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MSK Exam 4 > Spondyloarthropathies > Flashcards

Spondyloarthropathies Flashcards

1
Q

ANKYLOSING SPONDYLITIS

A

Ankylosing Spondylitis is a systemic inflammatory disorder that
primarily affects the axial skeleton

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2
Q

ANKYLOSING SPONDYLITIS pathophysiology

A

○ 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”

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3
Q

ANKYLOSING SPONDYLITIS presentation

A

○ Chronic back pain is the main
presenting symptom
■ Insidious onset
■ Chronic (>3 months)
■ Worse at night
■ Significant stiffness in the AM
■ Improves with activity

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4
Q

ANKYLOSING SPONDYLITIS diagnosis

A

○ 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)

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5
Q

Special tests for ANKYLOSING SPONDYLITIS

A
  1. Sacroiliac joint tenderness
  2. 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
  3. FABER maneuver may ↑ pain 2° to SI joint inflammation
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6
Q

Imaging for ANKYLOSING SPONDYLITIS

A

○ 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

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7
Q

ANKYLOSING SPONDYLITIS lab evaluations

A

○ 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

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8
Q

ANKYLOSING SPONDYLITIS mangement

A

○ 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

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9
Q

3 findings should prompt early Rheumatology referral for ANKYLOSING SPONDYLITIS

A

. (+) HLA-B27
2. Presence of inflammatory back pain
3. Imaging suggesting findings of sacroiliitis

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10
Q

JUVENILE IDIOPATHIC ARTHRITIS etiology

A
  • Cause = ?
  • Similar to synovitis in adult rheumatoid arthritis
  • Inflammatory process → joint pannus formation, with cartilage &
    bone erosions mediated by degradative enzymes
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11
Q

JUVENILE IDIOPATHIC ARTHRITIS presentation

A
  • 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
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12
Q

JUVENILE IDIOPATHIC ARTHRITIS diagnosis

A
  • 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)
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13
Q

JUVENILE IDIOPATHIC ARTHRITIS management

A
  • 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
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14
Q

JUVENILE IDIOPATHIC ARTHRITIS management

A
  • Systemic corticosteroids may be needed to control symptoms or to
    treat Macrophage Activation Syndrome
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15
Q

Reactive Arthritis (Reiter Syndrome) epidemiology

A
  • 9-27 per 100,000
  • 20-40 years old
  • Men > women, following genitourinary infection
  • Men = women, following gastrointestinal infection
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16
Q

Reactive Arthritis
(Reiter Syndrome) etiology

A
  • 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
17
Q

REACTIVE ARTHRITIS
(REITER SYNDROME) presentation

A
  • 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
18
Q

REACTIVE ARTHRITIS
(REITER SYNDROME) diagnosis

A
  • 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
19
Q

Often associated with systemic
disease, especially
Spondyloarthropathies & the
HLA-B27 antigen

A

Iritis (anterior uveitis)

20
Q

REACTIVE ARTHRITIS
(REITER SYNDROME) Diagnosis

A
  • 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
21
Q

REACTIVE ARTHRITIS
(REITER SYNDROME) Labs

A
  • 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
22
Q

REACTIVE ARTHRITIS
(REITER SYNDROME) management

A
  • 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
23
Q

REACTIVE ARTHRITIS
(REITER SYNDROME) complications

A
  • 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
24
Q

PSORIATIC ARTHRITIS etiology

A

Theory = Inappropriate immune response → triggered by environmental stimulus → in genetically predisposed patients

25
Q

PSORIATIC ARTHRITIS presentation

A
  • Peripheral joint disease = 95% of patients
  • Usually occurs as polyarthritis (≥ 5 joints affected)
  • May occur as oligoarthritis (< 5 joints affected)
  • Axial disease
  • 5% of patients
  • Combination of peripheral & axial disease
  • 20%-50% of patients
  • May present with:
  • Dactylitis (“sausage digit”)
  • Enthesitis
  • Achilles’ tendon or plantar fascia
  • Back pain
  • Nail lesions
26
Q

PSORIATIC ARTHRITIS diagnosis

A
  • CASPAR criteria (Classification of Psoriatic Arthritis)
  • Diagnosis based on inflammatory joint disease & ≥ 3 of the following:
    1. Current or personal hx of psoriasis, or FHx of psoriasis
    2. Psoriatic nail dystrophy, including onycholysis, pitting, & hyperkeratosis
    3. (-) RF by any method except latex (ELISA or nephelometry preferred)
    4. Current or history of dactylitis
    5. radiologic evidence of juxta-articular new bone formation (excluding
    osteophyte formation) with ill-defined ossification near joint margins on
    x-rays of hand or foot
27
Q

Labs and imaging for PSORIATIC ARTHRITIS

A
  • Blood test (no specific tests)
  • (-) Rh factor (most patients)
  • ↑ ESR, CRP
  • (+) HLA-B27 in patients with comorbid psoriasis
    Imaging
  • X-ray
  • Bone proliferation & resorption are typical signs
  • Severe disease manifests as a “pencil-in-cup” deformity
  • MRI may be more sensitive for articular & soft tissue inflammation
28
Q

PSORIATIC ARTHRITIS management

A
  • Peripheral arthritis, enthesitis, dactylitis, axial disease
  • NSAIDS
  • Possible intra-articular corticosteroid injection
  • Disease-modifying antirheumatic drugs (DMARDs)
  • Nail disease
  • Retinoids, oral psoralen-ultraviolet light, cyclosporine, TNF inhibitors
  • Refer to derm
  • Skin disease
  • Psoriasis

MSK Exam 4 (6 decks)

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