Term
|
Definition
| – Not associated with rheumatoid factor or other autoantibodies |
|
|
Term
|
Definition
– Spine and sacroiliac joints
– Variable peripheral involvement
– Variable extraarticular manifestations |
|
|
Term
| Prototypical spondyloarthropathy |
|
Definition
|
|
Term
| Ankylosing spondylitis Epidemiology |
|
Definition
– Prevalence: 0.1-6%
– M:F 3:1
– Average age of onset mid 20s
• Rare onset after age 40 |
|
|
Term
| Ankylosing spondylitis Clinical Presentation |
|
Definition
• Inflammatory back pain
– Insidious, persistent (>3 months)
– Nocturnal pain; worse with rest, better with
exercise
– Morning stiffness
• Sacroiliitis
– Buttock pain
– Lower anterior synovial portion of joint
• Enthesitis
– Plantar fascia, Achilles tendon
– Pelvis, tibial tubercles, sternal/chondrocostal
junctions
• Synovitis
– LE joints (hips), occasionally shoulders
– Often oligoarticular, asymmetric
• Systemic symptoms: fatigue
• Labs: ESR, CRP |
|
|
Term
| Ankylosing spondylitis Physical Exam and imaging |
|
Definition
-Decreased ROM
-Tenderness
pos Patrick's/FABER test- flex, abduct and externally rotate, pain = pos
-Schober test, reduced lfexion, on forward flexion doesn't inc to >15 cm
-bridging syndesmophyte on cervical spine Xray
-shiny corners are also a characteristic ankylosing spondylitis radiograph finding, also vertebrae appear squared and have lost concavity |
|
|
Term
| Modified NY criteria for ankylosing spondylitis |
|
Definition
1. low back pain for at least 3 months duration improsed by exercise and not relieved by rest
-limitation of lumbar spine motion in sagittal and frontal planes
-chest expansion dec relative to normal valuef for age and sex
-unilateral sacroilitis grade 3-4
-bilateral sacroillitis grad2 2-4
-sacroillitis and any of the 1st 3 criterion |
|
|
Term
| ankylosing spondylitis Extraarticular manifestations |
|
Definition
• Anterioruveitis – 1/3 of patients
– Unilateral, alternating
– Does not mirror AS flares
• Inflammatorybowel disease
– 10-15% have overt disease
– 60% have subclinical bowel inflammation
– Does not mirror AS flares
• Cardiac: Aortic dilatation/regurgitation (1%)
• Pulmonary
– Upper lobe fibrosis (1%) – Mild restrictive physiology
• Neurologic
– Spinal fracture:
• Nerve root or cord
• Minor trauma |
|
|
Term
|
Definition
HLA B27
• Allele of MHC 1
• More than 30 subtypes
• Present in >90% of patients with AS (Caucasian males), 50-75% of other spondyloarthropathies
• Theories:
– B27 causes improper handling of microbes -> inflammation
– B27 is an autoantigen (on its own or after aberrant processing)
– B27 binds peptides that trigger activation of autoreactive CD8 T cells
• Remember:
– Only a few B27 subtypes associated with AS – <5% of B27+ patients develop AS |
|
|
Term
|
Definition
| NSAIDS, PT, TNFi alone (also helps w IBD) |
|
|
Term
|
Definition
• Up to 1/3 of patients with psoriasis develop an inflammatory arthritis
• Prevalence: 0.1-1%
• M:F 1:1
• Classified as a spondyloarthropathy because:
– Seronegative
– Spinal/sacroiliac involvement
– Similar extrarticular features
– Association with HLA-B27 |
|
|
Term
| Psoriatic arthritis clinical findings |
|
Definition
-crumbling nails/oncholysis-pitting of nails/hyperkeratosis
-sausage fingers/dactylitis
-Xray: pencil and cup bony deformity- cupping of proximal portion of phalanges w central erosion, juxtaarticular new bone formation, wash out of the bone mext to the joints (also seen in other inflammatory arthritis), osteolysis of the bone- arthritis mutilans |
|
|
Term
| Radiographic features in Psoriatic arthritis |
|
Definition
• Involvement of DIP joints
• Erosion of the terminal tufts (acroosteolysis)
• Cupping of the proximal portion of the phalanges (pencil in cup deformity)
• Osteolysis of bones (arthritis mutilans)
• Ultrasound features of enthesitis and dactylitis |
|
|
Term
| Classification criteria- CASPAR Psoriatic arthritis |
|
Definition
1. Evidence of Psoriasis
• Current – 2 points
• Pasthx/FamilyHx–1point
2. Psoriatic nail dystrophy- 1 point
3. Negative rheumatoid factor- 1 point
4. Dactylitis- 1 point
5. Radiographic evidence of juxta articular new bone
formation- 1 point
• Need 3 or more points to have 99% specificity and 92% sensitivity for diagnosis of psoriatic arthritis |
|
|
Term
| Treatment Psoriatic arthritis |
|
Definition
• Physical therapy
– Postural education – Breathing exercises
• NSAIDs
• Glucocorticoids
• Sulfasalazine, Methotrexate
• Anti-TNF agents
• Surgery: hip replacement
• Similar to ankylosing spondylitis
• Methotrexate, sulfasalazine more effective (peripheral arthritis)
– liver toxicity
• Other biologics: TNF inhibitors , Ustekinumab, Secukinumab |
|
|
Term
|
Definition
• Sterile arthritis developing after a non- articular infection
• Formerly known as Reiter’s syndrome (1916): non-gonococcal urethritis, conjunctivitis (uveitis), arthritis
• ~50% post Chlamydia, Salmonella,
Shigella, Yersinia, Campylobacter
• Characteristically an asymmetric lower extremity oligoarthritis
• Enthesitis common (Achilles tendonitis, plantar fasciitis)
• Sacroiliitis in 50%, but rare progression to ankylosing spondylitis
-Conjunctivitis
-Tendinitis-heels
-Plantar Periostitis, Foot |
|
|
Term
| Reactive Arthritis: Extraarticular Manifestations |
|
Definition
• Keratoderma blenorrhagicum
• Circinate balanitis
• Urethritis
• Oral ulcers
• Acute anterior uveitis |
|
|
Term
| Reactive Arthritis: Cardiac Manifestations |
|
Definition
• Heart block
• Aortic Regurgitation
• Aortitis
• Pericarditis |
|
|
Term
| Musculoskeletal manifestations Reactive Arthritis |
|
Definition
• Arthritis
• Enthesitis
• Dactylitis
• Spondylitis |
|
|
Term
| Enteropathic Spondyloarthritis |
|
Definition
• Inflammatory bowel disease: Ulcerative colitis and Crohn’s disease
• Develop arthritis in 10-20%
– Peripheral:
• Pauciarticular, asymmetric, favors lower extremities
• Nonerosive
• Often correlated with bowel disease – Colectomy in UC->arthritis remission
– Axial: like AS
• Activity does NOT parallel bowel disease |
|
|
Term
| Peripheral arthritis associated with IBD types |
|
Definition
• Type1:
– acute in onset, asymmetrical, pauciarticular (<5)
– Associated with flares of IBD, erythema nodosum, uveitis
– Knee, ankle most common
• Type2:
– Symmetric, polyarticular
– Arthritis is independent of IBD activity – MCP > knees and ankles |
|
|
Term
| Enteropathic spondyloarthritis |
|
Definition
• Extraarticular manifestations:
– Skin: erythema nodsum, pyoderma gangrenosum
– Uveitis, oral ulcers
• Treatment:
– Minimize NSAID use
– SSZ: common treatment for IBD
– TNF blockers: • Infliximab, adalimumab treat bowel disease also • Etanercept: doesn’t work for bowel |
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