Psoriatic and Reactive Arthritis Flashcards by Tommy Klopcic

What is a type of seronegative spondyloarthopathy that presents as a combination of EROSIVE and PRODUCTIVE asymmetric oligoarthritis mainly in the DIPs and PIPs?

PsA (Psoriatic Arthritis)

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On avg, what percentage of patients with psoriasis will develop PsA?

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T/F After 1960, PsA was thought to be a type of RA

True, before 1960 it was considered a type of RA

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T/F Pts in their 60s are the most susceptible to PsA

False, 30-50

Note: Female = Male in incidence

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How long after the development of psoriasis can it take for a pt to develop PsA?

10-20 years

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1 out of __ people with PsA will have arthritis as a condition which will lead to psoriasis

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5 distinct subtypes of PsA. What are they?

mnemonic maybe?: Ao, Pd, SSA

Asymmetric Ologoarthritis 55-70%
Polyarthritis in DIPs
Symmetric (resembes RA)
Spondyloarthritis (30-50%)
Arthritis mutilans (3-5%)

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What is the etiology of PsA?

Autoimmune

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What lab test marker will be elevated in 60% of patients who have sacroiliitis?

HLA-B-27+

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What are some factors that may trigger the onset of PsA or exacerbations of psoriasis?

Recent infection, likely, GABHS organism (Strep A)
Regional trauma
Smoking/Alcohol

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Clinically, what would you see in a patient with PsA?

Psoriasis

Note: Guttate and Pustular psoriasis may manifest with more severe arthritis

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80% of cases of PsA will have what physical condition?

Psoriatic nail disease

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What is an important factor of PsA in the distal LE?

Enthesitis at the achilles and plantar fascia insertion

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PsA with sacroiliitis and spondyloarthropathy shows greater association with what ocular manifestations?

Uveitis and Keratoconjunctivitis

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T/F PsA may present with more severe pain and in more joints than RA?

FALSE, PsA may present with less severe pain and in fewer joints

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What is a key Dx finding that may lead you to the dx of PsA?

Morning stiffness and joint tenderness in asymmetrical distribution - esp. DIP and PIP
Note: MCP and wrist not commonly involved

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Soft tissue swelling especially in the ____ tendons may be seen

flexor

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What can be observed involving the entire digit, also known as a ‘sausage digit’ in PsA.

Dactilytis

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Pathology of PsA is seen as reactive ____ causing ___ and productive osseous changes…

Enthesitis, erosions

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T/F: Proliferative processes of PsA may lead to periostitis, osseous sclerosis and thickening of tissues especially of the digits…

True

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T/F: Much like RA bone erosions, these begin marginally but are followed by enthesitis with reactive periostitis, whiskering and fuzzy bone formation seen as “mouse ears” in the distal tufts…

True

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What three presentations can periostitis take in PsA?

Thin periosteal layer of new bone
Thick irregular layer
Irregular thickening of cortex itself

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Erosions may proress leading to more aggressive artilage and subchondral bone destruction leading to ______ with “________” deformity

arthritis mutilance, “pencil in cup”

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T/F: overall mineral bone density is affected like it is in RA

False; overall mineral bone density is NOT affected like it is in RA, aka bone density is maintained in PsA

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Severe cases of PsA, one can see a telescope formation of an "_-___"

"opera-glass"

Spinal involvement with PsA is seen as what?

Bilateral sacroiliitis - asymmetric involvement

What is the presentation in the thoraco-lumbar area of PsA?

Bulky paravertebral ossifications, aka. non-marginal syndesmophytes

T/F: PsA and ReA spinal involvement is not distinctly different from AS

False, PsA and ReA spinal involvement IS distinctly different from AS

At what vertebral level in the cervical spine should PsA and ReA be considered as a possible cause of instability and ligamentous laxity?

C1-C2 | Note: not frequent but has been seen

What are the hallmark changes seen in PsA?

Fluffy periostitis combined with severe erosive bone changes - can see an "ivory phalanx" - also pencil in cup deformity is common in the interphalangeal joints

T/F: in PsA sometimes erosions of the entire phalanx can be seen in addition to other patterns of erosive and productive bone changes

True

Ankylosing spondylitis will present with marginal syndesmophytes in the spine, what does PsA present with?

Non-marginal syndesmophytes, aka. paravertebral ossifications

PsA is a type of arthritis that can lead to complete destruction of joints and adjacent bone which is known as?

Arthritis Mutilants

Concertina (like an accordion) this describes the telescoping of the digits in what type of arthritis when the patient has arthritis mutilans?

PsA arthritis (concertina deformity is also opera glass deformity)

Treatment for PsA is what 5 things?

NSAID, DMARD Corticosteroid injections Physiotherapy MANIPULATION - HIGHLY CONTRAINDICATED!

ReA (Reactive arthritis) is formerly known as what?

Reiter syndrome

ReA can be defined as a triad of what?

Non-infections urethritis Conjunctivitis Arthritis (affecting heels and knees commonly) Note: this is present in less that 35% of cases...

How does ReA develop?

autoimmune response to an infections agent | salmonella, shigella, campylobacter, GU infection - chlamydia

ReA develops _____ weeks following infectious illness

1-3 weeks

There is a possible 4th component of development, what is this?

Mucosal and cutaneous features

ReA is 3:1 ___ : ___ and generally develops in 3-5 cases per 100,000 people

M:F | Males in their 20-30's

What immune histocompatibility complex is present in over 80% of people with ReA?

HLA-B27

What is the classic saying for ReA?

"Can't see, can't pee, can't climb a tree"

Is ReA asymmetrical or symmetrical?

Asymmetrical as distal oligoarthritis

_____ may present with burning, erythema, photophobia and ocular pain with reduced vision?

Conjuctivitis

_______ can be significant as keratoderma blennorhagicum and onychodystrophy, painful pustular eruptions on dorsum of extremities.

Skin involvement Hands - Palms (dorsum) Feet - Soles (not dorsum but yuri thinks so)

Psoriaiform lesions can be seen along with circinate blanatis... What is this?

Inflammation about the glans of penis

Are there any bacterial species identified in the synovial fluid of ReA patients?

What two markers will be elevated in labs that may help with Dx?

T2 helper cells increased | HLA-B27 increased

____ at the tendons and ligaments insertion sometimes identical to ____ can be seen at the plantar fascia and achilles... (25-50%)

Enthetitis, PsA

What are the most common target sites of ReA

``` Small foot joints Calcaneous Knees Ankles Note: Hands affected rarely ```

What are a few of the GENERAL radiographic features seen in ReA?

- Linear fluffy periostitis/enthesitis - Soft tissue thickening at the insertions of tendons and ligaments - Pre-achilles or retrocalcaneal bursitis

T/F: Overall bone density is not maintained

False, overall bones density is maintained

What type of osteoporosis can be observed?

Hyperemia-related Juxta-articular osteoporosis

T/F: Spinal changes in ReA are seen in 40-60% early onset and 5-10% chronic cases

False, 5-10% Early, 40-60% Chronic

Is There sacroiliitis noted and if so, is it bilateral or asymmetrical?

Sacroiliitis is noted | There is bilateral sacroiliitis, but it is ASYMMETRICAL

In the T/L spine, what type of syndesmophytes are seen?

Non-marginal aka paravertebral ossifications

What imaging modality can be used for early diagnosis and what does it show?

MRI - T2 specifically & STIR | shows: tenosynovitis, enthesitis, soft tissue inflammation

Are there oral lesions in ReA?

Yes

What is the typical treatment for ReA?

Systemic steroid and NSAID

Can one distinguish the difference between ReA and PsA on a radiograph of the T/L region?

No, the non-marginal osteophytes will look the same | Note: to distinguish you must look at specific deformities, joints involved, and initial cause

What are the target sites of ReA?

- LE - MTP's and 1st Ips - Calcaneous - Ankles - Knees

What is the prognosis for ReA?

Variable Mostly it is thought to be self-limiting in 3-12 months Note: cases with high HLA-B-27 tend to recurr in 15-50%, Therapy = inflammation control

What disease is defined as immune mediated triad or oral aphthous ulcers, genial ulcers and uveitis?

Behcet Disease

Why the hell is Behcet disease at all important to arthridities?

Most common articular involvement is usually with non-erosive inflammation induced synovitis presented as arthralgias (knee, ankle, foot) in 40-70% of cases Sacroiliitis in BD may appear similar to other seronegative spondyloarthropathies

Psoriatic and Reactive Arthritis Flashcards

(65 cards)