What are the characteristics of inflammatory back pain? (age of occurrence, duration, response to activity/rest)
-usually occurs before age 40
-insidious onset, lasts > 3m
-better with activity, worse with rest
Inflammatory back pain: at what point during the day is the pain worst? what is another unusual pain pattern with this type of back pain?
-pain at night, esp second half of the night
-alternating buttock pain
Mechanical/degenerative back pain: acute or chronic presentation? age of onset? response to activity/rest?
-more abrupt in onset than inflammatory back pain
-worst with activity, better with rest
-usually occurs at older age than inflammatory back pain
list the 5 types of (seronegative) spondyloarthropathies?
Aside from inflammatory back pain, what are other features of spondyloarthropathy? other body parts than can be involved?
-large joint arthritis of the lower extremeties
-hx of psoraisis
Spondyloarthropathy: ESR? CRP?
Elevations in both ESR and CRP may be present but are non-specific.
Spondyloarthropathy: what plain film imaging should I obtain? what will be seen on imaging (early v laste stage)?
Order plain films of sacroiliac joints, lumbar and thoracic spine.
Early on: may be normal
Later: erosions or sclerosis of the SI joints, enthesitis at the vertebral bodies or syndesmophytes
Spondyloarthropathy: if xrays are negative but I still suspect spondylo, what imaging should I order? What might I see?
MRI: may show early inflammation and bone marrow edema
HLAB27 testing: is it helpful? in what clinical context can it help support a dx?
-Debatable: positive in 8% of caucasians
-If clinical picture suggests spondylo but imaging does not support, HLAB27 can help tip the balance towards dx.
HLAB27: positive in what % of patients with spondyloarthropathy?
positive in 90%
HLAB27: in what scenario do I definitely NOT need to do this test?
If a patient has sacroiliitis on imaging (don't need further confirmation in that case)
Inflammatory back pain: responds to NSAIDs?
Yes. (70-80% of patients)
mechanical back pain: responds to NSAIDs?
Only 15% of patients
what are the only med treatments for ankylosing spondyloarthropathy?
- Physical Tx
- Hip replacement
Note: MTX and DMARDs DO NOT WORK in SpA
what is seen on this image?
ankylosing spondylitis: specifically, ossification of the annular ligaments that are on the lateral sides of the spinal cord
(in other words, syndesmophytes bridging the intervertebral disc spaces)
what is seen on this image? what do we call it?
ankylosing spondylitis: "Bamboo spine"
syndesmophytes bridging the interverterbral disc spaces
What is this?
This is an image Jen found on the internet that claims to be of ankylosing spondylitis. Pretty sure it is. Kinda helpful.
this s awesome/really helpful!!
Describe? What disease process?
ankylosing spondylitis again.
Widening of the SI joint. initially in this dz, the joint space will widen due to sclerosis/erosion. Eventually the joint space will narrow and fuse.
Shows what? part of what disease?
Ankylosing spondylitis: advanced sacroiliitis
Complege ankylosis/fusion of the SI joints
patient with 2 week hx of joint pain. High fever, pain and swelling in the 2nd and 3rd MCP and PIP joints of her left hand and the 2nd, 3rd and 4th MCP joints of her right hand which lasted for 3 days. Pain and swelling in her hands abated; Pain then went to wrist, then knee.
She has mild sore throat, some bumps on her arms. what label would you give this patient's symptoms? Chronic/acute? poly or mono? migratory or intermittent?
Acute migratory polyarthritis
patients with disseminated gonococcal infection can present with what triad of symptoms?
- MIGRATORY polyathralgia
(they may also present without this triad but rather with prurulent arthritis and NO skin lesions)
think of this: neisseria gonorrhoeae is MADE TO DELIVER cause it's an STD - it will deliver!! haha
what infections can present with a clinical picture of acute migratory polyarthritis and systemic symptoms of fever, sore throat, skin lestions? (three main ones, all with points of distinction)
-disseminated gonococcal infection (triad: tenosynovitis, dermatitis, polyarthralgia)
-meningococcal infection (will be severely ill, may be septic)
-Hep B (fever, polyarthritis, tenosynovitis, rash)
-similar: Acute HIV, secondary syphilis, parvovirus, acute rheumatic fever, bacterial endocarditis
If patient has acute migratory arthritis, but NO fever, what is on your differential? What tests or symptoms could confirm each possibility?
-Rheumatoid Arthritis (esp palindromic rheumatoid arthritis. Most will be ACPA +)
-Reactive Arthritis (may also have conjunctivitis or keratoderma blennorhagicum)
-Lupus can initially present as inflammatory arthritis (will also have malar rash, photosensitivity, oral ulcers, Raynauds)
These lesions are accompanied by acute migratory polyarthritis. They are consistent with what diagnosis?
Disseminated neisseria gonorrhea
Due to bacterial embolization to the skin -> microabscess formation
May only have 40-100 on whole body; not hundreds as with secondary syphilis
From conference answers: "Patients intially develop pinpoint macules that go on to become papules, pustules, vesicles or bullae which may become hemorrhagic or necrotic."
This rash shows what?
Erythema Chronica Migrans: Lyme disease
Conference answers document calls it a Bullous rash.
This rash is characteristic of what?
secondary syphilis: generalized pustular lesions on palms and soles
With secondary syph, you'd have HUNDREDS of these pustules
How would I confirm the diagnosis of disseminated gonoccal infection?
culture synovial fluid, skin, urethra/cervix, rectum. Hard to catch the actual organism but hopefully will find it at one of the mucosal sites.
also draw blood cultures
when screening for possible disseminated gonococcal infection (DGI), what other STDs should I screen for?
-HIV, syphilis - these frequently coexist with DGI
-also chlamydia: epidemiologically, 46% of pts with gonorrhea have chlamydia also
How should I go about treating disseminated gonorrhea?
Ceftriaxone is first line. (IV, IM every 24h: then can decrease to oral/daily)
Duration of antibiotics depends on the clinical situation (next slide)
Try to find and treat the sexual partners!
There are 2 presentation patterns of disseminated gonococcal infection: what are they? How is each one treated?
Jen has been ignoring this distinction and hoping it's not important. But it keeps coming up, damn it. So here it is:
-Some patients present with tenosynovitis, dermatitis, polyarthralgia (the triad). treat with ceftriaxone for 7d.
-Others present with prurulent arthritis and no skin involvement. may require ceftriaxone for 14d, plus drainage of joints.