Inflammatory Joint Pathologies Flashcards by Hannah Brule

How commonly is juvenile idiopathic arthritis seropositive?

Fewer than 10% of juvenile arthritis cases

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juvenile idiopathic arthritis

Is seropositive arthritis more common in males or females?

Females in 80% of cases

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juvenile idiopathic arthritis

___% of those with seropositive arthritis will develop severe disease

> 50%

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Seronegative polyarticular arthritis without systemic symptoms makes up ___% of juvenile arthritis cases.

25%

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juvenile idiopathic arthritis

Are the majority of those with seronegative polyarticular arthritis without systemic symptoms male or female?

90% female

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juvenile idiopathic arthritis

Seronegative polyarticular arthritis with systemic symptoms makes up ___% of polyarticular juvenile cases

20%

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juvenile idiopathic arthritis

Are the majority of those with seronegative polyarticular arthritis with systemic symptoms male or female?

60% male

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juvenile idiopathic arthritis

Which of the following conditions is more likely to lead to severe arthritis?

Seronegative polyarticular arthritis without systemic symptoms
Seronegative polyarticular arthritis with systemic symptoms

Those with systemic symptoms (25% vs <15% for those without)

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juvenile idiopathic arthritis

Name 8 systemic symptoms that may arise with seronegative polyarticular arthritis

Fever
Rash
Hepatosplenomegaly (common in mono)
Lymphadenopathy (armpits/groin pain with enlarged nodes)
Pleuritis
Pericarditis
Anemia (chronic disease, fatigue)
Leukocytosis

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juvenile idiopathic arthritis

How many joints are involved in seronegative pauciarticular arthritis?

Only a few large joints: knee, ankle, elbow, hip

(less than five)

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juvenile idiopathic arthritis

Seronegative pauciarticular arthritis more frequently affects which sex?

Females (80%)

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juvenile idiopathic arthritis

What sorts of arthritic and ocular damage occur for female seronegative pauciarticular arthritis cases?

1/3 of patients have ocular inflammation of the iris and ciliary body
Most have no long-term arthritic or ocular damage, usually self-limiting

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juvenile idiopathic arthritis

What sorts of arthritic and ocular damage occur for male seronegative pauciarticular arthritis cases?

Few have ocular inflammation of the iris and ciliary body
Most have no long-term arthritic or ocular damage, but some develop ankylosing spondylitis

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Inflammatory joint pathologies are characterized by an ___ response

osteolytic

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Inflammatory joint pathologies have potential for ___ joint fusion

fibrous or osseous

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Are inflammatory joint pathologies bilateral or unilateral?

Bilateral and symmetrical

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What are four inflammatory spondyloarthropathies?

Ankylosing spondylitis
Enteropathic arthritis
Psoriatic arthritis
Reactive arthritis

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seronegative spondyloarthropathies

What are the commonalities and differences between ankylosing spondylitis and enteropathic arthritis?

Identical in spine, bilateral and symmetrical
Difference is in presence of enteropathic disease

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seronegative spondyloarthropathies

What are the commonalities and differences between psoriatic arthritis and reactive arthritis?

Identical in spine, can be bilateral asymmetric or unilateral
ie. 1 SI more severe, or only 1 SI involved
Reactive arthritis however is due to bacterial infection and is not an autoimmune disease

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What makes seronegative spondyloarthropathies seronegative?

Negative for RF

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Seronegative spondyloarthropathies are associated with ___ protein on the surfaces of WBCs

human leukocyte antigen - 1B27 (HLA-B27)

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Does HLA-B27 gene cause seronegative spondyloarthropathies?

No, makes individuals more susceptible:
8% of population has gene; 2% develop spondyloarthropathies

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A patient is 20-40 years old and has back pain and stiffness with elevated CRP and ESR. Radiographs demonstrate marginal syndesmophytes in the spine and enthosophytic ossification outside the spine/SI joints.
What is the differential diagnosis?

Seronegative spondyloarthropathy: ankylosing spondylitis or enteropathic arthritis

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A patient is 20-40 years old and has back pain and stiffness with elevated CRP and ESR. Radiographs demonstrate non-marginal syndesmophytes (parasyndesmophytes) in the spine and enthosophytic ossification outside the spine/SI joints.
What is the differential diagnosis?

Seronegative spondyloarthropathy: psoriatic or reactive arthritis

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Which portions of the spine are primarily involved in seronegative spondyloarthropathies?

Sacroiliac and thoracolumbar involvement

#seronegative spondyloarthropathies Where do syndesmophytes occur? Where do enthesophytes occur?

Syndesmophytes are in the spine where the disc inserts into end plates Enthesophytes ossify outside the spine/SI joints where ligaments attach to bone

Psoriatic arthritis favors the ___ extremity Reactive arthritis favors the ___ extremity

upper lower

Rhizomelic arthropathy occurs at the root of the limb (shoulders, hips) Which types of seronegative spondyloarthropathy may display this peripheral joint involvement?

Ankylosing spondylitis or enteropathic arthritis

Ankylosing spondylitis and enteropathic arthritis may have peripheral joint involvement at the ___ limb Psoriatic and reactive arthritis may have involvement at the ___ limb

Ankylosing spondylitis and enteropathic arthritis are at **root** of the limb Psoriatic and reactive arthritis are at **distal** limb

#seronegative spondyloarthropathies Syndesmophytes create inflammation around discs and facets What is the result of this?

Ankylosis | rheumatoid arthritis does not like to result in this

What are some treatments for seronegative spondyloarthropathies?

* Low impact, regular activity * Anti-inflammatory diet * Drug therapy: NSAIDs early on, maybe DMARDs

What is the age of onset for ankylosing spondylitis?

15-30 years old

Ankylosing spondylitis is relatively common in the US. What is the first symptom?

Low back pain

What sort of rhizomelic joint involvement may be present with ankylosing spondylitis?

1/3 of patients have hip and shoulder involvement, decreasing range of motion

90% of patients with ankylosing spondylitis are ___ positive.

HLA-B27

Which sex is more commonly affected by ankylosing spondylitis?

Males (10:1)

How does pain initially present in a patient with ankylosing spondylitis?

May be transient, lasting only one or two days, may be only stiffness * Pain and stiffness over SI joints (focal, bilateral) * Severe pain relieved by movement * Maximal pain in morning (evening and night if after inactivity)

Patient presents with a kyphotic posture and reports pain and stiffness over both their SI joints. They report their pain is most severe in the morning and relieved by movement. If they were inactive throughout the day, they have pain in the night as well. Upon examination, their joints are rigid with loss of mobility. What is the likely diagnosis?

Ankylosing spondylitis | given no enteropathic disease

Why does ankylosing spondylitis lead to kyphotic posture?

Progressive shortening of inflamed ligaments

5% of patients with ankylosing spondylitis develop ___

AA amyloidosis and uremia

With ankylosing spondylitis, ___ involvement is rare, but possible

severe cardiac

Late ankylosing spondylitis can affect ___ ligaments and may decrease chest expansion

costotransverse ligaments

Late ankylosing spondylitis can affect costotransverse ligaments. How does this present?

Decreased chest expansion: decrease in normal breathing without a history of smoking

Which portion of the SI joints are initially involved in enteropathic arthritis?

Lower 2/3 of SI on iliac side

A patient's radiograph demonstrates that the lower 2/3 of their SI joints on the iliac sides have erosions at the margins with a rosary bead appearance. Sclerosis of the SI margins is also visible bilaterally. What is the diagnosis?

Enteropathic arthritis

A patient's radiograph demonstrates marginal lesions in the cervical spine, syndesmophytes, with a bamboo appearance. The spine can be described as "dagger sign", "trolley track sign", or "rail road sign". What is the likely diagnosis?

Ankylosing spondylitis (osseous ankylosis present) ## Footnote enteropathic arthritis appears similarly

Ankylosing spondylitis can involve decreased proprioception and sensation. What might this increase the risk of?

Pathological fracture (painless)

Where on the vertebrae do these bony growths occur? Osteophytes: Marginal syndesmophytes: Non-marginal syndesmophytes:

**Osteophytes**: corner of endplate **Marginal syndesmophytes**: corner of endplate connecting to corner of adjacent endplate **Non-marginal syndesmophytes**: Past the corner of endplate (not in mid portion) connecting to past the corner of endplate of adjacent vertebrae

# arthritis & ankylosis Ulcerative colitis and Crohn's disease are associated with ___ in 20% of cases, and with ___ in 10% of cases

**seronegative arthritis** in 20% of cases **spondylitis** in 10% of cases

What usually precedes an outbreak of enteropathic arthritis?

Diarrhea Gut symptoms usually are increased before and during arthritis attacks

What are some associated causes of enteropathic arthritis?

* Ulcerative colitis * IBS * Crohn's disease * Gastrointestinal infection (less common)

Which pathology has axial and extremity involvement identical to ankylosing spondylitis?

Enteropathic arthritis

What are the clinical manifestations of enteropathic arthritis?

* Axial and extremity involvement (same as ankylosing spondylitis) * Migratory and transient peripheral arthritis * Flare ups usually subside in six weeks

What are some treatments for enteropathic arthritis?

* Antibiotics (maybe) * Bowel resection in ulcerative colitis * Symptomatic management

How does enteropathic arthritis present radiographically?

Same as ankylosing spondylitis (SI and spine involvement)

7-10% of patients with ___ develop psoriatic arthritis

psoriasis (skin disease)

#psoriatic arthritis Where is psoriasis usually located?

Extensor surfaces around elbows, knees, and on the scalp

At what age does a patient with psoriatic arthritis typically develop joint symptomatology?

30-50 years old

Are psoriatic arthritis joint symptoms more often severe or mild?

Usually mild and slowly progressive, but occasionally severe and mutilating

20% of patients with psoriatic arthritis have ___ involvement

SI joint

Which joints are primarily affected by psoriatic arthritis?

Peripheral joints: distal interphalangeal joints of hands and feet in an asymmetrical distribution

Psoriatic arthritis is histologically similar to, but usually less severe than ___

rheumatoid arthritis

___ is histologically similar to, but usually less severe than rheumatoid arthritis

Psoriatic arthritis

How is psoriatic arthritis less severe than rheumatoid arthritis?

More frequent remissions and less joint destruction

What genetic factors are involved in the pathogenesis of psoriatic arthritis?

HLA haplotypes: **HLA-B27** and HLA-Cw6

What are two histological features of psoriatic arthritis?

Hyperkeratosis and parakeratosis

#psoriatic arthritis What is hyperkeratosis?

Over proliferation of keratinocytes Normal cell doubling time is 21 days; psoriasis cell doubling time is 3 days

#psoriatic arthritis What is parakeratosis?

Persistence of nuclei in stratum corneum cells

A patient reports that they had some swelling around their joints which has progressed to swelling of the digits resembling sausages. They have hand stiffness and pain in an asymmetrical distribution. Upon further examination, you discover a silvery, scaly rash with well-defined margins and pinpoint hemorrhagic foci in a 4-5cm area. Patient's fingernails also display some pitting. What is the diagnosis?

Psoriatic arthritis

#psoriatic arthritis How does a psoriatic skin rash appear?

4-5cm area of reddish plaques with inflamed borders and well-defined margins Neutrophilic pustules may be present

#psoriatic arthritis What is dactylitis?

Sausage digits (swelling of digits) preceded by spindle digits (swelling around joints)

The stiffness and pain involved in psoriatic arthritis is comparable to ___, but has an asymmetrical distribution

rheumatoid arthritis and ankylosing spondylitis (increased pain with inactivity)

#psoriatic arthritis Rash flares coincide with ___

joint symptoms

___% of patients with psoriatic arthritis will show some nail pitting

80%

Psoriatic arthritis can involve onycholysis What is this?

Painless separation of the nail from the bed

What are three deformities resulting from progressive marginal erosions due to psoriatic arthritis?

* Fluffy periostitis * Mouse ear deformities (created by fluffy periostitis) * Pencil-in-cup deformities (central erosion distally, peripheral erosion proximally; sharp proximal end fits into central erosion of distal bone)

What bone density is found in a radiograph of psoriatic arthritis?

Normal bone density (rheumatoid arthritis has periarticular osteopenia)

What are some radiographic characteristics of psoriatic arthritis?

* Marginal erosions, deformities * Normal bone density * Uniform narrowing of joint space * Asymmetrical sacroiliitis * Osseous ankylosis

A patient's radiographs display non-marginal syndesmophytes (parasyndesmophytes) in the spine and SI joints. Their hand radiographs demonstrate osseous ankylosis with remnants of mouse ear deformities. What is the likely diagnosis?

Psoriatic arthritis

Reactive arthritis occurs almost exclusively in ___

men

What is the age of onset for reactive arthritis?

20s-30s

What is the triad of symptoms for reactive arthritis?

"Can't see, can't pee, can't dance with me" * Conjunctivitis/uveitis * Non-gonococcal urethritis/cervicitis * Polyarthritis (prefers SI and LE)

90% of reactive arthritis cases are associated with which gene?

HLA-B27

What is the most common cause of reactive arthritis?

Chlamydia or gonorrhea

Reactive arthritis follows ___

venereal exposure or bacterial dysentery (shigella)

20% of HLA-B27 positive men contract ___ after dysentery

reactive arthritis

Reactive arthritis typically follows venereal exposure or bacterial dysentery, but can also affect ___ patients

HIV

Which inflammatory joint pathology was first described in 1916 when it was seen in military populations, especially Prussian military officers?

Reactive arthritis

What is generally the earliest symptom of reactive arthritis?

Urethritis (burning and frequency)

What can precede the onset of urethritis presentation due to reactive arthritis?

Perfuse watery diarrhea

How does conjunctivitis present with reactive arthritis?

Mild and bilateral, lasting days to weeks, generally self-limiting

How does asymmetrical polyarthritis present with reactive arthritis?

Involves knees, ankles, and feet; can manifest as Achilles tendonitis and SI joint issues

A patient presents with complaints of Achilles tendonitis and unilateral SI pain. They also have conjunctivitis. When you ask if they have had any GI changes, they report that they had diarrhea a while ago and have had some burning during urination. Which inflammatory joint pathology is the likely diagnosis?

Reactive arthritis

A patient presents with lower extremity complaints and mentions they have a mild conjunctivitis going on. Upon examination of the patient's palms, feet, then trunk, you find mucocutaneous lesions similar to pustular psoriasis. Which inflammatory joint pathology is the likely diagnosis?

Reactive arthritis

How might reactive arthritis affect the skin?

Mucocutaneous lesions (similar to pustular psoriasis): keratoderma blennorrhagica on palms, soles of feet, and trunk

20-50% of reactive arthritis cases develop:

* progressive arthritis * tendonitis * lumbosacral pain

Reactive arthritis is identical to ___ in the spine

psoriatic arthritis * Bilateral asymmetric or unilateral sacroiliitis * Non-marginal syndesmophytes

Why can't reactive arthritis patients dance?

Lower extremity involvement: inflammatory changes to the forefoot joints

What is lover's heel? Which inflammatory joint pathology features this change?

Lover's heel: inflammatory erosion from the retrocalcaneal bursa adjacent to the Achilles tendon insertion, inflammatory enthesitis at the plantar fascia origin Due to reactive arthritis

A patient's radiograph demonstrates inflammatory erosion from the retrocalcaneal bursa adjacent to the Achilles tendon insertion and inflammatory enthesitis at the plantar fascia origin. What is this called and what is the most likely diagnosis?

Lover's heel Likely reactive arthritis

What are other names for juvenile idiopathic arthritis?

* Juvenile rheumatoid arthritis (JRA) * Juvenile chronic arthritis (JCA)

What is juvenile idiopathic arthritis?

Inflammatory arthropathy with an onset prior to 16 years of age

Seropositive juvenile arthritis is also called ___

Still disease

# juvenile idiopathic arthritis What are the two types of seronegative juvenile arthropathies?

* Polyarticular * Pauciarticular

# juvenile idiopathic arthritis What are the relevant lab findings for seropositive arthritis?

- RF positive - ANA positive - HLA-D4 positive

Is Still disease/seropositive juvenile arthritis polyarticular or monoarticular?

Polyarticular

# juvenile idiopathic arthritis Which sex is most affected by Still disease?

Female | seropositive juvenile arthritis

# juvenile idiopathic arthritis >50% of patients with seropositive arthritis will develop ___

severe disease

# juvenile idiopathic arthritis What are the two subcategories of seronegative polyarticular arthritis?

- Without systemic symptoms (arthritis only) - With systemic symptoms

# juvenile idiopathic arthritis What joints are most commonly affected by pauciarticular arthritis?

- Knee - Ankle - Elbow - Hip

# juvenile idiopathic arthritis What are the two subcategories of seronegative pauciarticular arthritis? Which is more common?

Female > Male | (the categories are by sex)

# juvenile idiiopathic arthritis What are the relevant lab findings for female seronegative pauciarticular arthritis?

- RF negative - ANA positive - HLA positive | more common in females

# juvenile idiopathic arthritis What are the relevant lab findings for male seronegative pauciarticular arthritis?

- RF negative - ANA negative - HLA-B27 positive | less common in males

Which type of juvenile idiopathic arthritis is typically self-limiting?

Seronegative pauciarticular arthritis

# juvenile idiopathic arthritis What is a potential long term concern for males with seronegative pauciarticular arthritis?

Ankylosing spondylitis

Which type of juvenile idiopathic arthritis can have ocular inflammation of the iris and ciliary body?

Seronegative pauciarticular arthritis | more common in females