Spondyloarthropathies (SpA) Flashcards
Name the five types of SpA
- Ankylosing spondylitis (AS)
- Reactive Arthritis (ReA) (aka Reiter’s Syndrome)
- Psoriatic Arthritis (PsA)
- Enteropathic arthritis (EA)
- Undifferentiated (USpA) – doesn’t fit into diagnostic categories, but shares clinical features
What is this term?
– Inflammatory changes of the ligament, tendinous insertion into bone, or joint capsule
– Immune susceptibility to Allele B27 (human Leukocyte Antigen)
Enthesitis
Term for:
Inflammation of vertebrae
spondylitis
Term for: Anterior displacement of a vertebral body relative to the adjacent vertebral body below
Spondylolisthesis
Term for: Defect of the portion of bone between the inferior and superior articular process of vertebrae (pars interarticularis)
Spondylolysis
What two SpA have symmetrical SI involvement?
Asymmetrical?
Symmetrical - AS, EA
Asymmetrical - PA, ReA
- Course, non-marginal syndesmophyte. Iritis, conjuctivitis, and keratoderma.
- Course, non-marginal syndesmophyte. Psoriasis. No eye involvement.
ReA
PA
What two SpA have smooth, marginal syndesmophyte?
AS and EA
HLA association of all SpA
B27
Similarities of SpA
affecting axial skeleton spine, peripheral joints, periarticular structures associated with HLA B27 gene associated with extra-articular manifestations
hallmark of spondyloarthropathy in children…
planta fasciitis and achilles tendonitis
Tests/imaging in DDx of SpA
- HLA B27
- CRP, sed rate
- X-rays - SI joints AND lumber vertebrae
- CT of lumbar/pelvis if x-rays non diagnostic CBC
MRI sees inflammation before CT or XR sees any.
Pathogenesis of AS
- Immune mediated
- Inflamed SI joint – CD4, CD8, T cells infiltrated TNF alpha high level (high level of cytokines)
- Enteric bacteria
Five clinical manifestations of __
• Male, 20s
• Low back pain > 3 months
• Morning stiffness, improved with exercise, worse with rest
• Fatigue, weight loss and fever
• Symmetrical SI joint pain (sacroiliitis); loss of mobility/ flexibility; arthritis of hips
• Tendonitis, Planter fasciitis (achilles – heel pain)/Enthesitis
Ankylosing Spondylitis
Extra-articular manifestations of AS
- Eye – anterior uveitis (Iritis) 30% (not found in RA)
- Photophobia, eye pain, blurred vision
- Aortic insufficiency, aortic aneurysm (1-4%)
- Pulmonary fibrosis – restrictive
- IBD (10 – 20%)
- Psoriasis
Describe physical exam of AS
- schober test
- FABERE test
• Restricted forward flexion (Schober Test) and restricted chest expansion – FABERE test
• Loss of spinal mobility; Schober test measures flexion
of lumbar spine.
• Decreased chest expansion
Labs in AS
- Increase ESR, CRP
- HLA B27 positive (80 – 90% of patients)
- Anemia of chronic disease
- Negative RF, ACCP, ANA
Imaging in AS
• A-P radiographs of pelvis; bilateral SI changes
• Erosions of SI joints, pseudo widening, sclerosis, fuses, ankyloses, symmetric
• Vertebrae
– squaring (loss of anterior convexity)
– Shiny corners (vertebral edge sclerosis)
- bamboo spine/syndesmophytes
What are syndesmophytes?
Bridging of vertebrae (boney bridges cause ankylosis) - no more pain!
Test sensitive for erosions
CT
Test sensitive for inflammation - before changes seen on CT or XR
MRI
Late complications of AS
Restrictive lung disease, compression fractures, Cauda equina syndrome
Key points to remember when a person presents with hx of inflammatory back pain of AS
- Age of onset below __ y/o
- ___ onset
- Duration greater than ___ months before medical attention
- __ stiffness, reduction in spinal mobility (esp. lumbar flexion)
- Improvement with __
- Positive ___
- Age of onset below 40 y/o
- Insidious onset
- Duration greater than three months before medical attention
- AM stiffness, reduction in spinal mobility (esp. lumbar flexion)
- Improvement with exercise or activity
- Positive family history
Treatment of AS
• Exercise, physical therapy, swimming, stretching,
(preserve mobility/prevent kyphosis)
• NSAID – might reduce progression of spine damage –
pain control
• TNF – alpha inhibitors – decrease inflammation of axial
spine, improves mobility (infliximab, Remicade, adalimumab)
• Non-biologics – DO NOT USE. Metrotrex/sulfasal – okay for peripheral arthritis; not for axial disease. Limited usefulness
Associate GI/GU infections with…
What bugs?
ReA
• GI – Salmonella, Shigella, Yersinia, Campylobacter jejuni
• GU – Chlamydia trachomatis
Define ReA
Autoimmune disease; asymmetric mono-arthritis or oligo-arthritis (large joints) in lower extremities; urethritis; conjuctivitis
Three clinical manifestations of ReA in young men - arthritis, enthesitis, dactylitis - locations
- Arthritis – asymmetrical, oligo-arthritis, lower extremities (ankles, knees)
- Enthesitis – achilles tendon/ planter fasciitis
- Dactylitis – sausage digit; finger or toe
Describe SI pain, eye, and skin, manifestaitons in ReA
- SI pain – **asymmetrical
- Eyes – conjunctivitis/uveitis
- Skin - **Circunate balanitis (vesicles, ulcers on glans penis)
What is this (in ReA): painless eruption on palms/soles
Keratoderma blennorrhagicum
What is Reiter’s Syndrome
(no longer used);
urethritis, arthritis, conjunctivitis, mucocutaneous lesions (oral ulcers)
Labs seen in ReA upon joint aspiration
inflammatory synovial fluid
What is this:
• Peak age 40 – 60-year-old, equal sex ratio
• PsA presents in 5 – 20% of patients with psoriasis (20 – 50% HLA B27); associated with SI and axial involvement
Pitting nails and “pencil in cup”
Psoriatic Arthritis (PsA)
What is this?
• May be asymmetric or symmetrical
• DIP, PIP, MCP, MTP / also large joints involved
• Pitting nails
• Dactylitis and Enthesitis
• May have C1 – C2 (atlantoaxial instability)
• 5 – 10% have positive RF or anti CCP antibodies
• PsA flare up may be due to co-infection with HIV
• Soft tissue swelling (STS), erosions, periostitis, destruction of interphalangeal joints
Peripheral arthritis (caused by subset of enteropathic arthritis caused by IBD)
treatment of Peripheral Arthritis (IBD arthritis)
• NSAID – pain control
• Non biologics – used for peripheral arthritis
• Methotrex, sulfasal, hydroxychloro
• Biologics - TNF inhibitors prevent progression of joint
damage/psoriasis
• Combine methotrex with TNF inhibitor, infliximab, etanercept
What two GI diseases are associated with Enteropathic Arthritis?
IBD, Crohn’s and UC
Describe Enteropathic Arthritis- peripheral involvement
– Large joints lower extremity
– Small joints upper extremity
**Extra-articular manifestations of EA caused by CD
- Skin: Pyoderma Gangrenosum, Erythema Nodosum
- Eyes – Uveitis
- GI – CD/UC
- GU – Nephrolithiasis
- CV – Thrombolism
- Bones – fx, low bone density, vitamin D deficiency
Tx of EA
NSAID, steroids (short relief), MTX, TNF alpha
Tx of summary for SpA
- Exercise – maintain mobility, flexibility (swimming, stretching)
- NSAID – helpful
- Glucocorticoids
- Methotrexate - Peripheral arthritis: Not for axial disease or AS
- Sulfasalazine – PsA
- DMARD’s – PsA
- Antibiotics – Chlamydia urethritis
What symptom does AS have that RA does not?
anterior uveitis (Iritis)
