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Spondyloarthropathies Flashcards

1
Q

Spondyloarthropathies: A group of disorders characterized by what?
9

A
  1. Inflammatory axial spine involvement
  2. Asymmetrical peripheral arthritis
  3. Enthesitis (Inflammation of sites where tendons and ligaments attach to bone)
  4. Inflammatory eye disease
  5. Mucocutaneous features
  6. Negative Rheumatoid factor
  7. High frequency of HLA
  8. B27 Antibodies
  9. Familial aggregation
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2
Q

Spondyloarthropathies
Definition?

These diagnoses include what? 4

A

Definition: A group of inflammatory arthropathies that share distinctive clinical, radiographic and genetic features.

  1. Ankylosing spondylitis
  2. Reactive arthritis (Reiter’s syndrome)
  3. Psoriatic arthritis
  4. Enteropathic arthritis (Crohns and Ulcerative colitis)
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3
Q

HLA-B27 Disease Associations

6 in order of +HLA-B27

A
  1. Ankylosing Spondylitis >90%
  2. Reactive Arthritis 85%
  3. Reiter’s Syndrome 80%
  4. Inflammatory Bowel Disease 50%
  5. Psoratic Arthritis 50%
  6. Whipple’s Disease 30%
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4
Q

Ankylosing Spondylitis

  1. What is it?
  2. Higher incidence where?
  3. Changes seen where? 2
  4. Inflammation around what?
  5. Extra-articular manifestations? 3
A
  1. Chronic inflammatory disease of the joints of the axial skeleton
  2. Higher incidence at higher latitudes, Scandinavian countries
  3. Changes seen in
    - sacroiliac joints and
    - hips
  4. Inflammation around enethesis: the connective tissue between tendon or ligament and bone
  5. Extra-articular manifestations:
    - Anterior uveitis
    - Aortic valvular disease
    - Restricted chest expansion
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5
Q

AS Diagnostic Features

7

A
  1. Insidious onset low back pain > 3 months
  2. Improves with exercise not rest
  3. Morning stiffness > 30 minutes
  4. Awakened by pain during the 2nd half of the night
  5. Alternating buttock or posterior thigh pain
  6. Sites of enthesitis
  7. Sacroiliitis on x-ray
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6
Q

Ankylosing Spondylitis
Differentiating

Inflammatory vs

Mechanical Back Pain

Describe the following for each:

  1. AM Stiffness?
  2. Max. Pain/Stiffness?
  3. Exercise/activity?
  4. Duration?
  5. Age at Onset?
  6. Radiographs?
A

Inflammatory Back Pain

  1. Prolonged > 60min.
  2. Early AM
  3. Improves Symptoms
  4. Chronic
  5. 9-40 yrs.
  6. Sacroiliitis, Vertebral ankylosis, syndesmophytes

Mechanical Back Pain

  1. Minor less than 45 min.
  2. Late in day
  3. Worsens Symptoms
  4. Acute or Chronic
  5. 20-65 yrs.
  6. Osteophytes, malalignment
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7
Q

Ankylosing Spondylitis

What is the single most important imaging technique for diagnostics and follow up?

A

Radiographs

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8
Q

Ankylosing Spondylitis Radiograph changes?

6

A
  1. Early changes are at the sacral iliac joints- Erosion and sclerosis
  2. Involvement of the apophysial joints of the spine
  3. Ossification of the annulus fibrosus
  4. Calcification of the anterior and lateral spinal ligaments
  5. Squaring and generalized demineralization of the vertebral bodies
  6. Radiographic changes of the spine are often referred to as “BAMBOO SPINE”
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9
Q

AS: Characteristics

  1. Typical age and gender?
  2. Symptoms appear how?
  3. First symptoms are typically what?
  4. Also associated with what?
A
  1. Typical patient is male aged 20-40
  2. Symptoms appear gradually and are usually not specific to AS. Time to correct diagnosis is 8.5-14 years
  3. First symptoms are typically
    - chronic pain and stiffness in the middle spine associated
    - with referred to one or the other buttock or the back of the thigh
  4. Associated with morning stiffness that improves with exercise
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10
Q

Modified New York Criteria for Diagnosis for AS
5

  • Definite AS if?
A
  1. Limited lumbar motion
  2. Low back pain for > 3 months – improved with exercise, not relieved by rest
  3. Reduced chest expansion
  4. Bilateral Grade 2-4 sacroiliitis on xray
  5. Unilateral Grade 3-4 sacroiliitis on xray

Criteria 4 or 5 plus 1, 2 or 3

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11
Q

AS findings on PE? 6

A

AS:

  1. flat lumber spine,
  2. loss of lordosis,
  3. use hips for bending
  4. Enthesitis
  5. Skin rashes
  6. Anterior uveitis
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12
Q

XRAY findings for AS?

2

A

AS:Ossification of the annulus fibrosus

AS: Bamboo spine

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13
Q

AS: Extra-articular manisfestations may occur including?

4

A
  1. Skin rashes
  2. Eye inflammation - especially uveitis
  3. Lung involvement
  4. Cardiac involvement - with aortic valve disease
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14
Q

30 to 40% of people
with AS will
experience what ocular manifestation at least once?

A

Iritis or Anterior Uveitis

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15
Q 
Spectrum of AS
Describe Early manifestations in the following categories:
1. Symtpoms? 3
2. Extra-articular manifestations? 3
3. Disease Progression? 1
4. Morbidity/Mortality? 2
A

Early

    • LBP
    • Stiffness
    • Fatigue
    • Ocular
    • Skin/nail
    • Enthesitis
    • Sacroiliitis
    • Pain
    • Functional limitation
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16
Q 
Spectrum of AS
Describe Moderate manifestations in the following categories:
1. Symtpoms? 3
2. Extra-articular manifestations? 2
3. Disease Progression? 2
4. Morbidity/Mortality? 3
A
    • Spinal Limitation
    • Functional limits
    • Night Pain
    • Chronic Uveitis
    • IBD
    • Hip involvment
    • Spondylitis
    • AS complications
    • Drug toxicity
    • Comorbidities
17
Q 
Spectrum of AS
Describe Severe manifestations in the following categories:
1. Symtpoms? 1
2. Extra-articular manifestations? 3
3. Disease Progression? 2
4. Morbidity/Mortality? 2
A
  1. Spinal Immobility
    • Aortitis
    • Restrictive lung
    • Heart block
    • Periph.arthritis
    • Bamboo Spine
    • Fracture
    • Death
18
Q

Spondyloarthopathies – REACTIVE ARTHRITIS
1. What is it?

  1. What is the triad associated with this?
  2. What is the most common etiology?
    (other etiology?)
  3. Course? Without treatment?
  4. Complications? 4
A
  1. Acute inflammatory arthritis occurring 1-3 weeks after infectious event (GU, GI, idiopathic)
  2. TRIAD: arthritis + urethritis (cervicitis) + conjunctivitis (classic triad found in
19
Q

Spondyloarthopathies –Reiter’s Syndrome
1. Musculoskeletal manifestations? 3

  1. Extra-articular signs and symptoms? 6
A
  1. Musculoskeletal signs and symptoms:
    - Arthritis
    - Enthesitis
    - Dactylitis
  2. Extra-articular signs and symptoms
    - GU: dysuria and pelvic pain
    - Conjunctivitis
    - Oral ulcers
    - Rashes
    - Nail changes
    - Genital lesions
20
Q

Infectious Triggers for Reactive Arthritis

  1. Enteric infections? 4
  2. Urogenital Infections? 3
A
  1. Enteric Infections
    - Shigella
    - Salmonella
    - Yersinia enterocololitica
    - Campylobacter
  2. Urogenital Infections
    - Chlamydia trachomatis,
    - C. pneumoniae
    - Ureaplasma urealyticum
21
Q

Reiter’s PE symptoms?

9

A
  1. heel tendonitis
  2. pustules
  3. Keratoderma blenorrhagica
  4. Pustules+Keratoderma blenorrhagica
  5. tongue lesion
  6. palate erosion
  7. syndrome, conjunctivitis
  8. Nail dystrophy seen in Reiter’s and psoriasis
  9. Plantar periostitis
22
Q

PSORIATIC ARTHRITIS (PsA)

  1. What is it?
  2. Frequency of PsA increases with what?
  3. Nail changes? 3
  4. Course?
A
  1. Chronic inflammatory arthropathy in setting of psoriasis
  2. Frequency of PsA increases
    with disease severity and duration
  3. Nail changes:
    - pitting,
    - dystrophy,
    - onycholysis
  4. Course:
    - chronic, destructive arthritis in 30-50%
23
Q

Psoriatic Arthritis: Clinical Characteristics

10

A
  1. Inflammatory Arthritis in DIPs
  2. Asymmetric Arthritis
  3. Sausage Digits
  4. Nail pitting (Onycholysis)
  5. No Rheumatoid Nodules
  6. RF Test Negative
  7. Erosive Arthritis without Osteopenia
  8. Sacroiliitis, often asymptomatic
  9. Paravertebral Ossification
  10. Enthesopathy
24
Q

PsA PE findings

4

A
  1. Rash, nail dystrophy,
  2. sausage digits/arthritis
  3. DIPs and PIPs
  4. Pencil and Cup Deformity
25
Q

Treatment for all spondyloarthropathies

6

A
  1. Treat symptoms with NSAIDs initially
  2. Physical therapy, stretching and exercises to preserve spine and joint function
  3. Maintain good posture
  4. Sulfasalazine, Methotrexate found to be beneficial
  5. Anti-TNF aka TNF inhibitors (Remicade, Humira, Enbrel)
  6. Prevent eye complications by early recognition and treatment
26
Q
  1. NSAIDS are effective for? 4

2. No evidence for what?

A
    • inflammatory back pain,
    • spinal stiffness,
    • peripheral arthritis,
    • enthesopathy
  2. No evidence that NSAIDs inhibit disease progression
27
Q

FDA-approved NSAIDs for AS?
5

Anecdotal reports & few studies suggest that specific NSAIDs may be more effective such as? 3

A
  1. Indomethacin,
  2. indomethacin-SR,
  3. EC ASA,
  4. naproxen,
  5. sulindac, diclofenac.
  6. phenylbutazone: limited availability: risk of agranulocytosis
  7. indomethacin: especially in long acting form
  8. diclofenac: as effective as Indocin
28
Q

NSAID Resistant AS/SpA
Consider Disease Modifying Antirheumatic Drugs (DMARDs) when?
4

A
  1. Antiinflammatory therapy is insufficient to control symptoms
  2. Progression of inflammatory axial disease noted
  3. Active persistent polyarthritis
  4. Uncontrolled extra-articular disease
29
Q

For uncontrolled extra-articular dz of As/SpA?

3

A
  1. TNF Inhibitors
  2. Sulfasalazine
  3. Methotrexate

Rheumatology (11 decks)

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