Spondylitis/spondyloarthritis/Seronegative Spondyloarthropathies

Question 1

What is ankylosing spondylitis

Answer 1

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

Question 2

What are 5 Spondyloarthropathies

Answer 2

Ankylosing spondylitis (AS)*
Psoriatic arthritis (PSA)*
Reactive arthritis (ReA)*
Inflammatory Bowel disease (IBD) associated arthritis*
Crohn’s disease
Ulcerative colitis
6. Juvenile ankylosing spondylitis

Question 3

Undifferentiated spondylarthropathies

Answer 3

Patients not fulfilling individual criteria, but
possessing overlap features may be classified
as having Undifferentiated SpA (uSpA)

Question 4

Epidemiology of Ankylosing Spondylitis

Answer 4

In white populations 0.5-1.1%

Male/female 2/1

Many are Dxed late

Question 5

Etiology of AS

Answer 5

Unclear

Multigenic inheritance

HLA-B27 key role and association

Infective mechanisms?

Mucosal bowel inflammation in many individuals

Question 6

Clinical Criteria for AS

Answer 6

Low back pain and stiffness for more than 3 months that improves with exercise, but is not relieved by rest

2. Limitation of motion of the lumbar spine in both the sagittal and frontal planes
3. Limitation of chest expansion relative to normal values correlated for age and sex

Question 7

Radiologic Criteria for AS

Answer 7

Sacroiliitis grade ≥ 2 bilaterally or grade 3-4 unilaterally

Question 8

Diagnosis of AS

Answer 8

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

Question 9

Progression of AS

Answer 9

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

Question 10

Potential Complications of AS

Answer 10

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

Question 11

Early Symptoms of AS

Answer 11

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

Question 12

What does the Schober Test Measure?

Answer 12

Lumbar Flexion

Question 13

Imaging for AS

Answer 13

X-ray is still the preferred method

If there is a high index of suspicion MRI can be helpful but not always

Question 14

Things that can be seen on an X-ray for AS

Answer 14

bamboo spine
squaring of the vertebrae
Syndesmosphyte

Question 15

What are common extra articular manifestations of AS

Answer 15

include involvement of organs such as the

eyes (uveitis, conjunctivitis) , gut (IBD), prostate, and aorta.

Question 16

Peripheral joint manifestation for AS

Answer 16

1. Distribution different than RA but otherwise similar.

2. Tissue gradually replaced by fibrocartilage that becomes ossified.

Question 17

Osteoporosis AS

Answer 17

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

Question 18

Summary of AS

Answer 18

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

Question 19

Classic Triad for reactive arthritis

Answer 19

ARTHRITIS
UVEITIS/CONJUNCTIVITIS
URETHRITIS

Question 20

Reactive Arthritis ReA Clinical Features

Answer 20

Arthritis lasting >1 month
Assymetric, lower extremity, oligoarticular

1. Knees and ankles (large)
2. Toes and fingers (small)
3. Sausage digits (fusiform swelling)

Question 21

Enteric infections with reactive arthritis

Answer 21

SHIGELLA
SALMONELLA
CAMPYLOBACTER
YERSINIA

Question 22

REACTIVE ARTHRITIS ReA X-RAY FINDINGS

Answer 22

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.

Question 23

What is Enthesitis?

Answer 23

Periosteal new bone formation

*Subchondral bone inflammation & resorption

Question 24

Reactive Arthritis ReA Clinical Spectrum

Answer 24

Ocular- conjunctivitis,uveitis

Mucocutaneous- oral ulcers, balanitis

Keratoderma blenorrhagicum–>Hands and feet scaly rash

Question 25

Reactive Arthritis ReA Treatment

Answer 25

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.

Question 26

Enteropathic Arthritis Disease Associations

Answer 26

Crohn’s disease=MC
Ulcerative colitis

Prevalence is in 10-22% of patients with IBD
Higher incidence in CD than UC

Question 27

Enteropathic IBD Arthritis Axial Arthritis

Answer 27

Axial arthritis indistinguishable from AS
Arthritis is axial disease does not parallel GI disease
Surgery for UC or CD does not affect associated spondylitis

Question 28

Enteropathic Arthritis Peripheral Arthritis

Answer 28

Pauciarticular
Asymmetric
May be migratory

Question 29

Enteropathic Arthritis Diagnostic Studies

Answer 29

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

Question 30

Psoriatic Arthritis/Psoriasis: Epidemiology

Answer 30

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%.

Question 31

Psoriatic Arthritis PsA Clinical spectrum

Answer 31

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

Question 32

5 most common Psoriasis Locations

Answer 32

Elbows
Knees
Behind ear
Umbilicus
Gluteal cleft

Question 33

Psoriatic Arthritis PsA X-ray Findings

Answer 33

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

Question 34

Spondyloarthropathy Treatment Guidelines

Answer 34

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.

Question 35

Spondylitis Treatment Medications

Answer 35

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

Question 36

Anti-TNF agents in AS

Answer 36

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.

Question 37

Summary of Spondolysis

Answer 37

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