Spondyloarthritis Flashcards
Psoriatic arthritis general description
Patients have general psoriasis symptoms and arthritis. Tends to be an asymmetrical oligoarthritis in the lower extremities.
Spondyloarthritis is associated with this subset of cytokines
Th17-type
Although not necessarily Th17 cells themselves
enthesitis
inflammation at the bony insertions of tendons and ligaments
dacylitis
inflammation of whole digits manifesting as ‘sausage toe” or “sausage finger”
Spondyloarthritis general description
Group of diseases wherein there is inflammation of spinal joints, sacroiliac joint, and peripheral joints. Often associated with:
Enthesitis
Dactylitis
Psoriasis
IBD
Uveitis (inflammation of uvea of eye)
Spondyloarthritis Venn Diagram
Prototypic ankylosing spondylitis
Inflammation in the spine and back joints manifests as back pain and morning stiffness. Chronic inflammation leads to fusion of bony segments of spine to one another.
Characteristics of reactive arthritis
- Part of spondyloarthritis family
- Occurs within 4 weeks of Chlamdyia UTI
- However, joints are culture negative, this is an aseptic arthritis
- 50/50 remission and chronic disease
Psoriatic arthritis occurs in __% of patients with psoriasis.
Psoriatic arthritis occurs in 30% of patients with psoriasis.
HLA gene associated with all forms of spondyloarthritis
HLA-B27
__% of patients with spondyloarthritis are positive for HLA-B27
85% of patients with spondyloarthritis are positive for HLA-B27
HLA-B27 is normally present within __% of the US population.
HLA-B27 is normally present within 6.1% of the US population.
Clinical manifestations of enthesitis
Heel pain when the Achilles tendon enthesis is involved, foot pain at the plantar fascia insertion, or swelling of entire digits (dactylitis or sausage digit) due to inflammation of the flexor and extensor tendons and their attachments at the bones of the fingers or toes.
Spondyloarthritis histopathology
Histologically, the inflammation in spondyloarthritis is characterized by chronic inflammatory infiltrates that are nonspecific and largely indistinguishable from rheumatoid arthritis.
While rheumatoid arthritis is associated with pathological bone ___, spondyloarthritis is associated with pathological bone ___.
While rheumatoid arthritis is associated with pathological bone erosion, spondyloarthritis is associated with pathological bone production.
The usual presenting symptom of axial spondyloarthritis is. . .
. . . back pain!
Particularly inflammatory back pain which starts low in the back or in the deep gluteal region.
A classic presentation of axial spondyloarthritis
- Began very slowly, over years
- Started in deep gluteal region and began creeping up the spine
- Worsened by rest and improved by exercise (characteristic of all forms of inflammatory arthritis)
- Difficulty sleeping or sitting in one position for long periods of time due to discomfort
- Age of onset <40 years
A patient beginning to present with clinical symptoms of axial spondylarthropathy will have lost ___.
A patient beginning to present with clinical symptoms of axial spondylarthropathy will have lost lumbar lordosis.
Schober test
With the patient standing erect, a horizontal line is drawn at the L5–S1 region at the level of the “dimples of Venus” and another line 10 cm above that in the midline of the back.
With forward flexion, the distance between these two ends of the 10-cm line should increase by about 5 cm in the normal lumbar spine.
Psoriasis
Psoriasis affects 2-3% of the population. Up to 30% of patients with psoriasis may develop an inflammatory arthropathy. Nail psoriasis is associated with arthritis in the distal interphalangeal (DIP) joints. In the vast majority of patients with PsA, the skin disease is present first or arises at the same time as the joint disease
Classical presentation of psoriasis
While common in spondylarthritis, dactyltis may be associated with other diseases such as. . .
. . . gout.
___ of patients with ankylosing spodylitis have subclinical inflammation in their intestine.
2/3 of patients with ankylosing spodylitis have subclinical inflammation in their intestine.
Entheses map
Achilles tendon enthesis
Laboratory findings for spondyloathritis
- Hematologic studies normal except in severe cases where there is normocytic-normochromic anemia
- Normal to slightly elevated ESR and CRP
- Rheumatoid factor, anti-CCP and antinuclear antibodies (ANA) negative
- Normal levels of serum complement
- HLA-B27 positive may be highly suggestive in proper clinical context. Negative HLA-B27 does not rule out.
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Radiographic finding of new bone formation along the sacroiliac joints or spine are highly specific, also highly suggestive in peripheral joints with characteristics of inflammation. Sclerosis of bone edges may also be seen. Pencil-in-cup pattern and bone narrowing commonly seen on peripheral spondyloarthritis. Negative radiography does not rule out.
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Normocytic anemia
Your blood cells are normal, you just don’t have as many as you should.
Normochromic anemia
Your blood cells have the proper concentration of anemia, there just aren’t enough of them
Sacroiliac fusion in severe case of ankylosing spondylitis
Pencil-in-cup X-ray finding of psoriatic arthritis
Treatment of axial spondylarthritis
- NSAIDs
- Physical therapy
- Erect posture maintenance
- Firm bed and as small as possible of a pillow to prevent neck flexion while sleeping
- Breathing exercises to maintain chest expansion
- DMARDs (like methotrexate) and corticosteroids NOT effective
- For extreme cases, anti-TNFs or anti-IL-17A
An ideal diagnosis of spondylarthritis
HLA-B27, high CRP, positive family history for spondyloarthrits, positive MRI
Treatment of peripheral spondylarthritis
- NSAIDs
- Physical therapy
- Erect posture maintenance
- Firm bed and as small as possible of a pillow to prevent neck flexion while sleeping
- Breathing exercises to maintain chest expansion
- DMARDs (like methotrexate) and corticosteroids ARE effective (unlike in the axial form of the disease)
- For extreme cases, anti-TNFs or anti-IL-17A
For many, ____ is the first reason to seek medical care as an adult
For many, acute low back pain is the first reason to seek medical care as an adult
Many cases of acute low back pain are selflimited and resolve with little intervention. About 1/3 of patients will not fully recover within six months, although most will improve
Acute / subacute / chronic for back pain
acute (< 1 month), subacute (1-3 months) and chronic (> 3 months) low back pain
Lumbago
synonym for low back pain
Sciatica
pain radiating from the low back into one or both legs
pain may originate from ___
pain may originate from many spinal structures
Differential for lower back pain
Mechanical back pain
- Related to structural damage of the spine.
- Exacerbated by movements and relieved by lying down and resting
- Lumbar strain or sprain, idiopathic low back pain, and nonspecific low back pain are terms used to describe an episode of acute low back pain without a clearly defined cause that is typically self-limited.
The terms lumbar strain or sprain . . .
The terms lumbar strain or sprain lack a clear anatomic definition.
Non-mechanical back pain
- Etiologies include malignancy, infection, axial spondyloarthritis
- Typically not relieved by lying down or resting
- Inflammatory back pain is the hallmark of axial spondyloarthritis
Visceral back pain
- Low back pain may also arise from non-spinal structures
- Diseases of the gastrointestinal tract and pathologies in the pelvis or retroperitoneum may present with low back pain.
- Usually referred pain
‘Red flag’ histories for back pain
Recommendations for managing back pain
The Schober test is ___ sensitive and specific.
The Schober test is not particularly sensitive and specific.
