Flashcards in Spondyloarthropathies Deck (15):
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Spondyloarthropathy
-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
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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
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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
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Skin manifestations of spondyloarthropathies
-Psoriasis (nail pitting)
-Erythema nodosa: raised inflammatory lesions
-Pyoderma gangrenosum: ulcerations
-Keratoderma blenorrhagicum-> reactive arthritis
-Pustulosis parlmaris
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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
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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
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Dx of spondyloarthropathies
-Hx of inflammatory back pain
-Enthesitis
-HLA-B27+
-Inflammatory back pain requirements: <40yo, insidious onset, improvement w/ exercise, no improvement w/ rest, pain at night
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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
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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)
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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
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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
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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%
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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
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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
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