List group of disorders associated with Spondyloarthropathies
PAIR + 2
Inflammatory bowel disease
Reactive arthritis (Reiter Syndrome)
Juvenile chronic arthritis and Juvenile-Onset Ankylosing Spondylitis
Rheumatoid factor (+ or -) ?
High Association with what gene?
HLA - B27
More often in males or females?
Axial or appendicular skeleton involvement?
Axial skeletal involvement with sacroiliitis and spondylitis
Spondyloarthropathies large joint features
Poly or oligoarthritis?
Symmetric or asymmetric?
Upper or lower extremities?
Large joint asymmetric oligoarthritis predominantly in lower extremites
Absence of what (that are commonly seen in RA)
Absence of subcutaneous nodules and other extra-artiular manifestations of RA
HLA-B27 is what MHC class?
MHC Class I, binds antigenic peptides and presents them to CD8+ T cells
HLA-B27 is found in over 90% of patients with what disorder?
General population frequency?
8% of general population has HLA-B27. means that just b/c you have it, doesn't mean you have disorder
HLA-B27 is found in 75% of which patients?
Pts with Reactive Arthritis (Reiter's)
Frequency of HLA-B27 in Psoriatic Arthritis?
Ankylosing Spondylitis Epidemiology
Gender preference? Ratio?
Age: Adolescence to 35
Gender: Male:Female 3:1
Ankylosing Spondylitis has what pathologic findings (3)?
Inflammatory cell infiltrates
Synovial inflammation similar to RA
TNF alpha excess
Clinical features of Ankylosing Spondylitis?
Rapid vs insiduous onset?
Clinical features of Ankylosing Spondylitis?
Pt pain usually begins where in body?
Overtime where does pain go? What does this cause?
Pain usually begins in lower back, vertebral bodies eventually involved, causing fusion of the vertebrae "bamboo spine"
Bamboo spine refers to what pathology of which disorder?
Vertebral fusion, seen in Ankylosing spondylitis
What extra-articular manifestation are seen in Ankylosing spondylitis? Which is most common?
Eye: Anterior Uveitis (25-30%) = MOST COMMON
Cardiac: Aortitis (leading to aortic regurgitation), heart block, pericarditis, Increased risk for MI
Lungs: Apical lung fibrosis, thoracic cage restriction
If AS patient has peripheral joint involvement, what extra-articular symptoms are more common?
Aortic regurg and heart block 2x more common
Describe spine of Ankylosing Spondylitis patient?
- Fusion of spine causes limited ROM in all directions
- Loss of lumbar lordosis & development of thoracic and cervical kyphosis
Ankylosing Spondylitis Exam findings (3) ?
1. Abnormal Schober's test (< 3 cm)
2. Reduced chest expansion (<2.5 cm) measured at 4th Intercostal space
3. Increased occiput to wall distance
Spine probs in Ankylosing Spondylitis lead to what feature?
generalized osteopenia, increased risk for fractures
Drug of choice for AS? If pt cant take this type of drugs, next best drug of choice?
TNF blockers = BEST choice (Infliximab, adalimumab)
Indomethacin = next best if needed
Cant see, Cant pee, Cant climb a tree. What am I talking about?
Reactive Arthritis (Reiter syndrome)
Triad of: Arthritis, Urethritis, and Conjunctivitis
Urethritis might not be present for long
Reactive Arthritis Epidemiology.
Male or Female?
What gene is it most associated with?
More common in what subset of patients? Prognosis?
M/F ratio 5:1 (Goljian says 10:1)
75% pts have HLA-B27
ReA most common in HIV/AIDS (much more severe and resistant to therapy). Also a feature seen in Psoriatic Arthritis
Reactive Arthritis usually caused by?
Arises after infectious process
Urethritis in Reiter's most commonly due to what bacterial infection?
Arthritis in Reiter's most commonly associated with what bacterial infections?
Shigella, Salmonella, Campylobacter, Yersinia
Made you look. But seriously, what the hell is going on here?
Circinate balanitis. Feature of Reactive Arthritis. Rash on the distal shaft and glans penis that appears as vesicles, shallow ulcerations, or both
What is this called? Which spondyloarthropathy is it most associated with?
Enthesitis, most commonly seen in Reactive Arthritis
What is this? What disease is it associated with?
Keratoderma blennorrhagica, feature of Reactive arthritis
What lab tests does Dr. P get on all reactive arthritis patients?
HIV test, HLA-B27.
Also check ESR, CRP, blood culture (usually +), Serology
How long does reactive arthritis last? Will it ever recur?
Mean duration 2-3 months, Recurrence common, 20-50% demonstrate chronic course
Actual name of sausage shaped DIP joints? Associated with what disorder?
Dactylitis. Primarly associated with Psoriatic arthritis. Also enteropathic (IBS), reactive, and AS
What is going on here? What disease is it associated with?
Etensive nail pitting seen in Psoriatic Arthritis
Psoriatic Arthritis Immunopathology compared to RA
Synovial cytokines that are greater?
Synovial cytokines that are less than RA?
More TNF-alpha, IL-1 beta, IL-2, IL-10, and IFN Gamma as compared to RA
Less IL-4, IL-5 as compared to RA
Besides the cytokines mentioned in comparison to RA, what other synovial cytokine is present in psoriatic arthritis? Features of this cytokine?
IL-18. Member of IL-1 Superfamily
stimulates angiogenesis, upregulates chemokine expression on synovial fibroblasts, increases mononuclear cell recruitment
How many types of Psoriatic Arthritis? Name them
- Polyarticular pattern
- Oligoarticular pattern
- DIP involvement pattern
- Arthritis Mutilans
- Axial involvement
Which type of PsA involves >4 joints? What disorder is it similar to?
Polyarticular pattern. Similar to RA
Which type of PsA involves ≤ 4 joints? Symmetrical or Assymetrical involvement seen in this type?
Oligoarticular pattern. Assymetric involvement
Which type of PsA involves only a specific joint? which joint is this?
DIP involvement pattern
Which type of Psoriatic Arthritis is severe and destructive?
If PsA patient is B27+, what type of bone involvement is seen? Similar to what disease?
Axial involvement type (similar to sacroilitis and sponydlitis)
What is being shown here? What disease?
"pencil in cup" deformity seen in Psoriatic Arthritis
Another name for Enteropathic arthritis? Helps you to remember its association?
Inflammatory bowel disease associated arthritis
Enteropathic arthritis is associated with what other disorders?
Crohn's, Ulcerative colitis, Whipple's (rare)
Epidemiology. Enteropathic Arthritis gender association?
M = F
Enteropathic arthritis types? Which is associated with HLA-B27?
- axial associated with HLA-B27
Which comes first, the GI disease or enteropathic arthritis?
GI disease usually comes first
Axial vs Peripheral enteropathic arthritis.
Which is clinically and radiographically identical to idopathic Ankylosing spondylitis?
Axial vs Peripheral Enteropathic Arthritis.
Which often parallels GI disease (meaning the arthritis worsens when GI disease worsens)
Axial does not parallel. Can do what it wants.
Peripheral enteropathic arthritis is similar to what other form of spondyloarthropathy?
- oligoarticular, generally asymmetric; lower extremity joint involvement; Dactylitis and enthesitis; parallels GI inflammation
Which arthritis is associated with IgA deficiency?
Arthritis of Celiac Disease
In Arthritis of Celiac Disease, which comes first?
Arthritis can present prior to development of Celiac Diseaes. Can help distinguish this from enteropathic arthritis.
In DISH (diffuse idiopathic skeletal hyperostosis), calcification and ossification is most common on which side of the spine?
DISH is inflammatory or non-inflammatory?