SM 228a - Spondyloarthropathies

Question 1

What genetic factor is associated wtih seronegative spondyloarthropathies?

Answer 1

HLA-B27

Question 2

Which cytokines can be targeted using biologic therpay to treat psoriatic arthritis?

Answer 2

IL-23 (+/- IL-12)

IL-17

TNF

Question 3

What percentage of psoriasis patients will develop psoriatic arthritis?

Answer 3

~25%

Question 4

What pattern of articular disease defines seronegative spondyloarthropathies?

Answer 4

Inflammation

• Spine involvement
• Hands: PIP and DIP affected
  
  • MCP spared
• Asymmetric joint involvement
• Enthesitis

Question 5

What is the typical treatment for patients with seronegative arthritis?

Answer 5

• Anti-inflammatory agents (NSAIDs)
• Physical therapy
• If NSAIDs fail…
  
  • Corticosteroids
  • DMARDS
  • Biologics

Question 6

What are the typical extra-articular manifestations of the seronegative spondyloarthropathies?

Answer 6

Enthesitis

Iritis

Skin (psoriatic), GI (IBD-related)

Question 7

Which arthritis has both destructive and new-bone changes?

What pattern does this produce?

Answer 7

Psoriatic arthritis

“pencil in cup”

Question 8

Describe the presentation of ankylosing spondylitis

Answer 8

• Inflammatory back pain and stiffness
• Sacroiliitis
• Oligoarthritis
• Enthesitis
• Systemic symptoms
  
  • Fatigue, imparied sleep
• Extra-articular disease
  
  • Uveitis, IBD, aortitis
• Symptoms begin in 20’s, but diagnosis is often late

Question 9

List some of the relevant spondyloarthropathies

Answer 9

Spondyloarthropathies = inflammatory, seronegative

• Reactive arthritis
• Psoriatic arthritis
• Axial spondyloarthritis
• Arthritis associated with IBD

Question 10

Describe the clinical presentation of reactive arthritis

Answer 10

• Acute inflammatory arthritis
• Involves only a few joints
• Follows GI or GU infection
• Usually self-limited
  
  • May be recurrent or chronic

Question 11

What is spondyloarthritis?

Answer 11

A specific group of inflammatory arthritides that share some common elements

• Sero-Negative (negative for RF)
• Spine involvement
• Enthesitis
• Genetic markers
• Asymmetric joint involvement
• Iritis
• No female predominance

Question 12

How can you distinguish between rheumatoid arthritis and reactive arthritis?

Answer 12

• Rheumatoid Arthritis
  
  • More likely to be RF positive
  • MCP affected
    
    • DIP spared
  • Female predominance
• Reactive arthritis
  
  • Asymmetric
  • DIP and PIP affected
  • No female predominance

Question 13

Which picture shows osteoarthritis?

Which one shows inflammatory?

How do you know?

Answer 13

• 1 = ostoarthritis
  
  • No hypercellularity
  • Cartilage erosion
  • New bone formation
    
    • No bone erosions
• 2 = inflammatory arthritis
  
  • Hypercellularity in the synovium
  • Bone erosion

Question 14

Describe the pathophysiology of reactive arthritis

Answer 14

Previous infection can trigger an inflammatory reaction

• This is not an ongoing infection
• Must treat the inflammation - treating the microbe doesn’t work

Question 15

These nail changes are characteristic of which kind of arthritis?

Answer 15

Psoriatic arthritis

Question 16

A “Pencil in cup” feature of a joint is pathopneumonic for which arthritis?

Answer 16

Psoriatic arthritis

Requires both erosion and new bone formation

(psoriatic arthritis is the only arthritis that has both destrictive and new bone changes)

Question 17

What infections can trigger reactive arthritis?

Answer 17

• Enteric infections
  
  • Shigella, salmonella, yersinia, campylobacter, clostridium
• Urogenital infection
  
  • Chlamydia

Causative agent may be asymptomatic!

May be a genetic predispostion (HLA-B27) in addition to previous infection

Question 18

Which spondyloarthritides are classically “axial?” Which are classically “peripheral”?

Answer 18

• Axial
  
  • Axial spondyloarthritis (ankylosing spondylitis is a subset)
• Peripheral
  
  • Psoriatic arthritis

IBD arthritis, reactive arthritis are more in the middle

Question 19

What is the significance of HLA-B27 in reactive arthritis?

Answer 19

Some HLA-B27 subtypes may have an amino acid sequence homology with some infectious agents

• Yersinia enterocolitica
• Salmonella typhimurium
• Shigella flexneri
• Klebsiella

Infection by these agents triggers the immune system ot attack its own HLA-B27

Rats with high levels of HLA-B27 developed reactive arthritis spontaneously

Question 20

What is inflammatory enthesopathy?

Answer 20

Subchondral bone inflammation and resorption at the insertion of tendons

Periosteal new bone formation (not just calcification of the tendon)

Question 21

Describe the clinical features of psoriasis arthritis

Answer 21

• Cutaneous disease
  
  • Psoriatic plaques
  • Onycholysis and nail pitting
  • Skin disease usually (90%) precedes joint involvement
• Inflammatory polyarthritis
  
  • Asymmetric or symmetric
    
    • DIP and PIP, MCP spared
      (MCP usually involved in RA)
  • Axial
• Dactylitis
• Enthesitis
• RF negative

Psoriatic arthritis is a spondyloarthritis

Question 22

Describe the articular features of reactive arthritis

Answer 22

• Additive
• Asymmetric
• Mono or oligo arthritis
• More commonly affects large lower extremity joints
• Dactylitis
• Enthesitis
• Inflammatory lower back pain

Question 23

Which feature is shown in this radiograph?

Which arthritis is it characteristic of?

Answer 23

Bamboo spine

Due to ossification of the outer layers of the annulus fibrosis

Note: no osteophytes, which are characteristic of osteoarthritis