Spondylitis/spondyloarthritis/Seronegative Spondyloarthropathies Flashcards
What is ankylosing spondylitis
chronic, systemic, inflammatory disorder involving the sacroiliac (SI) joints, the spine, and often the hips1
Axial joints are always involved, but peripheral joints are frequently affected1,2
Characterized by recurrent back pain and loss of spinal mobility3,4
In severe cases, extensive fusion (ankylosis) of spinal vertebrae can increase the risk of spinal deformity, fracture, and disability
What are 5 Spondyloarthropathies
Ankylosing spondylitis (AS)* Psoriatic arthritis (PSA)* Reactive arthritis (ReA)* Inflammatory Bowel disease (IBD) associated arthritis* Crohn’s disease Ulcerative colitis 6. Juvenile ankylosing spondylitis
Undifferentiated spondylarthropathies
Patients not fulfilling individual criteria, but
possessing overlap features may be classified
as having Undifferentiated SpA (uSpA)
Epidemiology of Ankylosing Spondylitis
In white populations 0.5-1.1%
Male/female 2/1
Many are Dxed late
Etiology of AS
Unclear
Multigenic inheritance
HLA-B27 key role and association
Infective mechanisms?
Mucosal bowel inflammation in many individuals
Clinical Criteria for AS
Low back pain and stiffness for more than 3 months that improves with exercise, but is not relieved by rest
- Limitation of motion of the lumbar spine in both the sagittal and frontal planes
- Limitation of chest expansion relative to normal values correlated for age and sex
Radiologic Criteria for AS
Sacroiliitis grade ≥ 2 bilaterally or grade 3-4 unilaterally
Diagnosis of AS
Diagnosis combination of radiography, clinical manifestations1
Lab findings not diagnostic1
CRP and ESR may or may not be elevated
HLA-B27 + 90% to 95% of caucasians
Progression of AS
The first 10 years predictive of future course1
Initially SI joints are involved
May progress and involve the entire spine2
Hips predicts more severe disease
Potential Complications of AS
Loss of spinal mobility
Restricted expansion of chest
Progressive, ascending involvement of the spine may lead to complete fusion, or “bamboo spine,” and an increased risk of spinal fracture1,2
10% to 20% requiring joint replacement surgery
Involvement of peripheral joints
Extra-articular disorders
Early Symptoms of AS
The classic presentation of acute AS often occurs early in life and includes dull, insidious pain of the lower back and/or buttocks that is responsive to exercise.
Bone tenderness, may be present
Peripheral joints involved
late adolescence or early adulthood
What does the Schober Test Measure?
Lumbar Flexion
Imaging for AS
X-ray is still the preferred method
If there is a high index of suspicion MRI can be helpful but not always
Things that can be seen on an X-ray for AS
bamboo spine
squaring of the vertebrae
Syndesmosphyte
What are common extra articular manifestations of AS
include involvement of organs such as the
eyes (uveitis, conjunctivitis) , gut (IBD), prostate, and aorta.
Peripheral joint manifestation for AS
- Distribution different than RA but otherwise similar.
2. Tissue gradually replaced by fibrocartilage that becomes ossified.
Osteoporosis AS
Prevalence of vertebral osteoporosis in AS is between 20% to 60%¹
Relative risk of fractures is 6 times in early AS compared with controls²
Risk factors: disease duration, severity, male sex
Major etiologic factors: pro-inflammatory
Summary of AS
AS, is a chronic, systemic, inflammatory disorder involving the axial joints and, frequently, the peripheral joints1
AS is characterized by recurrent back pain, loss of spinal mobility, potential extra-articular manifestations and, in severe cases, fusion of the spinal vertebrae2,3
High prevalence of HLA-B27 suggests an immunologic basis of the disease3
Years may pass between onset of symptoms and diagnosis of AS; increased awareness and earlier diagnoses may help address the crippling effects of AS3
The diagnosis is made using a combination of clinical cues, imaging studies and lab results
Classic Triad for reactive arthritis
ARTHRITIS
UVEITIS/CONJUNCTIVITIS
URETHRITIS
Reactive Arthritis ReA Clinical Features
Arthritis lasting >1 month
Assymetric, lower extremity, oligoarticular
1. Knees and ankles (large) 2. Toes and fingers (small) 3. Sausage digits (fusiform swelling)
Enteric infections with reactive arthritis
SHIGELLA
SALMONELLA
CAMPYLOBACTER
YERSINIA
REACTIVE ARTHRITIS ReA X-RAY FINDINGS
Periosteal reaction and proliferative bone at tendons.
Boney erosions with adjacent proliferation of bone, and paravertebral ossification, and bony ankylosis occur.
Calcaneal spurs with fluffy irregularity common.
What is Enthesitis?
Periosteal new bone formation
*Subchondral bone inflammation & resorption
Reactive Arthritis ReA Clinical Spectrum
Ocular- conjunctivitis,uveitis
Mucocutaneous- oral ulcers, balanitis
Keratoderma blenorrhagicum–>Hands and feet scaly rash
Reactive Arthritis ReA Treatment
Antibiotics.. Patients with culture-proven infectious diarrhea shigella, salmonella, yersinia may benefit from appropriate antibiotic therapy.
Chlamydial-induced arthritis is documented by serology, culture, or dna probe,
Prolonged 3 months antibiotic therapy with doxycycline or tetracycline should be initiated.
Enteropathic Arthritis Disease Associations
Crohn’s disease=MC
Ulcerative colitis
Prevalence is in 10-22% of patients with IBD
Higher incidence in CD than UC
Enteropathic IBD Arthritis Axial Arthritis
Axial arthritis indistinguishable from AS
Arthritis is axial disease does not parallel GI disease
Surgery for UC or CD does not affect associated spondylitis
Enteropathic Arthritis Peripheral Arthritis
Pauciarticular
Asymmetric
May be migratory
Enteropathic Arthritis Diagnostic Studies
Anemia is common-chronic disease anemia
GI blood loss can also be common
Most often elevated inflammatory markers: ESR CRP
X-rays of the SIJ and spine are similar to AS
HLA-B27 is associated axial but not with peripheral arthritis
Psoriatic Arthritis/Psoriasis: Epidemiology
Prevalence of psoriasis:
Approximately 2% to 3% of Caucasian population
Rare in African Americans
Prevalence of psoriatic arthritis5% to 31% of patients with psoriasis –true prevalence probably ~ 25-30%
Equal prevalence in males and females
Skin manifestations precede articular in ~85%, follow articular manifestations in ~5-10% and are simultaneous in ~5-10%.
Psoriatic Arthritis PsA Clinical spectrum
Nail pitting
Onycholysis, transverse ridging in psoriatic arthritis.
Dactylitis of the second toe is present
DIPJ can be involved (ray distribution)
Arthritis mutilans-severe destruction of fingers
Sacroiliitis with or without spinal involvement
5 most common Psoriasis Locations
Elbows Knees Behind ear Umbilicus Gluteal cleft
Psoriatic Arthritis PsA X-ray Findings
Pencil in cup” deformity-erosive changes
Seen at DIPj of fingers and IPj of great toe this is unlike RA
Periosteal new bone-fluffy at enthesis
Spondyloarthropathy Treatment Guidelines
Reducing pain and stiffness.
Modify the course of disease with BRMs.
Patient education and joint protection.
Lifelong physical therapy to maintain posture and prevent slow deformity.
Therapeutic options are largely the same for most of the spondyloarthropathies and as such are considered together.
Spondylitis Treatment Medications
NSAIDS=very effective 50-75% (not with mechanical arthritis)
Glucocorticoids= don’t work all that well
Sulfasalazine
Methotrexate (Little Benefit) only in peripheral jts
Biologic Response Modifiers work well for the spine not for peripheral
Etanercept (Not Indicated For IBD)
Infliximab
Anti-TNF agents in AS
All five anti-TNF agents are efficacious in AS achieved by around 60% of patients.
Approximately 25% achieved partial remission and productivity score improved.
Response to treatment was sustained over 5 years without concomitant DMARDs
Anti-TNF agents were generally well tolerated
Anti-TNF agents improved MRI activity but there efficacy in reducing x-ray progression is not yet fully known.
Summary of Spondolysis
Spondyloarthropathies are a group of diseases with shared features.
They share symptoms of inflammation.
The hallmark of spondylitis is back stiffness.
X-ray findings are axial and involve the SIJ
and anterior longitudinal ligament.
Diagnosis can be delayed
