

viral septic arthritis: how does it compare to bacterial?

less aggressive, self-limited, and without major sequelae

clinical presentation for NG septic arthritis, what causes pain? what joint is most commonly involved?

Sudden acute pain, swelling and heat over joint - pain w/ ROM - knee most common

PE for NG septic arthitis

Fever - systemically sick, acute Soft tissue swelling or joint effusion warmth & erythema If prosthetic joint then may be loosened Painful and decreased ROM

labs: NG septic arthritis

increased WBCs ESR/CRP increased - ESR may normal but CRP will be VERY high Blood cultures positive in 50%

what does joint fluid analysis show for NG septic arthitis?

WBCs > 50,000 (specific for synovial fluid) with >90% neutrophils

xray of NG septic arthritis

Are negative early, then demineralization | Erosions and degenerative change in 2 weeks

3 part txt of NG septic arthritis

1. Antibiotics (4-8wks: IV then PO, broad --> narrow) 2. Drain joint of infected fluid, either with needle or surgically 3. Rest acutely, then move, to maintain mobility of the joint

2 types of drainage for NG septic arthritis

Arthrocentesis: Aspirating joint (draw all fluid off) daily if clinically improving. Continue until dry Arthrotomy: Surgically opening the joint to drain

whens is arthrotomy used over arthrocentesis? (for NG septic arthritis)

Do this over arthrocentesis if hip or not getting better with arthrocentesis

NG septic arthritis: rest and splint joint until clinically better, then do what?

ASAP active range of motion exercise to preserve joint ROM and function

3 potential complications of NG septic arthritis

1. 10% die from sepsis 2. Osteoarthritis and bony ankylosis 3. Osteomyelitis

what is gonococcal septic arthritis ?

Joint can be normal- just need GC infection - not as much as an emergency as non-gonoccocal

epidemiology of Gon. Septic arthritis

- If acute monoarticular arthritis < 35 yo it is GC until proven wrong - Women

-Most common acute bacterial arthritis

gonococcal septic arthritis

how does someone get Gon. arthritis?

GC spread hematogenously (through blood) to joint | not super destructive though

clinical presentation of Gon. arthritis? (two phases)

1. Multiple joint pains without frank arthritis 2. Then one of two things... Tenosynovitis or Purulent monoarthritis(Knee most common)

PE of Gon. arthritis

1. +/- fever 2. One swollen joint or tenosynovitis 3. Rash (lesions on arms/legs, palms and soles)

what does CBC and synovial fluid show for Gon. arthritis?

CBC: Mildly elevated serum WBCs | Synovial fluid: looks infected, WBCs> 50,000

Dx: gold standard for Gon. arthritis? what an alternative Dx method?

culture it! hard to culture, but gonorrhea is a reportable disease, so culture everything (NAAT is a good alternative to culture)

txt for gon. arthritis? (4)

1. most likely admit 2. (make sure not endocarditis) - echo to check 3. Ceftriaxone for 48 hours, then oral cephalosporins for 7-10 days 4. Don’t forget it’s an STD and to check/treat for Chlamydia