Flashcards in Spondyloarthritis Deck (72)
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
What is enthesitis?
inflammation at the sites where tendons and ligaments attach to bone
What is Dactylitis?
swelling of toes/fingers (duh); "sausage-like"
>90% of patients with AS are (+) for ____, even though it is only ~8% prevalent in the population.
Patients with psoriasis or IBD that are HLA-B27 positive are more likely to develop
axial (spinal) arthropathy
In ANKYLOSING SPONDYLITIS (AS), where does inflammation occur?
--spinal joints (causes bony fusion of spine)
Adolescents to age 35
--Inflammatory cell infiltrate
--Synovial inflammation similar to RA
--TNF alpha excess
AS: Clinical features of axial disease
--Chronic low back pain
--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)
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
AS: exam findings
--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
AS: X-ray findings
--Sacroiliitis (usually bilateral)
--“Squaring” of vertebral bodies
--Generalized spinal osteopenia
--Eventual bony ankylosis
--Common = Vertebral fractures (occur even after minimal trauma, due to rigidity + osteopenia)
AS: Non-articular peripheral manifestations
--Eyes: Anterior Uveitis
--Cardiac: Aortic regurgitation, heart block
--Pulmonary: Apical lung fibrosis, thoracic cage restriction
AS: Trx of axial + peripheral disease
NSAIDs, TNF blockers, local corticosteroids
AS: Indicated only for trx of peripheral disease
Confers increased disease susceptibility and disease severity
In Crohn's disease, what can result in relative immune deficiency?
(related to GI lymphoid tissue and microbiota interaction, which balances inflammatory defense and tolerance)
______ is common in adults, 25% of whom have joint manifestations
Microscopic colitis is accompanied by:
extraenteric autoimmune manifestations
Intolerance to GI microbiome results in...
inability to maintain gut homeostasis = IBD
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
ENTEROPATHIC ARTHRITIS = Inflammatory arthritis associated with...
Whipple’s disease (rare)
ENTEROPATHIC ARTHRITIS: epidemiology
In ENTEROPATHIC ARTHRITIS, Axial disease is associated with
When does ENTEROPATHIC ARTHRITIS often occur in patients?
following onset of their GI disease (*usually)
ENTEROPATHIC ARTHRITIS: peripheral manifestations
--GI inflammation often parallels arthritis
ENTEROPATHIC ARTHRITIS: axial manifestations
--Clinically/radiographically identical to idiopathic AS
--Does not parallel GI disease
Trx for enteropathic arthritis which shows efficacy in UC but not CD?
Sulfasalazine (and its derivative, 5-ASA)
**inhibit NFk B
Trx for enteropathic arthritis that are generally effective for all forms?
NSAIDs (symptomatic trx)
Trx for enteropathic arthritis, effective in both forms of IBD?
Azathioprine and methotrexate
Trx for enteropathic arthritis, effective in CD?
Infliximab and adalimumab
Trx for enteropathic arthritis, effective in UC?
Reactive arthritis is an inflammatory process arising after:
What is the classic triad?
arising after an infectious process
What are the clinical features of reactive arthritis?
1. asymm oligoarthritis (predom LE)
2. enthesitis (achilles, plantar, symphesis p, ribs)
4. proven infection
6. axial disease (sacroiliitis and spondylitis)
7. oral ulcerations
9. Circinate balanitis
10. skin + nails (onycholysis)
reactive arthritis: epidemiology?
75% HLA B27 (+)
More common in HIV/AIDS (and more severe + resistant to therapy)
most common species to induce ReA?
Reactive Arthritis: GI infections
Pathogen which causes reactive arthritis 10 to 30 days after diarrhea?
Pathogen which causes reactive arthritis within 3 to 4 weeks?
Reactive Arthritis: GU infections
Chlamydia (Chlamydia trachomatis)
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
Psoriatic arthritis should be suspected in a patient with:
asymm joint distribution pattern
inflammatory-type back pain
PSORIATIC ARTHRITIS: markers of poor outcome
How do you distinguish PSORIATIC ARTHRITIS from RA?
increase in vascularity
presence of neutrophils
PSORIATIC ARTHRITIS: What demonstrates clinical response to trx?
Change in synovial CD3+ T cell infiltration
PSORIATIC ARTHRITIS may originate (where)?
PSORIATIC ARTHRITIS: effective trx for skin and joint disease
PSORIATIC ARTHRITIS: what cells may be responsible for disease?
CD8 and MHC-1
(or TLR activation)
PSORIATIC ARTHRITIS develops in 10-40% of pts with _____
Pathogenesis of Psoriasis?
inflammation of the skin and keratinocyte proliferation
Pathogenesis of PSORIATIC ARTHRITIS?
Synovial inflammation with mononuclear cell infiltration, new vessel formation and synovial proliferation
Immunopathology of PA?
1. Elevated plasma levels of Ig
2. T cells express:
--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
Synovial cytokine profile in PA?
Serum cytokines upregulated in PA?
Fibroblast Growth Factor
Compared to RA, PA synovium produces more:
TNF-alpha, IL1-beta, IL2, IL10, INF-gamma
Compared to RA, PA synovium produces less:
Cytokine produced by PA but not RA:
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?)
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
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+)
Nail abn in PA?
Where are skin lesions in PA, and when do they appear?
Scalp, perineum, natal cleft, umbilicus
Usually present long before arthritis
If very severe PA, think...
“Pencil – in - a – cup”
Erosive & proliferative
Axial disease resembles AS
*is this even important?
PA responds well to what drug?
What joints does Brucella arthritis affect?
spine = adults
peripheral joints = children
(especially knees, hips and ankles)
*sacroilitis can be extremely acute and painful!
Possible complication of Brucella arthritis?
destructive arthritis, if trx delayed
What types of bursitis are caused by Brucella arthritis?
prepatellar and olecranon
Caused by an immune reaction by T lymphocytes in the gut of genetically HLA-DQ2-positive or HLA-DQ8-positive individuals
**react to partially digested wheat gluten
What serum antibodies are present in celiac disease?
IgA antitissue transglutaninase
IgA antiedomysial antibodies
What conditions, presenting with profuse diarrhea, are associated with a variety of rheumatic diseases?
Microscopic colitis (MC)
(2 forms = collagenous colitis and lymphocytic colitis)