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Flashcards in Spondyloarthritis Deck (72):
1

SPONDYLOARTHROPATHIES: Common Features

1. RF (-)
2. HLA-B27 (MHC class I)
3. Axial skeletal involvement
4. Large-joint asymm oligoarthritis (pred in LE)
5. Significant familial aggregation
6. Enthesitis
7. Dactylitis

2

What is enthesitis?

inflammation at the sites where tendons and ligaments attach to bone

3

What is Dactylitis?

swelling of toes/fingers (duh); "sausage-like"

4

>90% of patients with AS are (+) for ____, even though it is only ~8% prevalent in the population.

HLA B27

5

Patients with psoriasis or IBD that are HLA-B27 positive are more likely to develop

axial (spinal) arthropathy

6

In ANKYLOSING SPONDYLITIS (AS), where does inflammation occur?

--spinal joints (causes bony fusion of spine)
--peripheral joints

7

AS: epidemiology

Adolescents to age 35
M>F

8

AS: Pathology

--Inflammatory cell infiltrate
--Synovial inflammation similar to RA
--TNF alpha excess

9

AS: Clinical features of axial disease

--Insidious onset
--Chronic low back pain
--Back stiffness
--Symptoms are worse in the morning and improve with exercise
--Symptoms gradually ascend up the spine (as disease progresses)

sacroiliitis and spondylitis = WASP (workout, AM/Ascend, stiff, pain)

10

AS: Peripheral disease joint manifestations

--Involves: hips, shoulders, knees and ankles
--Oligoarticular + often asymm
--Dactylitis may occur
--Enthesitis (*esp Achilles or plantar tendon insertions = heel pain)
**note: these are present in 1/3 of patients

11

AS: exam findings

--Sacroiliac tenderness
--Limited spine ROM in all directions
--Loss of lumbar lordosis, thoracic and cervical kyphosis (=flexion contracture)
--Abn Schober’s test (<3cm)
--Reduced chest expansion, measured @ 4th intercostal space
--Increased occiput to wall distance

12

AS: X-ray findings

--Sacroiliitis (usually bilateral)
--“Squaring” of vertebral bodies
--Syndesmophyte formation
--Generalized spinal osteopenia
--Eventual bony ankylosis
--Common = Vertebral fractures (occur even after minimal trauma, due to rigidity + osteopenia)

13

AS: Non-articular peripheral manifestations

--Eyes: Anterior Uveitis
--Cardiac: Aortic regurgitation, heart block
--Pulmonary: Apical lung fibrosis, thoracic cage restriction

14

AS: Trx of axial + peripheral disease

NSAIDs, TNF blockers, local corticosteroids

15

AS: Indicated only for trx of peripheral disease

sulfasalazine

16

Confers increased disease susceptibility and disease severity

HLA-B27

17

In Crohn's disease, what can result in relative immune deficiency?

Genetic polymorphisms

(related to GI lymphoid tissue and microbiota interaction, which balances inflammatory defense and tolerance)

18

______ is common in adults, 25% of whom have joint manifestations

Celiac disease

19

Microscopic colitis is accompanied by:

extraenteric autoimmune manifestations

20

Intolerance to GI microbiome results in...

inability to maintain gut homeostasis = IBD

21

What causes the joint symptoms related to IBD?

circulating microbial material and increases in IgA/lymphocytes/macrophages result in circulating immune complexes, which deposit in joint + cause synovitis

22

ENTEROPATHIC ARTHRITIS = Inflammatory arthritis associated with...

Crohn’s disease
Ulcerative colitis
Whipple’s disease (rare)

23

ENTEROPATHIC ARTHRITIS: epidemiology

M=F

24

In ENTEROPATHIC ARTHRITIS, Axial disease is associated with

HLA B27

25

When does ENTEROPATHIC ARTHRITIS often occur in patients?

following onset of their GI disease (*usually)

26

ENTEROPATHIC ARTHRITIS: peripheral manifestations

--Oligoarticular
--Generally asymmetric
--LE joints
--Dactylitis
--Enthesitis
--GI inflammation often parallels arthritis

27

ENTEROPATHIC ARTHRITIS: axial manifestations

--Clinically/radiographically identical to idiopathic AS
--Does not parallel GI disease

28

Trx for enteropathic arthritis which shows efficacy in UC but not CD?

Sulfasalazine (and its derivative, 5-ASA)

**inhibit NFk B

29

Trx for enteropathic arthritis that are generally effective for all forms?

GC
NSAIDs (symptomatic trx)

30

Trx for enteropathic arthritis, effective in both forms of IBD?

Azathioprine and methotrexate

31

Trx for enteropathic arthritis, effective in CD?

Infliximab and adalimumab

32

Trx for enteropathic arthritis, effective in UC?

Infliximab

33

Reactive arthritis is an inflammatory process arising after:

What is the classic triad?

arising after an infectious process

Arthritis
Urethritis
Conjunctivitis

34

What are the clinical features of reactive arthritis?

1. asymm oligoarthritis (predom LE)
2. enthesitis (achilles, plantar, symphesis p, ribs)
3. uretritis
4. proven infection
5. dactylitis
6. axial disease (sacroiliitis and spondylitis)
7. oral ulcerations
8. conjuctivitis
9. Circinate balanitis
10. skin + nails (onycholysis)

35

reactive arthritis: epidemiology?

M>F (5:1)
75% HLA B27 (+)
More common in HIV/AIDS (and more severe + resistant to therapy)

36

most common species to induce ReA?

Salmonella typhimurium

37

Reactive Arthritis: GI infections

Shigella
Salmonella
Campylobacter
Yersinia

38

Pathogen which causes reactive arthritis 10 to 30 days after diarrhea?

Shigella

39

Pathogen which causes reactive arthritis within 3 to 4 weeks?

Salmonella

40

Reactive Arthritis: GU infections

Chlamydia (Chlamydia trachomatis)
Ureaplasma

41

Why is it important to follow up with a patient w/ Reactive Arthritis (Reiter's)?

Recurrences are common, and 20-50% of patients demonstrate a chronic course

42

Psoriatic arthritis should be suspected in a patient with:

asymm joint distribution pattern
dactylitis
enthesitis
inflammatory-type back pain
RF (-)

43

PSORIATIC ARTHRITIS: markers of poor outcome

Polyarticular disease
elevated ESR

44

How do you distinguish PSORIATIC ARTHRITIS from RA?

increase in vascularity
presence of neutrophils

45

PSORIATIC ARTHRITIS: What demonstrates clinical response to trx?

Change in synovial CD3+ T cell infiltration

46

PSORIATIC ARTHRITIS may originate (where)?

enthesis

47

PSORIATIC ARTHRITIS: effective trx for skin and joint disease

TNF inhibitors

48

PSORIATIC ARTHRITIS: what cells may be responsible for disease?

CD8 and MHC-1
(or TLR activation)

49

PSORIATIC ARTHRITIS develops in 10-40% of pts with _____

psoriasis

50

Pathogenesis of Psoriasis?

inflammation of the skin and keratinocyte proliferation

51

Pathogenesis of PSORIATIC ARTHRITIS?

Synovial inflammation with mononuclear cell infiltration, new vessel formation and synovial proliferation

*TNF alpha

52

Immunopathology of PA?

1. Elevated plasma levels of Ig

2. T cells express:
--HLA-DR
--receptors for IL2 and adhesion molecules

3. Secretion of IL-6 and other proinflammatory cytokines from T cells

4. Fibroblasts from skin + synovium prolif/secrete IL-1 beta, IL-6, and PDGF

53

Synovial cytokine profile in PA?

TNF-alpha
IL-1
IL-6
IL-8

54

Serum cytokines upregulated in PA?

IL-10
IL-13
IFN-alpha
VEGF
Fibroblast Growth Factor

55

Compared to RA, PA synovium produces more:

TNF-alpha, IL1-beta, IL2, IL10, INF-gamma

56

Compared to RA, PA synovium produces less:

IL4

57

Cytokine produced by PA but not RA:

IL5

58

How is PA synovium structurally different than RA?

PSA synovium has less lining layer thickness and more vascularity

(why didn't he just put "thinner lining layer"...am I missing something?)

59

What is the function of IL18, an upregulated cytokine in PA?

1. Stimulates angiogenesis
2. Upregulates chemokine expression on synovial fibroblasts
3. Increases mononuclear cell recruitment

60

PA patterns (5)?

1. Polyarticular pattern (>4 joints, RA-like)
2. Oligoarticular pattern (<4 joints, asymm)
3. DIP involvement pattern
4. Arthritis Mutilans (severe, destructive)
5. Axial involvement (sacroiliitis + spondylitis, B27+)

61

Nail abn in PA?

Pitting
Hyperkeratosis
Onycholysis

62

Where are skin lesions in PA, and when do they appear?

Scalp, perineum, natal cleft, umbilicus

Usually present long before arthritis

63

If very severe PA, think...

HIV

64

PA: XR?

DIP involvement
“Pencil – in - a – cup”
Periostitis
Bony ankylosis
Erosive & proliferative
Axial disease resembles AS

*is this even important?

65

PA responds well to what drug?

Infliximab

66

What joints does Brucella arthritis affect?

spine = adults

peripheral joints = children
(especially knees, hips and ankles)

*sacroilitis can be extremely acute and painful!

67

Possible complication of Brucella arthritis?

spinal stenosis
destructive arthritis, if trx delayed

68

What types of bursitis are caused by Brucella arthritis?

prepatellar and olecranon

69

Caused by an immune reaction by T lymphocytes in the gut of genetically HLA-DQ2-positive or HLA-DQ8-positive individuals

celiac disease
**react to partially digested wheat gluten

70

What serum antibodies are present in celiac disease?

IgA antitissue transglutaninase
IgA antiedomysial antibodies

71

What conditions, presenting with profuse diarrhea, are associated with a variety of rheumatic diseases?

Microscopic colitis (MC)
(2 forms = collagenous colitis and lymphocytic colitis)

72

What cell is activated in PA, which causes bone destruction?

osteoclast