Spondyloarthropathies Flashcards
ANKYLOSING SPONDYLITIS
Ankylosing Spondylitis is a systemic inflammatory disorder that
primarily affects the axial skeleton
ANKYLOSING SPONDYLITIS pathophysiology
○ Chronic enthesitis
* Inflammation of the insertion point of ligaments or tendons to bone
* CD4 & CD8 T lymphocytes & macrophages infiltrate tendon & ligaments
at the bony insertion
* Medicated by several cytokines, esp. Tumor Necrosis Factor alpha
* Outer fibers of the intervertebral discs become fibrotic eventually
ossify, which leads to the classic “bamboo spine”
ANKYLOSING SPONDYLITIS presentation
○ Chronic back pain is the main
presenting symptom
■ Insidious onset
■ Chronic (>3 months)
■ Worse at night
■ Significant stiffness in the AM
■ Improves with activity
ANKYLOSING SPONDYLITIS diagnosis
○ Inflammatory Back Pain
* Onset of back discomfort before the age of 40 years
* Insidious onset
* Improvement with exercise
* No improvement with rest
* Pain at night (with improvement upon arising)
Special tests for ANKYLOSING SPONDYLITIS
- Sacroiliac joint tenderness
- Limited range of motion of spine
* Schober test
* Lateral spinal flexion
§ Pt standing straight with heel & back against a wall
§ The distance between the tip of the middle finger & the floor is
measured
§ Pt bends sideways without bending knees or lifting heels - FABER maneuver may ↑ pain 2° to SI joint inflammation
Imaging for ANKYLOSING SPONDYLITIS
○ Radiographic findings are most diagnostic
■ Degenerative, fused vertebrae
“Bamboo Spine”
■ MRI for those who do not show typical
radiographic findings
■ More useful in the early phase
of the disease
ANKYLOSING SPONDYLITIS lab evaluations
○ Labs
* HLA-B27
§ (+) 85-95% in Caucasian patients with Ankylosing Spondylitis
v Good screening tool in patients with chronic LBP (>3 months)
* Acute (Inflammatory) Phase Reactants
§ Erythrocyte Sedimentation Rate (85% of cases)
§ C-Reactive Protein
* (-) RF & anti-CCP antibodies
ANKYLOSING SPONDYLITIS mangement
○ Consult with orthopedics & rheumatology
○ NSAIDs are 1st line treatment
* Indomethacin (Indocin® )
○ Tumor Necrosis Factor-alpha Inhibitors (TNF-alpha)
* For patient’s not well-controlled on NSAIDs
* Etanercept (Enbrel® ), Infliximab, (Remicade ® ), Adalimumab (Humira® )
Ixekizumab (Taltz ® )
○ Oral sulfasalazine (Azulfidine® ) is helpful in those with coexisting
inflammatory bowel disease
3 findings should prompt early Rheumatology referral for ANKYLOSING SPONDYLITIS
. (+) HLA-B27
2. Presence of inflammatory back pain
3. Imaging suggesting findings of sacroiliitis
JUVENILE IDIOPATHIC ARTHRITIS etiology
- Cause = ?
- Similar to synovitis in adult rheumatoid arthritis
- Inflammatory process → joint pannus formation, with cartilage &
bone erosions mediated by degradative enzymes
JUVENILE IDIOPATHIC ARTHRITIS presentation
- Depends on the type
- Abrupt onset:
- fever
- rash
- Systemic: weight loss, myalgias, fatigue
- Joint pain & tenderness &/or decreased range of motion
- Monophasic – present with active disease, resolves in 4-6 months
- Polycyclic (Least Common) – recurrent active disease with long
periods of inactivity (months to years) - Persistent (Most Common) – some symptoms persist despite
resolution of others
JUVENILE IDIOPATHIC ARTHRITIS diagnosis
- Arthritis in ≥ 1 joint with (or preceded by) fever of at least 2 weeks
duration that is documented to be daily for at least 3 days, &
accompanied by ≥ 1 of: - Evanescent (quickly fading) erythematous rash
- Generalized lymph node enlargement
- Hepatomegaly &/or splenomegaly
- Serositis (pericarditis &/or pleuritis &/or peritonitis)
JUVENILE IDIOPATHIC ARTHRITIS management
- Interleukin inhibitors (IL) are 1st line therapy
- Anakinra (Kineret®) (IL-1 receptor antagonist)
- Canakinumab (Ilaris®) (IL-1 antibody)
- Tocilizumab (Actemra®) (IL-6 receptor antibody)
- NSAIDs useful for symptomatic relief
JUVENILE IDIOPATHIC ARTHRITIS management
- Systemic corticosteroids may be needed to control symptoms or to
treat Macrophage Activation Syndrome
Reactive Arthritis (Reiter Syndrome) epidemiology
- 9-27 per 100,000
- 20-40 years old
- Men > women, following genitourinary infection
- Men = women, following gastrointestinal infection
Reactive Arthritis
(Reiter Syndrome) etiology
- Systemic inflammatory disorder characterized by aseptic arthritis arising 1-6 weeks after an extra-articular infection, usually of gastrointestinal or urogenital origin
- Especially sexually & dysenteric diseases
- Chlamydia trachomatis, Shigella, Salmonella, Yersinia, Clostridium difficile, & Campylobacter
- The specific pathogenesis is unknown
- More common in patients positive for HLA-B27
REACTIVE ARTHRITIS
(REITER SYNDROME) presentation
- Classic presentation (uncommon)
- Triad - urethral, conjunctival, & synovial symptoms
- Actual presentation
- Varies considerably
- Mild to severe
- Localized <—–> Multisystem disease
- 95% of cases are acute, asymmetric oligoarthritis
- <5 joints-usually knee, ankle, &/or heel pain present in 95% of cases
- Conjunctivitis: usually mild & may precede arthritis
REACTIVE ARTHRITIS
(REITER SYNDROME) diagnosis
- lower limb, asymmetrical peripheral arthritis
- low back or buttock pain suggestive of sacroiliitis
- Enthesitis (inflammation at tendon/ligament/joint capsule insertions)
- Extra-articular lesions
- keratoderma blenorrhagica (5-10%) → scaly rash on palms & soles
- Circinate balanitis → painless, shallow ulcers on shaft/glans penis
- Family history of spondyloarthropathy or related disease may support
diagnosis - Initiating infection may be asymptomatic & require testing to identify
Often associated with systemic
disease, especially
Spondyloarthropathies & the
HLA-B27 antigen
Iritis (anterior uveitis)
REACTIVE ARTHRITIS
(REITER SYNDROME) Diagnosis
- Diagnosis of peripheral & axial inflammatory arthritis can usually
be made on the basis of an appropriate history, physical exam, &
basic investigations - Imaging
- X-ray abnormalities develop after disease present for several
months - MRI may allow for early diagnosis of sacroiliitis
REACTIVE ARTHRITIS
(REITER SYNDROME) Labs
- CBC with diff → neutrophilic leukocytosis, thrombocytosis, & anemia
- CMP
- ESR & CRP → ↑ in acute stage of disease
- Serum negative for autoantibodies
- Analyze serum for antibodies against the common causative pathogens
- Chlamydia trachomatis, Shigella, Salmonella, Yersinia, Clostridium
difficile, & Campylobacter - Urine studies
- UA may show ↑ leukocytes, hematuria, & mild proteinuria
during acute disease - 1st morning void for Chlamydia trachomatis
- Polymerase chain reaction (PCR)
- Stool studies
- Stool cultures usually negative by the time arthritis occurs
- Consider if diarrhea present or recently resolved
REACTIVE ARTHRITIS
(REITER SYNDROME) management
- Self-limited disease & usually spontaneously resolves without treatment
- Mean recovery 3-5 months-but can take up to 12 months
- Medications
- NSAIDs for the acute phase of reactive arthritis
- Glucocorticoids for patients with severe inflammation
- Disease-modifying antirheumatic drugs (DMARDs)
- For patients not adequately treated with NSAIDs & steroids or for
those who develop chronic or erosive reactive arthritis
REACTIVE ARTHRITIS
(REITER SYNDROME) complications
- Chronic reactive arthritis (>6 months) 30-50%
- Cardiac complications are rare but include: proximal aortitis, aneurysmal
aortic dilation, ventricular dilation, myo/pericarditiis - Erosive joint damage
- Ankylosis of the spine
- Glomerulonephritis
- Heel & foot involvement leads to poor functional outcomes & disability
PSORIATIC ARTHRITIS etiology
Theory = Inappropriate immune response → triggered by environmental stimulus → in genetically predisposed patients
