Spondyloarthritis

Question 1

Psoriatic arthritis general description

Answer 1

Patients have general psoriasis symptoms and arthritis. Tends to be an asymmetrical oligoarthritis in the lower extremities.

Question 2

Spondyloarthritis is associated with this subset of cytokines

Answer 2

Th17-type

Although not necessarily Th17 cells themselves

Question 3

enthesitis

Answer 3

inflammation at the bony insertions of tendons and ligaments

Question 4

dacylitis

Answer 4

inflammation of whole digits manifesting as ‘sausage toe” or “sausage finger”

Question 5

Spondyloarthritis general description

Answer 5

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)

Question 6

Spondyloarthritis Venn Diagram

Answer 6

Question 7

Prototypic ankylosing spondylitis

Answer 7

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.

Question 8

Characteristics of reactive arthritis

Answer 8

• 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

Question 9

Psoriatic arthritis occurs in __% of patients with psoriasis.

Answer 9

Psoriatic arthritis occurs in 30% of patients with psoriasis.

Question 10

HLA gene associated with all forms of spondyloarthritis

Answer 10

HLA-B27

Question 11

__% of patients with spondyloarthritis are positive for HLA-B27

Answer 11

85% of patients with spondyloarthritis are positive for HLA-B27

Question 12

HLA-B27 is normally present within __% of the US population.

Answer 12

HLA-B27 is normally present within 6.1% of the US population.

Question 13

Clinical manifestations of enthesitis

Answer 13

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.

Question 14

Spondyloarthritis histopathology

Answer 14

Histologically, the inflammation in spondyloarthritis is characterized by chronic inflammatory infiltrates that are nonspecific and largely indistinguishable from rheumatoid arthritis.

Question 15

While rheumatoid arthritis is associated with pathological bone ___, spondyloarthritis is associated with pathological bone ___.

Answer 15

While rheumatoid arthritis is associated with pathological bone erosion, spondyloarthritis is associated with pathological bone production.

Question 16

The usual presenting symptom of axial spondyloarthritis is. . .

Answer 16

. . . back pain!

Particularly inflammatory back pain which starts low in the back or in the deep gluteal region.

Question 17

A classic presentation of axial spondyloarthritis

Answer 17

• 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

Question 18

A patient beginning to present with clinical symptoms of axial spondylarthropathy will have lost ___.

Answer 18

A patient beginning to present with clinical symptoms of axial spondylarthropathy will have lost lumbar lordosis.

Question 19

Schober test

Answer 19

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.

Question 20

Psoriasis

Answer 20

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

Question 21

Answer 21

Classical presentation of psoriasis

Question 22

While common in spondylarthritis, dactyltis may be associated with other diseases such as. . .

Answer 22

. . . gout.

Question 23

___ of patients with ankylosing spodylitis have subclinical inflammation in their intestine.

Answer 23

2/3 of patients with ankylosing spodylitis have subclinical inflammation in their intestine.

Question 24

Entheses map

Answer 24

Question 25

Answer 25

Achilles tendon enthesis

Question 26

Laboratory findings for spondyloathritis

Answer 26

* 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.** * **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.** *

Question 27

Normocytic anemia

Answer 27

Your blood cells are normal, you just don't have as many as you should.

Question 28

Normochromic anemia

Answer 28

Your blood cells have the proper concentration of anemia, there just aren't enough of them

Question 29

Answer 29

Sacroiliac fusion in severe case of ankylosing spondylitis

Question 30

Answer 30

Pencil-in-cup X-ray finding of psoriatic arthritis

Question 31

Treatment of axial spondylarthritis

Answer 31

* 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

Question 32

An ideal diagnosis of spondylarthritis

Answer 32

HLA-B27, high CRP, positive family history for spondyloarthrits, positive MRI

Question 33

Treatment of peripheral spondylarthritis

Answer 33

* 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

Question 34

For many, ____ is the first reason to seek medical care as an adult

Answer 34

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

Question 35

Acute / subacute / chronic for back pain

Answer 35

acute (\< 1 month), subacute (1-3 months) and chronic (\> 3 months) low back pain

Question 36

Lumbago

Answer 36

synonym for low back pain

Question 37

Sciatica

Answer 37

pain radiating from the low back into one or both legs

Question 38

pain may originate from \_\_\_

Answer 38

pain may originate from **many spinal structures**

Question 39

Differential for lower back pain

Answer 39

Question 40

Mechanical back pain

Answer 40

* 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.

Question 41

The terms lumbar strain or sprain . . .

Answer 41

The terms lumbar strain or sprain **lack a clear anatomic definition.**

Question 42

Non-mechanical back pain

Answer 42

* Etiologies include malignancy, infection, axial spondyloarthritis * Typically not relieved by lying down or resting * **Inflammatory back pain is the hallmark of axial spondyloarthritis**

Question 43

Visceral back pain

Answer 43

* 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

Question 44

'Red flag' histories for back pain

Answer 44

Question 45

Recommendations for managing back pain

Answer 45

Question 46

The Schober test is ___ sensitive and specific.

Answer 46

The Schober test is **not particularly** sensitive and specific.