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Flashcards in Spondyloarthropathies Deck (15):


-Chronic systemic inflammatory disease involving SI (sacroiliac) joints, axial skeleton, peripheral joints, and extraarticular manifestations
-Includes: ankylosing spondylitis (AS), reactive arthritis, enteropathy-associated arthritis (Crohn's and ulcerative colitis), psoriatic arthritis


Pathogenesis of ankylosing spondylitis (AS)

-T cells present self HLA-B27 escapes deletion and propagates after exposure to mimicking microbial antigen
-Misfolding of B27 protein triggers Ag response and propagates Th17, causing inflammatory response
-Fluctuating inflammation causes bone erosion w/ replacement by repair tissue (osteoproliferation) resulting in syndesmophytes (bridging of bones)
-Osteitis occurs w/ ensuing effusions, enthesitis (swelling of sites where tendons/ligaments insert into bone), but not synovitis (as seen in RA)
-HLA B27 presence does not guarantee disease


Extraarticular manifestations of spondyloarthropathies

-Gut, eye (acute iritis), urogenital manifestations all prototypical
-Not prototypical but occur: lung, heart, kidney, nerve involvement
-These include aortic regurgitation, apical lung pneumonitis, amyloidosis in kidneys, causa equina syndrome


Skin manifestations of spondyloarthropathies

-Psoriasis (nail pitting)
-Erythema nodosa: raised inflammatory lesions
-Pyoderma gangrenosum: ulcerations
-Keratoderma blenorrhagicum-> reactive arthritis
-Pustulosis parlmaris


Psoriatic arthritis vs RA

-DIPs are affected in psoriatic arthritis, and there is no osteopenia at the joints in psoriatic arthritis (there is in RA)
-MCPs/PIPs are affected in RA, not DIPs


Radiographic features of spondyloarthropathies

-Pencil in cup deformity at joints (usually DIP)-> psoriatic arthritis
-Sacroiliitis: fusion of sacrum to ilium (AS usually)
-Shiny corners of joints: syndesmophytes-> bridging spondylophytes (abnormal healing from inflammation)
-Zygoapophyseal (facet joint) ankylosing
-Vertebral fractures
-Enthesitis: usually on spinal and peripheral ligaments


Dx of spondyloarthropathies

-Hx of inflammatory back pain
-Inflammatory back pain requirements: <40yo, insidious onset, improvement w/ exercise, no improvement w/ rest, pain at night


Rx of spondyloarthropathies

-PT is key
-Continuous NSAIDs
-DMARDs not useful
-Usually regimen is 2+ NSAIDs w/ sulfasalazine and local steroid injections, also can use methotrexate
-TNFa Rx when needed
-Reconstructive surgery when necessary


Spondyloarthropathies vs RA

-Spondyloarthropathies (HLA-B27 arthritides) differ from RA in the following ways
-High incidence of spinal joint involvement
-Usually asymmetrical lower limb involvement
-Men much more frequently affected than women
-High frequency of HLA-B27
-RF absent
-DIPs affected (PIP/MCPs affect in RA)


Ankylosing spondylitis (AS)

-Inflammation starts at SI joints and progress superiorly to involve the spine
-There's inflammation followed by abnormal healing resulting in ankylosing (fusion) of joints and ossification of paraspinal ligaments
-Position of comfort is flexion of the back
-Enthesitis, among other complications can result and cause pain at extraarticular areas


Clinical manifestations of AS

-Low back pain and stiffness of >3mo, unrelieved by rest
-Limited motion of the lumbar spine (especially flexion)
-Reduced chest expansion
-Bilateral sarcoiliitis on Xray
-40% develop peripheral arthritis mainly in hips, shoulders and knees


Reactive arthritis

-Chronic recurring inflammatory disease consisting of urethritis or infectious diarrhea, conjunctivitis, arthritis, and mucocutaneous lesions
-Mainly affects lower extremity joints and is asymmetrical
-Usually self limited (lasts 2-6 mo), but recurs in 50%
-Toes involved are res and swollen, sometimes SI and spinal arthritis occurs
-Xrays can show periostitis near involved joint
-Association w/ HLA-B27: 80%


Mucocutaneous lesions of reactive arthritis

-Circinate balanitis: on penis, is painless
-Painless superficial ulcers of the palate and buccal mucosa
-Keratodermia blennorrhagica: on soles of feet usually, dry hyperkeratotic rash


Psoriatic arthritis

-Chronic arthritis that accompanies psoriasis in 6% of pts
-Can involve peripheral joints, SI joints, and/or spinal joints
-Psoriatic sponylitis is associated w/ HLA B27 but peripheral psoriatic arthritis is not
-Rx: methotrexate or sulfasalazine and PT. Anti-TNFa can help, so can corticosteroids


Clinical features of psoriatic arthritis

-Psoriasis first, when arthritis starts it usually affects the DIPs
-Psoriatic nail involvement frequent
-Sausage (dactylitis/enthesitis) of toes or fingers
-Skin lesions of psoriasis and arthritis may wax and wane together
-Remissions more frequent than in RA
-Specific radiologic features: pencil-in-cup, whittling, periostitis and non-marginal spinal syndesmophytes