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List the Spondyloarthropathies AS; Reactive Arthritis; Psoriatic Arthritis; Enteropathic Arthritis; Undifferentiated Spondyloarthropathy
Spondylos characterized by: enthesopathies; SI joint involvement
Spondylo assoc with: FH; infxs agents; HLA B-27; peripheral arthritis; young age of onset
Enthesopathies = inflammation at sites of attachment of bone to a tendon or ligament
Sites of enthesitis Achilles, plantar fascia, symph pubis, ischium, iliac crest, gr trochanter, finger & toes, anterolateral ribs, spine
Spondylo dx criteria inflam spinal pain or synovitis (asym, LE); and 1 or more: FH; Psoriasis; IBD; Urethritis, cervicitis or acute diarrhea 1 mo before arthritis; Alt buttock pain; Enthesopathies; Sacroiliitis
Spondylo LBP: Inflammatory insidious onset; worse w/ inactivity; improves w/ exercise; >3 mo; A.M. stiffness; often radiates to buttocks, thighs
Spondylo LBP: Non-Inflammatory (mechanical) acute onset; worse w/ activity; improves w/ rest; last 2-4 wks; no A.M. stiffness; rarely radiates
Spondylo labs inc acute phase reactants (ESR, CRP); hi plts; N/N anemia; hi serum IgA; (rare: hi AlkPhos); hi CPK; mild hi CSF protein & complement
Spondylo: eye involvement: (strongly assoc w/ HLA-B27); uveitis, conjunctivitis, sicca sx
Spondylo: Cardiac: (rare) AI, conduction delays
Spondylo: Renal: (1-3%) IgA nephropathy, amyloidosis
Spondylo: Neurologic: C-spine fractures or dislocations; rare: cauda equina syndromes (assoc w/ w/acute onset of neuro deficits)
Spondylo: GI: occult or overt colitis
Spondylo: Skin: manifestations only in psoriatic arthritis and reactive arthritis
Spondylo prevalence 2:1000; usu adolescence or early adulthood;
Spondylo first or presenting sx = inflammatory back pain usually first or presenting symptom
Spondylo clin findings Enthesopathies: tenderness; Periph involvemt (esp root joints: hips & shoulders); usu LE jts, usu asymmetric; nearly 100% have bilateral sacroilitis +/- spondylitis; dec chest expansion
Spondylo: Indicators of poor prognosis: severe hip dz, early age of onset, persistent elevation of ESR
Reactive arthritis = Acute inflame arthritis, follows GI or GU infection (1-4 wks); asym oligoarthritis of the LE; common in young adults; M=F
Reactive arthritis occurs where: at site remote from original infection
Reiter’s classic triad = urethritis, arthritis & conjunctivitis
Reactive arthritis clin features enthesopathies; dactylitis; skin & mucous mems; recovery usu spont w/ good prognosis; susceptibility assoc w/ HLA B-27
Reactive arthritis: chronic cases SI joint & axial disease assoc w/ chronicity
Reactive arthritis: skin lesions Keratoderma blennorrhagicum & balanitis circinata
Reactive arthritis Tx Abx if nec; Rest; NSAIDs; Consider intra-art c’steroid; chronic dz: consider DMARDs
Psoriatic arthritis prevalence in psoriasis pts inflam arthritis in 5-20% of psoriasis pts (usu precedes joint dz 2 decades); 40-50 y.o.; poss occult psoriatic findings; weak assoc w/ HLA-B27; 1:1 M:F
Psoriatic arthritis clin findings Dactylitis; Periph arthritis usu oligoarticular / asym; extra-articular sx outside of skin / nails are rare; Strong genetic predisposition
Psoriatic arthritis: SI joint involvement about 20% and asymmetric
Psoriatic arthritis: arthritic symptoms often provoked by: Infection & trauma
Psoriatic arthritis: 5 clinical types DIPs only; symm polyarthritis (sim to RA); Asym oligoarthritis of small joints; Arthritis mutilans w/ sacroiliitis; AS-type w/ sacroiliitis & spondylitis
Most common form of Psoriatic arthritis Symmetric polyarthritis
Psoriatic arthritis: Tx Pts have 2 chronic dz; NSAIDs (or combo NSAIDS & sulfasalazine); Physical therapy; Methotrexate in refractory. Antimalarials exacerbate psoriasis.
Psoriatic arthritis: Tx: Oligoarthritis form: Consider c’steroid injections
Enteropathic arthritis = inflam arthritis assoc w/ known IBD; more w/ Crohn dz than UC
Most common extra-intestinal manifestation of IBD = Arthritis
Prevalence inflammatory arthritis in IBD pts 30-35%
Enteropathic arthritis: 2 clinical types: axial (10-15%) & peripheral (20%)
Enteropathic arthritis comorbids 10-20% sacroiliitis (usu symmetric); 7-10% spondylitis; 50% HLA B-27 in spondylitis pts
Enteropathic arthritis: clin findings usu oligoarticular / asymmetric; usu in LE; Dactylitis & enthesopathies; GI sx & arthritis flares usu temporally related
Enteropathic arthritis: Tx NSAIDs (indomethacin: AS); DMARDs for chronic / refractory; Abx if nec; Ct guided intra-art injections; PT & lifestyle mod
Ankylosing spondylitis epi M>F. 15-30 yo
Ankylosing spondylitis clinical features gradual, LBP, AM stiffness; cannot put head down when supine; sxs advance cephalad; movement restricted.
Ankylosing spondylitis extraskeletal manifestations: uveitis, aortitis, colitis, arachnoiditis, amyloidosis, sarcoidosis, Ht dz, pulmo fibrosis
Ankylosing spondylitis on imaging = bamboo spine
Ankylosing spondylitis mgmt preserve motion. NSAIDS -> TNF inhibitoors (eg infliximab). Osteotomy if severe
Reactive arthritis: causative organisms STIs usually C trachomatis (need to determine if Ureaplasma). GI bugs Salmo, Shigella, Yersinia, Campy
Seronegative spondyloarthropathy = Ankylosing Spondylitis
Male w/ LBP, stiffness; pain worse on waking, improves during day; decreased ROM at spine; plain films: sacroiliac abnormality; HLA-B27 pos Ankylosing spondylitis; tx NSAIDs (indomethacin)
Conjunctivitis, iritis, arthritis, cervicitis, urethritis Reiter syndrome
HLA-B27 Ankylosing spondylitis, Reiter syndrome
Seronegative spondyloarthropathy: HLA-B27 usually positive
Ankylosing Spondylitis: Sx: Chronic LBP young adults; morning stiffness, improves with movement; 20% peripheral joint sx (Enthesopathies common; 25% with anterior uveitis)
Ankylosing Spondylitis: PE: Schobers test (normal is 5 - 7 cm movement)
Ankylosing Spondylitis: Rx: PT, NSAIDs, Sulfasalazine, Infliximab
Testing Spinal Mobility: Schobers Test
Schobers Test: 2 midline marks 10 cm apart starting at PSIS (dimple of Venus); remeasure w/ lumbar spine at maximal flexion
Schobers Test: Less than 5 cm difference suggests: pathology
Ankylosing Spondylitis = Calcification btw vertebral bodies at edge of discs; gives appearance of bamboo stalk; sclerosis of SI joint
Created by: Adam Barnard Adam Barnard