Week 2 Spondyloarthropathies

Question 1

Define and give the clinical picture of ankylosing spondylitis.

Answer 1

• chronic inflammatory systemic disease with involvement of the SI joints, axial skeleton, and peripheral joints
• low back pain and stiffness >3 months, unrelieved by rest
• limited motion of lumbar spine, esp. flexion
• reduced chest expansion w/ reduced vital capacity
• bilateral sacroilitiis on xray
• 40% develop peripheral arthritis, mainly of hips, shoulders, and knees

Question 2

Describe the pathogenesis of spondyloarthritis.

Answer 2

1. T cell presents HLA-B27 self antigen, escapes from deletion and propagates
2. misfolded B27 triggers antigen response and propagates Th17 cells–>inflammatory response
3. APCs and T cells effect response in end organs
4. fluctuating inflammation causes bone destruction with repair–>decreased inflammation & replacement w/repair tissue–>osteoproliferation (syndesmophytes)

Question 3

Classify the spondyloarthropathies based on predominant manifestation: axial vs peripheral

Answer 3

axial: Ankylosing spondylitis
peripheral: juvenile AS, IBD assoc. arthritis, psoriatic arthritis, HLA B27 uveitis

Question 4

Discuss the epidemiology of spondyloarthropathies.

Answer 4

• For AS: 5-7 year delay in diagnosis from first symptoms to age at first diagnosis
• 1-1.5% in US prevalence of AS, 8% HLA-B27 prevalence

Question 5

What are extra-articular manifestations of spondyloarthritis?

Answer 5

1. Concept related: Eye-skin-gut-GU
   - frequent, any moment of disease evolution
   - proven effect of TNF blocker
2. not concept related: lung-kidney-heart-nerve
   - very rare
   - aortic regurg, atypical lung pneumonitis, amyloidosis deposition in kidneys, cauda equina syndrome
   - no effect of classical SpA drugs
3. Skin manifestations
   - psoriasis, erythema nodosa, pyoderma gangrenosum, keratoderma blenorrhagicum (RA assoc.), pustulosis palmaris

Question 6

What are common radiographic features of SpA?

Answer 6

1. pencil in cup deformity
2. sacroiliitis
3. shiny corners–>syndesmophytes–>bridging spondylophytes
4. Facet joint ankylosing
5. bamboo spine
6. vertebral fractures
7. costovertebral joints
8. enthesitis-inflammation of tendon insertion into bone, e.g. Achilles tendon
9. non radiographic stage

Question 7

How is spondyloarthropathy diagnosed?

Answer 7

Three factors

1. history of inflammatory back pain
   - less than 40 yo, insidious onset, improvement with exercise, no improvement with rest, pain at night
2. Enthesitis
3. HLA B27

Question 8

What is the treatment for spondyloarthropathy?

Answer 8

• physiotherapy
• DMARDS not very effective for AS
• NSAIDs, local steroid injections, Sulfasalazine
• TNF a therapy

Question 9

What are the characteristics of psoriatic arthritis?

Answer 9

• nail pitting
• psoriatic plaques
• affects DIP joints
• pencil and cup changes
• doesn’t cause osteopenia in joints like RA
• sausage toes or fingers

Question 10

What are the clinical features of reactive arthritis?

Answer 10

A chronic recurring inflammatory disease, consisting of urethritis, infectious diarrhea, conjunctivitis, arthritis, mucucutaneous lesions

1. Arthritis most persistent feature
   - mainly lower extremity joints, asymmetrical
   - self limited but recurring
   - toes are red and diffusely swollen=sausage toes/digits or dactylics
   - SI and spinal arthritis occasionally occurs
   - periostitis near involved joint may be present
2. Mucutaneous lesions
   - circinate balanitis-lesions on penis
   - ulcers-painless of palate and buccal mucosa
   - keratodermia blennorrhagica-dry hyperkeratotic rash on soles of feat