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What are the features that are characteristic of spondyloarthropathies?

It involves sacroiliac joints (uncommon in rheumatoid arthritis)
Peripheral arthritis that is usually asymmetric and oligoarticular
Absence of rheumatoid factor
Associated with HLA-B27 in more than 90% of the cases
It’s an enthesopathic (bone attachment) disorders


What are the four diseases associated with an increased frequency of HLA-B27 and the frequency in each disease?

Ankylosing spondylitis (HLA-B27 90%)
Reactive arthritis (HLA-B27 80%)
Enteropathic spondylitis (HLA-B27 75%)
Psoriatic spondylitis (HLA-B27 50%)


What are the joints affected in ankylosing spondylitis?

Affects the sacroiliac joints, the spring and the peripheral joints


What are the Sx of ankylosing spondylitis?

It is a chronic systemic inflammatory disease. Low back pain and decreased spinal motion and reduced chest expansion. Insidious onset, duration of more than 3 months, morning stiffness, improvement with exercise, family history, involvement of other systems.


What is the age of onset of ankylosing spondylitis?

15-40years old


What are the radiographic findings of ankylosing spondylitis?

sacroiliac involvement with erosion, “pseudo widening” of joint space, sclerosis (both side of sacroiliac joint) and fusion. Spine involvement with squaring of superior and inferior margins of vertebral body, syndesmophytes and bamboo spring.


What are the lab findings of ankylosing spondylitis?

Increased erythrocyte sedimentation rate. An anemia of chronic disease and rheumatoid factor is absent


What are the extraspinal involvement seen in ankylosing spondylitis?

Enthesopathic involvement is characteristic of ankylosing spondylitis and the other spondyloarthropathies and consists of plantar fasciitis, Achilles tendinitis and costcochondritis
Hip and shoulder involvement are common (50%)


What are the extraskeletal involvement seen in ankylosing spondylitis?

Fatigue, weight loss, osteoporosis, low grade fever and iritis (not in rheumatoid arthritis)
Late complication can include traumatic spinal fracture leading to cord compression, cauda equine syndrome, fibrotic changes in upper lung fields and aortic insufficiency


What are the Tx of ankylosing spondylitis?

Physical therapy (upright position), exercise (swimming), cessation of smoking, genetic counseling and drug therapy with NSAIDs (indomethacine) and TNF α inhibitor


What are the organisms of Reactive arthritis?

Salmonella, shigella, Yersinia, campylobacter, chlamydia and Ureaplasma


What are the joints involved with Reactive arthritis?

Toes (sausage toes), asymmetric large joints in the lower extremities and distal interphalangeal joints in the hands


What are the extra-articular conditions of Reactive arthritis?

Cardiac conduction disturbances and aortitis can develop, Sacroiliitis can occur.


What are the Tx of Reactive arthritis?

NSAIDs (indomethacin).
Sulfasalazine and methotrexate are used in patients with chronic disease.
Tetracycline or erythromycin ab to decrease the duration and severity of illness caused by chalamydia triggered reactive arthritis


What are the joints involved with psoriatic arthritis?

finger and toes


What are the Sx of psoriatic arthritis?

Pitting of nails. Patients with more severe skin disase are at higher risk. “Sausage” finger or toe is characteristic of psoriatic arthritis. It develops in patients with psoriasis (7% or less)


What are the radiological findings of psoriatic arthritis?

Distal interphalangeal joint with erosions. It can also cause “pencil-in-cup” deformity of the distal interphalangeal and proximal interphalangeal joints.


What are the criteria for the diagnosis of SLE?

Malar rash
Discoid lupus
Oral ulcers
Nonerosive arthritis
Proteinuria ( protein > 0.5g/day) or cellular casts
Seizures or psychosis
Pleuritis or pericarditis
Hemolytic anemia, leukopenia, lumphopenia or thrombocytopenia
Antibody to native DNA, antibody Smith, IgG or M antiphospholipid ab, positive test for lupus anticoagulant or false-positive result of VDRL test
Positive results of fluorescent antinuclear ab test.


What are the most frequently affected gender, race, and age at onset of SLE?

Gender: Female during reproductive year
Race: American blacks, Native Americans and Asians.
Age at onset of SLE: second and fourth decades of life


What are the human histocompatibility complexes seen with increased frequency seen in SLE?



What are the clinical manifestations of SLE?



What are the articular manifestations of SLE?

It’s inflammatory but nondeforming and nonerosive. Avascular necrosis of one occurs and not only in patients taking steroids. The femoral head, navicular one and tibial plateau are most commonly affected.


What are the cardiopulmonary manifestations of SLE?

Pericarditis, myocarditis, valvular involvement, accelerated coronary atherosclerosis and coronary vasculitis. There is an association between SLE and coronary artery disease. Risk factor for hypertension and hyperlipidemia.
Pleurisy, pleural effusion, pneumonitis, pulmonary hypertension, hemorrhage and diaphragmatic dysfunction.


What are the neuropsychiatric manifestations of SLE?

Impaired cognitive function, seizures, long tract signs, cranial neuropathies, psychosis and migraine like attack happens in CNS lupus. Immune complexes in the choroid plexus happen in both CNS and non-CNS lupus. Increased CSF protein IgG, pleocytosis and antineuronal antibodies.


What are the findings on lumbar puncture and MRI of neuropsychiatric SLE?

Lumbar puncture: Normal results of CSF
MRI: Shows areas of increased signal in the periventricular white matter, similar to those found in MS. It is usually nonspecific and sometimes can be seen in patients who have SLE w/o CNS manifestation


Pregnant women with SLE have higher chance of what?

Spontaneous abortion


What are the lab findings and clinical manifestations in infants of SLE mothers?

Lab findings: Anti-SS-A (Ro) + but there is no HLA association in the child.
Clinical manifestations in infants: Thromboyctopenia and leukopenia can develop. They also can have transient cutaneous lesions and complete heart block.


What are the lab findings of SLE including anemias, ITP, ESR, and hypocomplementemia?

Anemia of chronic disease and hemolytic anemia (coombs positive) can occur. Anti-lymphocyte ab causes lymphopenia in SLE. Idiopathic thrombocytopenic purpura (ITP) with the presence of platelet Ab is initial manifestation of SLE.
Polyclonal gammopathy due to hyperactivity of the humoral immune system is common
The erythrocyte sedimentation rate (ESR) usually correlates with disease activity.
Hypocomplementemia (CH50, C3,C4) usually correlates with active disease and hypocomplementemia with increased anti-native DNA abs usually implies renal disease or skin disease.
A positive result of an antinuclear antibody test (ANA) is by no means specific for lupus.


Why can patients with SLE may have false positive results of VDRL testing?

It will have false positive results of the VDRL test as a result of ab to phospholipid, which cross-reacts with VDRL


What are the two drugs that are strongly implicated in drug-induced lupus?