The Spondyloarthropathies (SpA)

Question 1

Seronegative Spondyloarthropathies

• Clinical manifestations of SpA
• Predilection for spine, SI joints
• New bone formation at sites of inflammation
• Joint ankyloses; fusion, rigidity/Kyphosis

-you loss lordosis, legs are bent, prominent thoracic kyphosis

• Asymmetric peripheral arthritis
• Enthesitis- inflammation of insertion points of tendons and ligaments onto bones - Immune susceptibility to Allele B27 (human Leukocyte Antigen)
• Ocular inflammation

Answer 1

GLOSSARY of TERMS

• Axial Skeleton – Bones of cranium and vertebral column
• Dactylitis - Swelling of a finger or toe – reactive arthritis/psoratic arthritis
• Enthesis - Site of ligamentous attachment to bone
• Enthesitis – Inflammatory changes of the ligament, tendinous insertion into bone, or joint capsule
• Monoarticular – One joint • Oligoarticular – Few joints
• Osteitis – Inflammation of a bone
• Periarticular – Around a joint
• Spondylitis – Inflammation of vertebrae
• Spondylolisthesis – Anterior displacement of a vertebral body relative to the adjacent vertebral body below
• Spondylolysis – Defect of the portion of bone between the inferior and superior articular process of vertebrae (pars interarticularis)

Question 2

RA

female

HLA associated: DR4

Joint pattern: symmetrical, peripheral

the other spondyloarthropathies are majority males, HLA-B27, involve axial and symmetrical except reactive arthritis, which is symmetrical

Question 3

What are the Spondyloarthropathies?

Rheumatic disorders that share clinical features, affecting axial skeleton spine, peripheral joints, periarticular structures associated with HLA B27 gene associated with extra-articular manifestations

1. GI/GU inflammation – “sometimes” associated with bacterial infection
2. Anterior ocular inflammation
3. Psoriasi form skin/nail lesions
4. Lesions of aortic root, cardiac conduction system
5. Absence of rheumatoid factor and ACCP/ ”seronegative spondyloarthropathies”
6. Peripheral asymmetric oligo arthritis
7. Plantar fasciitis, achilles tendonitis, costochondritis; more likely SpA than RA. Enthesitis (inflammation at sites where tendons, ligaments and joint capsule insert into bone)

It is the hallmark of spondyloarthropathy in children

Answer 3

what labs do you want?

• HLA B27
• CRP, sed rate
• X-rays of pelvis – attention SI joints
• X-rays of lumbar vertebrae
• CT of lumbar/pelvis if x-rays non diagnostic CBC

Question 4

Ankylosing Spondylitis (AS)

• Associated with HLA B27
• B27 can’t diagnose, confirm or exclude; can provide a probability of SpA
• Most common inflammatory disorder of axial skeleton; SI joints involved
• Present in 80 – 90% of patients with AS
• 20% of B27 positive patients with affected family member
• 3:1 (male to female); 5:1
• Peak age of onset is 2nd – 3rd decade

Clinical Manifestations

• 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

Answer 4

Extra-articular

• Eye – anterior uveitis (Iritis) 30%
• Photophobia, eye pain, blurred vision
• Aortic insufficiency, aortic aneurysm (1-4%)
• Pulmonary fibrosis – restrictive
• IBD (10 – 20%)
• Psoriasis

Iritis is not found in RA. Can find iritis in SLE, herpes simplex.

Physical Exam

Restricted forward flexion (Schober Test) and restricted chest expansion

Loss of spinal mobility; Schober test measures flexion of lumbar spine. Measure 5 cm below and 10 cm above LS junction. Bend forward and measure distance between marks. If less than 4 cm that is a decreased mobility.

Decreased chest expansion if less than 5 cm​

Question 5

Ankylosing Spondylitis (AS)

Lab

• Increase ESR, CRP
• HLA B27 positive (80 – 95% of patients)
• Anemia of chronic disease
• Negative RF, ACCP, ANA

Imaging

• 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; sclerosis at edge of vertebral bodies

Syndesmophytes-Bridging of vertebrae (boney bridges cause ankylosis) (bamboo spine)

Tests

• CT More sensitive for erosions
• MRI detects inflammation before changes seen on x-rays or CT

Answer 5

Differential Diagnosis

DISH – diffuses idiopathic skeletal hyperosteosis

• Calcification along lateral aspect of four (4) contiguous vertebrae bodies. SI joints okay

Osteitis condensans ilii – Young, middle aged females

• Normal SI joints - X-ray shows sclerosis on iliac side of SI joint

Cauda Equina Syndrome
Late complications restrictive lung disease, compression fractures

Syndrome includes: bladder, bowel, pelvis, low back pain

Question 6

History of inflammatory back pain of AS

1. Age of onset below 40 y/o
2. Insidious onset
3. Duration greater than three (3) months before medical attention
4. AM stiffness, reduction in spinal mobility (esp. lumbar flexion)
5. Improvement with exercise or activity
6. Positive family history

Answer 6

treatment

• Exercise, physical therapy, swimming, stretching, (preserve mobility/prevent kyphosis)
• NSAID – May slow progression of spine damage – pain control
• TNF – alpha inhibitors – decrease inflammation of axial spine, improves mobility (infliximab, Remicade, adalimumab) - helps 50%
• Non-biologics – DMARD - Metrotrex/sulfasal – okay but limited in peripheral arthritis; not for axial disease.

Question 7

Reactive Arthritis (ReA)

Autoimmune disease; asymmetric mono-arthritis or oligoarthritis (large joints) in lower extremities

• May be associated with infection (extra-articular) from GI/GU track
• GI – Salmonella, Shigella, Yersinia, Campylobacter jejuni
• GU – Chlamydia trachomatis
• HLA B27 is present in 75% of ReA and IBD associated arthritis

Answer 7

Clinical Manifestations – Young Men

• Arthritis – asymmetrical, oligoarthritis, lower extremities (ankles, knees)
• Enthesitis – achilles tendon/ planter fasciitis
• Dactylitis – sausage digit; finger or toe
• SI pain – asymmetrical
• Reiter’s Syndrome (no longer used); urethritis, arthritis, conjunctivitis, mucocutaneous lesions (oral ulcers)
• Skin - Circunate balanitis (vesicles, ulcers on glans penis)
• Keratoderma blennorrhagicum – painless eruption on palms/soles
• Eyes – conjunctivitis/uveitis

Circinate Balanitis on glans penis in a man with reactive arthritis.

Question 8

Lab – Reactive Arthritis

same as AS

(increased ESR, CRP, HLA 27, anemia of chronic disease

negative for RF, ACCP, ANA)

inflammatory synovial fluid (WBC 2,000-50,00)

Imaging would show SI joint being asymmetrical

ReA Treatment

• Usually self-limiting in six (6) months
• NSAID, steroids (intra-articular)
• If chronic progression use DMARD (Sulfasalazine, Metrotrex, Leflunomide)
• Urethritis: chlamydia: azithromycin or doxycycline

differential

• GC arthritis – upper/lower extremities
• Sepsis
• ReA plus HIV
• Endocarditis
• Viral infections – parvo virus

Answer 8

Psoriatic Arthritis (PsA)

Peak age 30 – 50-year-old, equal sex ratio

clinical manifestation

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

Progression of DIP Arthritis

A. Narrowed joint space and condylar erosions

B. Reactive subperiosteal new bone

C. Pencil in cup appearance

Question 9

Psoriatic Arthritis (PsA) Treatment

• NSAID – pain control
• DMARD - 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

Answer 9

Enteropathic Arthritis (EA)/IBD Associated with Arthritis

1:1 ratio male to female

• Arthritis associated with Crohn’s Disease (CD) or ulcerative colitis (UC)
• Axial involvement – like AS/asymmetric SI involvement
• Peripheral arthritis - Parallels activity of IBD - Large joints lower extremity - Small joints upper extremity
• All extra-articular manifestations occur more commonly in CD
• 50 - 75% HLAB27 positive

Extra Articular Manifestations

• Skin • Pyoderma Gangrenosum • Erythema Nodosum • Eyes – Uveitis
• GI – CD/UC
• GU – Nephrolithiasis
• CV – Thrombolism
• Bones – fx, low bone density, vitamin D deficiency

Treatment

NSAID

Steroid-short relief

MTX/Sulfasal

TNF-alpha-effective for IBD arthritis

Question 10

Treatment Summary for SpA

• Exercise – maintain mobility, flexibility (swimming, stretching)
• NSAID – helpful
• Glucocorticoids
• Methotrexate - Peripheral arthritis: Not for axial disease or AS
• Sulfasalazine – PsA
• DMARDs – PsA
• Antibiotics – Chlamydia urethritis