SeroNegative Spondyloarthropathies (Darrow) - SRS

Question 1

What are the six spondyloarthropathies?

Answer 1

1. Ankylosing Spondylitis
2. Psoriatic Arthritis
3. Reactive Arthritis (Reiter’s Syndrome)
4. Arthritis associated with IBD
5. Undifferentiated spondyloarthropathy
6. Acute Anterior Uveitis

Question 2

What is the gender preferance for seroneg. spondyloarthropathies?

Onset age?

Answer 2

Male preponderance

Onset before 40

Question 3

Seronegative Spondyloarthropathies are inflammatory processes of the spine and SI joints. What HLA type are they associated with?

Answer 3

HLA-B27+

Question 4

What is the serum profile of each of the Seronegative Spondyloarthropathies for:

RF

CCP

ANA

Answer 4

RF -, CCP -, ANA -

Question 5

What are 6 non-vertebral symptoms of spondyloarthropathies?

Answer 5

1. Asymmetric Peripheral Arthritis
2. Arthritis of the Toe IP Joints
3. Sausage Digits
4. Enthesopathy
5. Uveitis
6. Mucocutaneous lesions

Question 6

What is a bacteria that many AS patients have in their stools?

Why is this significant?

Answer 6

Klebsiella

This bacteria can express HLA-B27

Question 7

What immunologic pathway and its cytokines are key in the pathophys of PsA, ankylosis spondylitis (AS) and other spondyloarthritides?

Answer 7

TH17

Question 8

Which of the TH17 Interleukins is more potent than the others?

Where will it be found in patients who have spondyloarthritides?

Answer 8

IL-17

Found in…

• circulation
• joints
• skin plaques

Question 9

Is HLA-B27 necessary for development of spondyloarthropathies?

Answer 9

Neither necessary, nor sufficient to cause spondyloarthropathies.

Question 10

What is the HLA - B27 assciation rate with each of the following?

• AS
• Reiter’s
• IBS + Spondylitis
• Psoriatic Arthritis

Answer 10

• AS: 90%
• Reiter’s: 75%
• IBS + Spondylitis: 50%
• Psoriatic Arthritis: 50%

Question 11

So, HLA-B27 isn’t enough to dx. What must there be additionally?

Answer 11

HLA-B27 positive plus 2 features

Question 12

If you have a patient with chronic low back pain and age of onset under 45 y/o, and find sacroiliitis on imaging, how many additional features of spondyloarthropathy must there be for a diagnosis?

Answer 12

Plus one feature

Question 13

25 y/o male presents with a three year history of low back pain. The pain wakes him at night and he arises in order to exercise for relief. He has occasional loose stools. He is tender over the anterior chest wall and iliac crest. He is unable to put his occiput to the wall when standing with his back against the wall. There is a grade 2/6 diastolic murmur at the right intercostal area. Chest expansion is limited with a deep breath. The eyes are red with a ciliary flush. Sed rate is 40 mm/hr. To diagnose this disease, one needs the presence of (a); (an):

A.sacroiliitis.

B.enthesopathy.

C.aortic valve disease.

D.Iritis.

E.restricted neck flexion.

Question 14

Identify each of the clinical complaints/findings indicated on Mr. Ankylosing Spondylitis.

Answer 14

1. ‘Bamboo spine’ – brittle, rigid
2. Sacroiliac inflammation/pain
3. Increased kyphosis
4. Fatigue (systemic symptom)
5. Ocular inflammation, uveitis
6. Reduced rib expansion - reduced inhalation
7. Weight loss (systemic sym.)
8. Possible atlantoaxial subluxation
9. Pulmonary fibrosis
10. Aortic insufficiency

Question 15

What is one testing protocol for AS?

Answer 15

Schober’s test

Question 16

What are the following in AS?

ESR

RF

CBC

Answer 16

ESR – increased in 85%

RF – characteristically negative (as is anti-CCP)

Mild anemia

Question 17

Imaging studies for AS may involve X-ray, CT, or what modality which may be better?

Why is this preferable?

Answer 17

MRI (gadolinium) - whole body.

This may show edema at enthesitis sites

Question 18

What is shown here?

Answer 18

Andersson Lesion simulating Diskitis

(AS)

Question 19

What is indicated in these imaging studies from an AS patient?

Answer 19

Syndesmophytes - “Bamboo spine”

Question 20

What sign is shown here in this radiograph from an AS patient?

Answer 20

“Shiny corner sign” = Reactive sclerosis

Question 21

This patient has no SI Joint involvement, and you find this on x-ray.

What is the finding?

What is the disease?

Answer 21

Diffuse Interosseous Skeletal Hyperostosis (DISH)

Flowing ossification

No involvement of SI joints and syndesmophytes are more anterior and thicker.

Question 22

What is shown in this x-ray of a patient with AS?

Answer 22

Osteitis condensans ilii

Question 23

What are the main complications of AS? 5

Answer 23

1. Uveitis
2. Upper lobe PF
3. Cauda Equina Fibrosis
4. Aortic Regurgitation
5. Heart Block

Question 24

What are the components of the treatment protocols for ankylosing spondylitis?

Answer 24

1. PT/OT
2. Exercise
3. NSAIDS (watch for CHF)
4. Sulfsalazine
5. Anti-TNF agents

Question 25

A 35 y/o male presents with a markedly swollen and painful left middle digit. A migratory asymmetric polyarthritis was present 3-4 months ago. He complains of low back pain and stiffness as well. Exam shows the following skin findings. RF and CCP is negative. Sed rate is 48 mm/hr. Uric acid is elevated. There is a unilateral sacroiliitis. This patient has which type of arthritis? A.Reactive B.Psoriatic C.SLE D.Behcet’s E.Kawasaki’s

Answer 25

B.Psoriatic

Question 26

This patient is complaining of low back and right heel pain. He has: A.ankylosing spondylitis. B.sarcoid. C. Lyme disease. D. nummular eczema. E. psoriasis.

Answer 26

E. psoriasis.

Question 27

Identify the arthritis based on the patterns shown.

Answer 27

1. Left: RA 2. Right: Psoriatic Arthritis

Question 28

What are three buzz phrases for Psoriatic arthritis?

Answer 28

1. Pencil in a cup deformity 2. Opera Glass hand 3. Arthritis mutilans (same thing as opera glass hand)

Question 29

What is this finding? Associated with?

Answer 29

Opera Glass hand - Arthritis mutilans Associated with psoriatic arthritis

Question 30

What is this deformity? Associated with?

Answer 30

1. Pencil in a cup deformity 2. Psoriatic Arthritis

Question 31

What are the 5 patterns of arthritis in psoriatic arthritis?

Answer 31

1. Oligoarthritis 2. SI 3. Asymmetrical polyarthritis 4. DIP 5. Opera glass “arthritis mutilans"

Question 32

What will the following labs look like in psoriatic arthritis? * RF * CCP * Uric Acid * Fe++

Answer 32

* RF - negative * CCP - negative * Uric Acid - increased * Fe++ - decreased

Question 33

What organism is associated with psoriatic arthritis?

Answer 33

HIV

Question 34

How often does psoriasis precede arthritis?

Answer 34

80% of the time

Question 35

PsA is usually assymetric with what appearance of the fingers and toes?

Answer 35

Sausage appearance of fingers and toes

Question 36

What type of sacroilitis is typical of PsA?

Answer 36

Unilateral

Question 37

X-ray findings in PsA include? 5

Answer 37

1. Osteolysis 2. **pencil in a cup** 3. lack of osteoporosis 4. bony ankylosis 5. atypical syndesmophytes

Question 38

What are the components of the management of PsA?

Answer 38

1. Topicals 2. PUVA 3. NSAIDs 4. MTX 5. Anti-TNF 6. IL17/IL23 blockers 7. PDE4 inhibitor 8. Surgery

Question 39

What should not be used in PsA?

Answer 39

Steroids

Question 40

What are the anti-TNF agents like etanercept and adalimumab especially good for as far as psoriasis?

Answer 40

nail and cutaneous lesions

Question 41

A 19 y/o male presents with left heel pain at the achilles insertion. He has pain in the knees, hips, and low back. He has a pustular geographic tongue. There is a rash on the soles of the feet. A month ago he had a slight, clear penile discharge for three days. Which of the following would be unusual in this patient? A. Campylobacter B. Death in 30% C. “Lover’s heels” D. C trachomatis E. Low back pain

Question 42

What is this called?

Answer 42

Circinate balanitis

Question 43

What is this? What does it look like?

Answer 43

Keratoderma blenorrhagicum Looks like pustular psoriasis

Question 44

Reactive arthritis can be caused by what veneral organisms? 3

Answer 44

1. Chlamydia trichomatis 2. Ureaplasma urealyticum (men) 3. Mycoplasma genitalium

Question 45

Reactive arthritis can be caused by what enteric organsims? 6

Answer 45

1. Shigella flexneri 2. Salmonella species 3. Yersinia enterocolitica 4. Yersinia pseudotuberculosis 5. Campylobacter jejuni 6. Clostridium difficile

Question 46

What is a "miscellaneous" organism that can cause reactive arthritis?

Answer 46

Streptococcus

Question 47

What is a virus that is noteably able to cause reactive arthritis?

Answer 47

HIV

Question 48

If a genital chlamydia infection contains ocular forms of the organism, by what process does a chlamydia induced arthritis arise? 4 steps

Answer 48

1. The ocular forms are snatched up by monocytes 2. The monos foolishly take them to joints 3. They make them their home and begin a constitutive TH1 reaction 4. IL-1, TNF-alpha, IFN-gamma, and HSP are produced

Question 49

In addition to the ocular form of chlamydia what other form can cause Reiter's syndrome?

Answer 49

The pneumonic forms of Chlamydia

Question 50

Each arrow indicates a chlamydia pneumonia. Which is associated with what organism?

Answer 50

Left: Chlamydophila psittaci Right: Chlamydophilia pneumonia

Question 51

What do the following serovars of chlamydia trachomatis cause? ## Footnote 1. strains A-C = 2. Strains D-K = 3. Strains L1-L3 =

Answer 51

1. strains A-C = trachoma 2. Strains D-K = NGU 3. Strains L1-L3 = LGV

Question 52

Reactive arthritis (aka Reiter's syndrome) is a seronegative asymmetric arthritis arising most often following one of what three infection types?

Answer 52

1. Urethritis 2. Cervicitis 3. Infectious diarrhea

Question 53

What are some examples of physical findings associated with Reiter's syndrome? 7

Answer 53

**Enthesopathy - “Lover’s heels”.** Inflammatory eye disease. Palmar pustulosis. **Circinate balanitis.** **Keratoderma blenorrhagicum.** Oral ulcers (painless unlike Behcets). Sacroiliitis in 20%.

Question 54

Describe the joint involvement in reactive arthritis.

Answer 54

Large joint oligoarthritis or sacroiliitis

Question 55

Reiter's syndrome classically presents with what triad?

Answer 55

Uveitis/conjunctivitis Urethrtitis Arthritis (can't see, can't pee, can't climb a tree)

Question 56

What cardiac findings may be present in a patient with reactive arthritis?

Answer 56

1. Carditis 2. Aortic reguritation

Question 57

What are the key aspects of managing reactive arthritis syndrome? 5 with 2 bold

Answer 57

1. **Antibiotics** 2. **NSAIDs** 3. Sulfasalazine 4. anti-TNF 5. Ophthalmic meds

Question 58

Specifically what antibiotics does Darrow recommend for Reactive arthritis?

Answer 58

Doxycycline + Rifampin Or Azithromycin + Rifampin

Question 59

IBD with Arthritis is typically of which type?

Answer 59

Crohns mostly

Question 60

IBD arthritis is a Nondeforming asymmetric oligoarthritis that parallels bowel disease. Usually acquired after bowel disease is apparent. What is the sacroiliitis like in this?

Answer 60

Bilateral and symmetrical sacroilliitis (as in AS)

Question 61

What should you tx IBD arthritis with? 4

Answer 61

1. Sulfasalazine 2. Corticosteroids 3. Aza or 6-MP 4. TNF inhitors

Question 62

A 22 y/o hemophiliac male presents with right knee arthralgias and pain for the past 3 weeks. He takes on-demand clotting factor concentrate. He has had an occasional episodes of non-bloody diarrhea over the past few years. He has had multiple episodes of bilateral ankle and elbow synovitis. He had an episode of bilateral heel pain 6 months ago that took 4 months to clear. His mother had psoriasis. An uncle had some eye disease. Joint exam showed bilateral boggy synovitis of the elbows and ankles. An effusion was present in the right knee from which joint fluid was taken. Joint fluid showed no crystals, no organisms and 300 WBCs and no RBCs. Serum Hb was 10.6 gm Hb with MCV of 68. WBC was 11,500 x 109/L. What is the most probable cause of his elbow and ankle arthritis? A.RA B.Psoriatic arthritis C.IBD arthritis D.Hemarthrosis E.Adult onset Stills disease

Answer 62

Hemarthrosis

Question 63

Hemarthrosis is a recurrent hemorrhage typically seen in what joints?

Answer 63

Elbows Knees Ankles

Question 64

What is typically hypertrophied in hemarthrosis? What is seen to be deposited in this condition in the joint?

Answer 64

* Synovial hypertrophy. * Hemosiderin deposition

Question 65

Hemarthrosis comes with fibrosis and ankylosis. Describe each of these things as seen in hemarthrosis. * Synovitis * Cartilage

Answer 65

* Persistent “boggy” synovitis. * Cartilage erosion.

Question 66

What is the best way to dx hemarthrosis early? What can be seen on x-ray?

Answer 66

* MRI better than Xray for early damage. * Xray can show hemosiderin.

Question 67

What should be the tx for hemarthrosis?

Answer 67

Prophylactic clotting factors (QOD) rather than on-demand.

Question 68

A 22 y/o hemophiliac male presents with right knee arthralgias and pain for the past 3 weeks. He takes on-demand clotting factor concentrate. He has had an occasional episodes of non-bloody diarrhea over the past few years. He has had multiple episodes of bilateral ankle and elbow synovitis. He had an episode of bilateral heel pain 6 months ago that took 4 months to clear. His mother had psoriasis. An uncle had some eye disease. Joint exam showed bilateral boggy synovitis of the elbows and ankles. An effusion was present in the right knee from which joint fluid was taken. Joint fluid showed no crystals, no organisms and 300 WBCs and no RBCs. Serum Hb was 10.6 gm Hb with MCV of 68. WBC was 11,500 x 109/L. What is the most probable cause of his elbow and ankle arthritis? Most likely diagnosis for the acute knee finding would be: A.undifferentiated spondyloarthropathy. B.enteropathic (IBD) arthritis. C.juvenile idiopathic arthritis. D.pseudogout. E.reactive arthritis.

Answer 68

A.undifferentiated spondyloarthropathy.

Question 69

A 35 y/o male IV drug abuser is admitted with pain and swelling in the right sternoclavicular area. He is febrile and states the pain started 3 days ago. He has pain using his right arm. Examination of the sternoclavicular area shows severe tenderness and the area is fluctuant. The left wrist is painful to motion. Aspiration of the fluctuant area shows a WBC of 30,000 with 90% neutrophils. Gram stain is shown. Most likely organism?

Answer 69

Strep - based on gram stain and strips.

Question 70

A 35 y/o male IV drug abuser is admitted with pain and swelling in the right sternoclavicular area. He is febrile and states the pain started 3 days ago. He has pain using his right arm. Examination of the sternoclavicular area shows severe tenderness and the area is fluctuant. The left wrist is painful to motion. Aspiration of the fluctuant area shows a WBC of 30,000 with 90% neutrophils. Gram stain is shown. You end up being right, and the organisms showed the group B lancefield antigen. Meaning this is what specific type of strep?

Answer 70

Agalactiae

Question 71

Monoarthritis is what until proven otherwise?

Answer 71

Septic

Question 72

The more joints involved, the less likely it is septic arthritis, with what three specific exceptions?

Answer 72

1. RA - (not sure what he is getting at here. maybe he will clarify in lecture) 2. Group B strep 3. Endocarditis

Question 73

Persons using what type of therapy are 2x more susceptible to septic arthritis?

Answer 73

Those using anti-TNF therapy

Question 74

What are the essentials of dx for septic arthritis?

Answer 74

1. Sudden onset of acute arthritis 2. monoarticular 3. large, weight bearing joints 4. previous joint damage or IV drugs 5. Infection with causative organisms elsewhere in the body

Question 75

Characterize the size of joint effusions seen in septic arthritis. What is the WBC?

Answer 75

Large Over 50,000

Question 76

Blood cultures will be positive in over 50% of septic arthritis cases. If your patient with septic arthritis is on anti-TNF drugs or has HIV, what should you check for?

Answer 76

AFB

Question 77

What percent of septic arthritis is caused by Gram +? Gram -?

Answer 77

+ = 90% - = 10%

Question 78

What are the main gram + organisms responsible for septic arthritis?

Answer 78

1. Staph aureus - 50% 2. MRSA 3. Group B Strep (multi joint as is RA and endocarditis) 4. Pneumococcal (associated pulmonary or CNS)

Question 79

What are the main gram - organisms that cause septic arthritis?

Answer 79

E coli Pseudomonas DGI – septic or sterile immune complex mediated Salmonella

Question 80

What organisms tend to infect prosthetic joints?

Answer 80

Staph and pseudomonas

Question 81

What are the elements of tx for septic arthritis?

Answer 81

* 3rd generation cephalosporin: ceftriaxone 1 gm daily, cefotaxime 1 gm q 8 hrs. * Vancomycin 1 g q 12 hrs. * Treat for 4-6 weeks. * Drainage

Question 82

This patient presented with fever and the following changes. She also has migratory polyarthgralgias, meningitis and pancarditis. She also most likely has: A.Behcets syndrome. B.RA. C.inflammatory DJD. D.perihepatitis. E.sarcoid.

Question 83

A disseminated gonococcal infection (DGI) presenting with Arthritis/Dermatitis syndrome may have what 5 presentation forms?

Answer 83

(1) Oligoarthritis form (usually preceeded by migratory polyarthritis). (2) Tenosynovitis form. (3) Rash –pustules especially palms and sole. (4) Fever. (5) May also get osteomyelitis,

Question 84

What are some risk factors for gonococcal arthritis?

Answer 84

Menstruation Pregnancy C5-9 deficiencies

Question 85

What test must you do if a patient gets gonococcal arthritis?

Answer 85

Complement assay, d/t the C5-9 deficiencies

Question 86

Where should you obtain cultures from to dx gonococcal arthritis?

Answer 86

Urethra Throat Cervic\x Rectum

Question 87

What are the three elements of spinal septic arthritis (discitis)? Where does it typically hit?

Answer 87

Chronic unrelenting back pain Fever Local tenderness (thoracolumbar region)

Question 88

If spinal septic arthritis is caused by TB what is it called? Where does it usually strike?

Answer 88

Pott's Disease T10-L2 region

Question 89

What are two findings you might see with spinal septic arthritis?

Answer 89

Gibbus deformity Paraspinal cold abcess

Question 90

A 20 year old nursery nurse has recently been camping in Maine. She had also eaten cheese imported from Mexico. She presents with fever and migratory arthritis in the left ankle, right and left wrist and left and right MCP joints. She had an effervescent rash over the arms and legs one week ago. A sister had a history of rheumatic fever. The left knee is swollen and tender. RF and ANA are weakly positive. What would be a logical cause of her arthritis. Describe the reasons for consideration of each answer. A.Viral B.Reactive C.Post Streptococcal D.CTD E.Bacterial arthritis\*

Answer 90

A.Viral

Question 91

A 20 year old nursery nurse has recently been camping in Maine. She had also eaten cheese imported from Mexico. She presents with fever and migratory arthritis in the left ankle, right and left wrist and left and right MCP joints. She had an effervescent rash over the arms and legs one week ago. A sister had a history of rheumatic fever. The left knee is swollen and tender. RF and ANA are weakly positive. What would be a logical cause of her arthritis. Describe the reasons for consideration of each answer. What infections specifically need to be considered here?

Answer 91

Brucellosis, lyme disease, GC

Question 92

What are 7 common agents for viral arthritis?

Answer 92

1. **Parvo B19** 2. **HIV** 3. Hepatitis B & C 4. EBV 5. Adeno and coxsackie 6. Rubella 7. Mumps

Question 93

Viral arthritis may present as migratory arthralgia/itis or polyarthritis affecting the wrists, hands & knees. will be Frequently symmetric and a Rash may be present. What does arthritis from Hep C look like?

Answer 93

RA – so differentiate with anti-CCP. Arthritis in Hep C may relate to cryoglobulins.

Question 94

What is Hepatitis B arthritis similar to?

Answer 94

Serum sickness with decreased compliment and urticaria

Question 95

A 40 y/o female has a history of dry eyes and dry mouth for a year. She has a dry cough. She has intermittent severe joint pains and myalgias with weakness. She has a psoriatic rash on her palms and feet. Exam shows palmoplantar pustular psoriasis and tender muscles. ALT and AST are mildly increased, CPK is elevated. U1-RNP is negative as is ANA, RF, ANCA, ENA, ACE and anti-CCP. There are mild bilateral pulmonary infiltrates. What are the considerations in this case? A.SLE B.Primary Sjogrens C.Polymyositis D.Overlap syndrome E.HIV

Answer 95

E.HIV

Question 96

What is Diffuse infiltrative lymphocytosis (DILS) syndrome?

Answer 96

HIV

Question 97

A 40 y/o female has a history of dry eyes and dry mouth for a year. She has intermittent joint pains and myalgias with weakness. She has a psoriatic rash on her palms and feet. Exam shows palmoplantar pustular psoriasis and tender muscles. CPK is elevated. U1-RNP is negative as is ANA, RF, ANCA, ENA, ACE and anti-CCP. Further testing in this patient produced a positive HIV test with CD4 count of 190. Treatment with HAART was begun. One month later the patient developed lymphadenopathy, dyspnea and cough, symmetric ankle periarthritis, hepatosplenomegaly, and the following rash on each leg. Chest Xray showed hilar adenopathy. Which test was done at this point? A.HLA-DR3 B.p-ANCA C.ANA D.ACE E.ASOT

Answer 97

D.ACE