Spondyloarthropathies, PMR, FM Flashcards
1
Q
What are spondyloarthropathies?
A
group of inflammatory arthropathies that share distinctive clinical, radiographic and genetic features:
- inflammatory axial spine involvement
- asymmetrical peripheral arthritis
- enthesitis (inflammation of sites where tendons and ligaments attach to bone)
- inflammatory eye disease
- mucocutaneous features
- negative RF
- high freq of HLA B27 abs
- familial aggregation
these are:
- ankylosing spondylitis
- reactive arthritis (Reiter’s syndrome)
- psoriatic arthritis
- enteropathic arthritis (crohns and UC)
2
Q
Disease associations w/ HLA-B27?
A
- ankylosing spondylitis: over 90%
- reactive arthritis 85%
- reiters syndrome 80%
- IBD 50%
- psoriatic arthritis 50%
- whipple’s disease 30%
3
Q
What is ankylosing spondylitis (AS)? Extra-articular manifestations?
A
- chronic inflammatory disease of jts of the axial skeleton
- higher incidence at higher latitudes, Scandinavian countries
- changes seen in sacroiliac jts and hips
- inflammation around enethesis
- extra-articular manifestations:
anterior uveitis
aortic valvular disease
restricted chest expansion
4
Q
Diagnostic features of AS?
A
- insidious onset low back pain for longer than 3 months
- improves w/ exercise not rest
- morning stiffness for longer than 30 min
- awakened by pain during the 2nd half of the night
- alternating buttock or posterior thigh pain
- sites of enthesitis
- sacroiliitis on x-ray
5
Q
diff in characteristics of inflammatory back pain and mechanical back pain?
A
- inflammatory: prolonged AM stiffness and max pain is early AM, exercise improves sxs, chronic duriation, 9-40 age at onset, on xray: sacroiliitis, vertebral ankylosis, syndesmophytes
- mechanical: minor am stiffness (less than 45 min), late in day max pain, exercise worsen sxs, duration can be acute or chronic, age at onset: 20-65 yrs, X-ray: osteophytes, malalignment
6
Q
What willl you see on radiograph of ankylosing spondylitis?
A
- single most impt imaging technique for dx and f/u
changes: - early changes are at sacral iliac jts: erosion and sclerosis
- involvement of apophysial jts of spine
- ossification of the annulus fibrosus
- calcification of the anterior and lateral spinal ligaments
- squaring and generalized demineralization of the vertebral bodies
- radiographic changes of the spine and are referred to as the bamboo spine
7
Q
Characteristics of AS?
A
- typical pt is males aged 20-40
- sxs appear gradually and are usually not specifc to AS, time to correct dx is 8.5-14 yrs
- first sxs are typically chronic pain and stiffness in the middle spine assoc w/ referred to one or the other buttock or in the back of the thigh
- assoc w/ morning stiffness that improves w/ exercise
8
Q
What is the modified New York criteria for dx for AS?
A
- limited lumbar motion
- low back pain for longer than 3 months - improved w/ exercise, not relieved w/ rest
- reduced chest expansion
- bilateral grade 2-4 sacroiliitis on xray
- unilateral grade 3-4 sacroiliitis on xray
* definite AS if: criteria 4 or 5 plus 1, 2 or 3
9
Q
What is Enthesitis?
A
inflammation of the entheses, sites where tendons or ligaments insert into the bone
10
Q
What are extra-articular manifestations that may occur in AS?
A
- skin rashes (presents like psoriasis - onchylosis, nail pitting)
- eye inflammation: esp uveitis
- lung involvement
- cardiac involvement: w/ aortic valve disease
11
Q
How common is anterior uveitis in AS?
A
- 30-40% of people w/ AS will experience iritis at least once
12
Q
Early presentation of AS?
A
- sxs: LBP, stiffness, fatigue
- extra auricular manifestations: ocular skin/nail enthesitis
- disease progression: sacroiliitis
- morbidity/mortality: pain, fxnl limitation
13
Q
Moderate AS presentation?
A
- sxs: spinal limitation, fxnl limits, night pain
- extra-articular manifestations: chronic uveitis, IBD
- disease progression: hip involvement, spondylitis
- morbidity/mortality: AS complications, drug toxicity, comorbidities
14
Q
Severe AS presentation?
A
- sxs: spinal immobility
- extra-articular manifestations: aortitis, retristrictive lung, heart block
- disease progression: bamboo spine
- morbidity/mortality: fracture, death
15
Q
What is Reactive arthritis? Triad? Diff types? Complications?
A
- acute inflammatory arthritis occurring 1-3 wks after infectious event (GU, GI, idiopathic)
- triad: arthritis+urethritis (cervicitis)+ conjunctivitis (classic triad found in less than 1/3 of pts)
- post-veneral onset (Reiters): MC and more common in males 5:1
- post-dysenteric: less common, equal in M and F
- course: usually self limiting (less than 6 mos), can become chronic w/o tx
- complications: acute anterior uveitis 5%, myocarditis, fasciitis
- decreasing incidence in HIV era (condom use)
16
Q
Presentation of Reiter’s syndrome?
A
msk signs and sxs: - arthritis - enthesitis- heel tendonitis - dactylitis extra-articular signs and sxs: - GU: dysuria and pelvic pain - conjunctivitis - oral ulcers, tongue lesions - palate erosion - rashes- pustules, keratoderma blenorrhagica - nail changes - dystophy - genital lesions - plantar periostitis
17
Q
Infectious triggers for reactive arthritis?
A
- enteric infections: shigella salmonella yersina enterocolotica campylobacter - urogenital infections: chlamydia trachomatis, C. pneumoniae ureaplasma urealyticum
18
Q
What is psoriatic arthritis? How common is this? Presentation and course?
A
- chronic inflammatory arthropathy in setting of psoriasis
- etiology and genotype unclear
- 1-5% of US pop has psoriasis: 5-42% of these develop psoriatic arthritis (skin usually preceded jts):
frequency of PsA increases w/ disease severity and duration, est 350-400,000 pts in USA - nail changes: pitting, dystrophy, onycholysis
- course: chronic, destructive arthritis in 30-50%
19
Q
Clinical characteristics of psoriatic arthritis?
A
- inflammatory arthritis in DIPs, PIPs (pencil and cup deformity)
- asymmetric arthritis
- sausage digits
- nail pitting (onycholysis)
- no rheumatoid nodules
- RF test negative
- erosive arthritis w/o osteopenia
- sacroiliitis, often asx
- paravertebral ossification
- enthesopathy
- rash
20
Q
Tx for all the spondyloarthropathies?
A
- tx sxs w/ NSAIDs initially
- PT, stretching and exercises to preserve spine and jt fxn
- maintain good posture
- sulfasalazine, methotrexate found to be beneficial
- anti-TNF aka TNF inhibitors (Remicade, Humira, Enbrel)
- prevent eye complications by early recognition and tx
21
Q
Use of NSAIDs in tx spondyloarthropathies?
A
- effective for: inflammatory back pain, spinal stiffness, peripheral arthritis, enthesopathy
- no evidence that they inhibit disease progression
- FDA approved NSAIDs for AS: indomethacin, indomethacin-SR, EC ASA, naproxen, sulindac, diclofenac
- anecdotal reports and few studies suggest that specific NSAIDs may be more effective:
phenylbutazone: limited availability: risk of agranulocytosis
indomethacin: esp in long acting form
diclofenac: as effective as Indocin
