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Spondyloarthritis Flashcards

1
Q

SPONDYLOARTHROPATHIES: Common Features

A
  1. RF (-)
  2. HLA-B27 (MHC class I)
  3. Axial skeletal involvement
  4. Large-joint asymm oligoarthritis (pred in LE)
  5. Significant familial aggregation
  6. Enthesitis
  7. Dactylitis
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2
Q

What is enthesitis?

A

inflammation at the sites where tendons and ligaments attach to bone

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3
Q

What is Dactylitis?

A

swelling of toes/fingers (duh); “sausage-like”

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4
Q

> 90% of patients with AS are (+) for ____, even though it is only ~8% prevalent in the population.

A

HLA B27

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5
Q

Patients with psoriasis or IBD that are HLA-B27 positive are more likely to develop

A

axial (spinal) arthropathy

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6
Q

In ANKYLOSING SPONDYLITIS (AS), where does inflammation occur?

A
  • -spinal joints (causes bony fusion of spine)

- -peripheral joints

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7
Q

AS: epidemiology

A

Adolescents to age 35

M>F

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8
Q

AS: Pathology

A
  • -Inflammatory cell infiltrate
  • -Synovial inflammation similar to RA
  • -TNF alpha excess
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9
Q

AS: Clinical features of axial disease

A
  • -Insidious onset
  • -Chronic low back pain
  • -Back stiffness
  • -Symptoms are worse in the morning and improve with exercise
  • -Symptoms gradually ascend up the spine (as disease progresses)

sacroiliitis and spondylitis = WASP (workout, AM/Ascend, stiff, pain)

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10
Q

AS: Peripheral disease joint manifestations

A
  • -Involves: hips, shoulders, knees and ankles
  • -Oligoarticular + often asymm
  • -Dactylitis may occur
  • -Enthesitis (*esp Achilles or plantar tendon insertions = heel pain)
  • *note: these are present in 1/3 of patients
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11
Q

AS: exam findings

A
  • -Sacroiliac tenderness
  • -Limited spine ROM in all directions
  • -Loss of lumbar lordosis, thoracic and cervical kyphosis (=flexion contracture)
  • -Abn Schober’s test (<3cm)
  • -Reduced chest expansion, measured @ 4th intercostal space
  • -Increased occiput to wall distance
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12
Q

AS: X-ray findings

A
  • -Sacroiliitis (usually bilateral)
  • -“Squaring” of vertebral bodies
  • -Syndesmophyte formation
  • -Generalized spinal osteopenia
  • -Eventual bony ankylosis
  • -Common = Vertebral fractures (occur even after minimal trauma, due to rigidity + osteopenia)
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13
Q

AS: Non-articular peripheral manifestations

A
  • -Eyes: Anterior Uveitis
  • -Cardiac: Aortic regurgitation, heart block
  • -Pulmonary: Apical lung fibrosis, thoracic cage restriction
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14
Q

AS: Trx of axial + peripheral disease

A

NSAIDs, TNF blockers, local corticosteroids

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15
Q

AS: Indicated only for trx of peripheral disease

A

sulfasalazine

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16
Q

Confers increased disease susceptibility and disease severity

A

HLA-B27

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17
Q

In Crohn’s disease, what can result in relative immune deficiency?

A

Genetic polymorphisms

related to GI lymphoid tissue and microbiota interaction, which balances inflammatory defense and tolerance

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18
Q

______ is common in adults, 25% of whom have joint manifestations

A

Celiac disease

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19
Q

Microscopic colitis is accompanied by:

A

extraenteric autoimmune manifestations

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20
Q

Intolerance to GI microbiome results in…

A

inability to maintain gut homeostasis = IBD

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21
Q

What causes the joint symptoms related to IBD?

A

circulating microbial material and increases in IgA/lymphocytes/macrophages result in circulating immune complexes, which deposit in joint + cause synovitis

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22
Q

ENTEROPATHIC ARTHRITIS = Inflammatory arthritis associated with…

A

Crohn’s disease
Ulcerative colitis
Whipple’s disease (rare)

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23
Q

ENTEROPATHIC ARTHRITIS: epidemiology

A

M=F

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24
Q

In ENTEROPATHIC ARTHRITIS, Axial disease is associated with

A

HLA B27

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25
When does ENTEROPATHIC ARTHRITIS often occur in patients?
following onset of their GI disease (*usually)
26
ENTEROPATHIC ARTHRITIS: peripheral manifestations
- -Oligoarticular - -Generally asymmetric - -LE joints - -Dactylitis - -Enthesitis - -GI inflammation often parallels arthritis
27
ENTEROPATHIC ARTHRITIS: axial manifestations
- -Clinically/radiographically identical to idiopathic AS | - -Does not parallel GI disease
28
Trx for enteropathic arthritis which shows efficacy in UC but not CD?
Sulfasalazine (and its derivative, 5-ASA) **inhibit NFk B
29
Trx for enteropathic arthritis that are generally effective for all forms?
GC | NSAIDs (symptomatic trx)
30
Trx for enteropathic arthritis, effective in both forms of IBD?
Azathioprine and methotrexate
31
Trx for enteropathic arthritis, effective in CD?
Infliximab and adalimumab
32
Trx for enteropathic arthritis, effective in UC?
Infliximab
33
Reactive arthritis is an inflammatory process arising after: What is the classic triad?
arising after an infectious process Arthritis Urethritis Conjunctivitis
34
What are the clinical features of reactive arthritis?
1. asymm oligoarthritis (predom LE) 2. enthesitis (achilles, plantar, symphesis p, ribs) 3. uretritis 4. proven infection 5. dactylitis 6. axial disease (sacroiliitis and spondylitis) 7. oral ulcerations 8. conjuctivitis 9. Circinate balanitis 10. skin + nails (onycholysis)
35
reactive arthritis: epidemiology?
M>F (5:1) 75% HLA B27 (+) More common in HIV/AIDS (and more severe + resistant to therapy)
36
most common species to induce ReA?
Salmonella typhimurium
37
Reactive Arthritis: GI infections
Shigella Salmonella Campylobacter Yersinia
38
Pathogen which causes reactive arthritis 10 to 30 days after diarrhea?
Shigella
39
Pathogen which causes reactive arthritis within 3 to 4 weeks?
Salmonella
40
Reactive Arthritis: GU infections
Chlamydia (Chlamydia trachomatis) | Ureaplasma
41
Why is it important to follow up with a patient w/ Reactive Arthritis (Reiter's)?
Recurrences are common, and 20-50% of patients demonstrate a chronic course
42
Psoriatic arthritis should be suspected in a patient with:
``` asymm joint distribution pattern dactylitis enthesitis inflammatory-type back pain RF (-) ```
43
PSORIATIC ARTHRITIS: markers of poor outcome
Polyarticular disease | elevated ESR
44
How do you distinguish PSORIATIC ARTHRITIS from RA?
increase in vascularity | presence of neutrophils
45
PSORIATIC ARTHRITIS: What demonstrates clinical response to trx?
Change in synovial CD3+ T cell infiltration
46
PSORIATIC ARTHRITIS may originate (where)?
enthesis
47
PSORIATIC ARTHRITIS: effective trx for skin and joint disease
TNF inhibitors
48
PSORIATIC ARTHRITIS: what cells may be responsible for disease?
CD8 and MHC-1 | or TLR activation
49
PSORIATIC ARTHRITIS develops in 10-40% of pts with _____
psoriasis
50
Pathogenesis of Psoriasis?
inflammation of the skin and keratinocyte proliferation
51
Pathogenesis of PSORIATIC ARTHRITIS?
Synovial inflammation with mononuclear cell infiltration, new vessel formation and synovial proliferation *TNF alpha
52
Immunopathology of PA?
1. Elevated plasma levels of Ig 2. T cells express: - -HLA-DR - -receptors for IL2 and adhesion molecules 3. Secretion of IL-6 and other proinflammatory cytokines from T cells 4. Fibroblasts from skin + synovium prolif/secrete IL-1 beta, IL-6, and PDGF
53
Synovial cytokine profile in PA?
TNF-alpha IL-1 IL-6 IL-8
54
Serum cytokines upregulated in PA?
``` IL-10 IL-13 IFN-alpha VEGF Fibroblast Growth Factor ```
55
Compared to RA, PA synovium produces more:
TNF-alpha, IL1-beta, IL2, IL10, INF-gamma
56
Compared to RA, PA synovium produces less:
IL4
57
Cytokine produced by PA but not RA:
IL5
58
How is PA synovium structurally different than RA?
PSA synovium has less lining layer thickness and more vascularity (why didn't he just put "thinner lining layer"...am I missing something?)
59
What is the function of IL18, an upregulated cytokine in PA?
1. Stimulates angiogenesis 2. Upregulates chemokine expression on synovial fibroblasts 3. Increases mononuclear cell recruitment
60
PA patterns (5)?
1. Polyarticular pattern (>4 joints, RA-like) 2. Oligoarticular pattern (<4 joints, asymm) 3. DIP involvement pattern 4. Arthritis Mutilans (severe, destructive) 5. Axial involvement (sacroiliitis + spondylitis, B27+)
61
Nail abn in PA?
Pitting Hyperkeratosis Onycholysis
62
Where are skin lesions in PA, and when do they appear?
Scalp, perineum, natal cleft, umbilicus Usually present long before arthritis
63
If very severe PA, think...
HIV
64
PA: XR?
``` DIP involvement “Pencil – in - a – cup” Periostitis Bony ankylosis Erosive & proliferative Axial disease resembles AS ``` *is this even important?
65
PA responds well to what drug?
Infliximab
66
What joints does Brucella arthritis affect?
spine = adults peripheral joints = children (especially knees, hips and ankles) *sacroilitis can be extremely acute and painful!
67
Possible complication of Brucella arthritis?
spinal stenosis | destructive arthritis, if trx delayed
68
What types of bursitis are caused by Brucella arthritis?
prepatellar and olecranon
69
Caused by an immune reaction by T lymphocytes in the gut of genetically HLA-DQ2-positive or HLA-DQ8-positive individuals
celiac disease | **react to partially digested wheat gluten
70
What serum antibodies are present in celiac disease?
IgA antitissue transglutaninase | IgA antiedomysial antibodies
71
What conditions, presenting with profuse diarrhea, are associated with a variety of rheumatic diseases?
``` Microscopic colitis (MC) (2 forms = collagenous colitis and lymphocytic colitis) ```
72
What cell is activated in PA, which causes bone destruction?
osteoclast

MS/Rheum (23 decks)

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