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Spondyloarthropathy
Rheumatology
| Question | Answer |
|---|---|
| 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:
Abarnard
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