Spondyloarthropathies (SpA)

Question 1

Name the five types of SpA

Answer 1

• Ankylosing spondylitis (AS)
• Reactive Arthritis (ReA) (aka Reiter’s Syndrome)
• Psoriatic Arthritis (PsA)
• Enteropathic arthritis (EA)
• Undifferentiated (USpA) – doesn’t fit into diagnostic categories, but shares clinical features

Question 2

What is this term?
– Inflammatory changes of the ligament, tendinous insertion into bone, or joint capsule
– Immune susceptibility to Allele B27 (human Leukocyte Antigen)

Answer 2

Enthesitis

Question 3

Term for:

Inflammation of vertebrae

Answer 3

spondylitis

Question 4

Term for: Anterior displacement of a vertebral body relative to the adjacent vertebral body below

Answer 4

Spondylolisthesis

Question 5

Term for: Defect of the portion of bone between the inferior and superior articular process of vertebrae (pars interarticularis)

Answer 5

Spondylolysis

Question 6

What two SpA have symmetrical SI involvement?

Asymmetrical?

Answer 6

Symmetrical - AS, EA

Asymmetrical - PA, ReA

Question 7

• Course, non-marginal syndesmophyte. Iritis, conjuctivitis, and keratoderma.
• Course, non-marginal syndesmophyte. Psoriasis. No eye involvement.

Answer 7

ReA

PA

Question 8

What two SpA have smooth, marginal syndesmophyte?

Answer 8

AS and EA

Question 9

HLA association of all SpA

Answer 9

B27

Question 10

Similarities of SpA

Answer 10

affecting axial skeleton spine, peripheral joints, periarticular structures associated with HLA B27 gene associated with extra-articular manifestations

Question 11

hallmark of spondyloarthropathy in children…

Answer 11

planta fasciitis and achilles tendonitis

Question 12

Tests/imaging in DDx of SpA

Answer 12

• HLA B27
• CRP, sed rate
• X-rays - SI joints AND lumber vertebrae
• CT of lumbar/pelvis if x-rays non diagnostic CBC

MRI sees inflammation before CT or XR sees any.

Question 13

Pathogenesis of AS

Answer 13

• Immune mediated
• Inflamed SI joint – CD4, CD8, T cells infiltrated TNF alpha high level (high level of cytokines)
• Enteric bacteria

Question 14

Five clinical manifestations of __
• Male, 20s
• Low back pain > 3 months
• Morning stiffness, improved with exercise, worse with rest
• Fatigue, weight loss and fever
• Symmetrical SI joint pain (sacroiliitis); loss of mobility/ flexibility; arthritis of hips
• Tendonitis, Planter fasciitis (achilles – heel pain)/Enthesitis

Answer 14

Ankylosing Spondylitis

Question 15

Extra-articular manifestations of AS

Answer 15

• Eye – anterior uveitis (Iritis) 30% (not found in RA)
• Photophobia, eye pain, blurred vision
• Aortic insufficiency, aortic aneurysm (1-4%)
• Pulmonary fibrosis – restrictive
• IBD (10 – 20%)
• Psoriasis

Question 16

Describe physical exam of AS

• schober test
• FABERE test

Answer 16

• Restricted forward flexion (Schober Test) and restricted chest expansion – FABERE test
• Loss of spinal mobility; Schober test measures flexion
of lumbar spine.
• Decreased chest expansion

Question 17

Labs in AS

Answer 17

• Increase ESR, CRP
• HLA B27 positive (80 – 90% of patients)
• Anemia of chronic disease
• Negative RF, ACCP, ANA

Question 18

Imaging in AS

Answer 18

• A-P radiographs of pelvis; bilateral SI changes
• Erosions of SI joints, pseudo widening, sclerosis, fuses, ankyloses, symmetric
• Vertebrae
– squaring (loss of anterior convexity)
– Shiny corners (vertebral edge sclerosis)
- bamboo spine/syndesmophytes

Question 19

What are syndesmophytes?

Answer 19

Bridging of vertebrae (boney bridges cause ankylosis) - no more pain!

Question 20

Test sensitive for erosions

Answer 20

CT

Question 21

Test sensitive for inflammation - before changes seen on CT or XR

Answer 21

MRI

Question 22

Late complications of AS

Answer 22

Restrictive lung disease, compression fractures, Cauda equina syndrome

Question 23

Key points to remember when a person presents with hx of inflammatory back pain of AS

1. Age of onset below __ y/o
2. ___ onset
3. Duration greater than ___ months before medical attention
4. __ stiffness, reduction in spinal mobility (esp. lumbar flexion)
5. Improvement with __
6. Positive ___

Answer 23

1. Age of onset below 40 y/o
2. Insidious onset
3. Duration greater than three months before medical attention
4. AM stiffness, reduction in spinal mobility (esp. lumbar flexion)
5. Improvement with exercise or activity
6. Positive family history

Question 24

Treatment of AS

Answer 24

• Exercise, physical therapy, swimming, stretching,
(preserve mobility/prevent kyphosis)
• NSAID – might reduce progression of spine damage –
pain control
• TNF – alpha inhibitors – decrease inflammation of axial
spine, improves mobility (infliximab, Remicade, adalimumab)
• Non-biologics – DO NOT USE. Metrotrex/sulfasal – okay for peripheral arthritis; not for axial disease. Limited usefulness

Question 25

Associate GI/GU infections with... | What bugs?

Answer 25

ReA • GI – Salmonella, Shigella, Yersinia, Campylobacter jejuni • GU – Chlamydia trachomatis

Question 26

Define ReA

Answer 26

Autoimmune disease; asymmetric mono-arthritis or oligo-arthritis (large joints) in lower extremities; urethritis; conjuctivitis

Question 27

Three clinical manifestations of ReA in young men - arthritis, enthesitis, dactylitis - locations

Answer 27

* Arthritis – asymmetrical, oligo-arthritis, lower extremities (ankles, knees) * Enthesitis – achilles tendon/ planter fasciitis * Dactylitis – sausage digit; finger or toe

Question 28

Describe SI pain, eye, and skin, manifestaitons in ReA

Answer 28

* SI pain – **asymmetrical * Eyes – conjunctivitis/uveitis * Skin - **Circunate balanitis (vesicles, ulcers on glans penis)

Question 29

What is this (in ReA): painless eruption on palms/soles

Answer 29

Keratoderma blennorrhagicum

Question 30

What is Reiter's Syndrome

Answer 30

(no longer used); | urethritis, arthritis, conjunctivitis, mucocutaneous lesions (oral ulcers)

Question 31

Labs seen in ReA upon joint aspiration

Answer 31

inflammatory synovial fluid

Question 32

What is this: • Peak age 40 – 60-year-old, equal sex ratio • PsA presents in 5 – 20% of patients with psoriasis (20 – 50% HLA B27); associated with SI and axial involvement **Pitting nails and "pencil in cup"**

Answer 32

Psoriatic Arthritis (PsA)

Question 33

What is this? • May be asymmetric or symmetrical • DIP, PIP, MCP, MTP / also large joints involved • Pitting nails • Dactylitis and Enthesitis • May have C1 – C2 (atlantoaxial instability) • 5 – 10% have positive RF or anti CCP antibodies • PsA flare up may be due to co-infection with HIV • Soft tissue swelling (STS), erosions, periostitis, destruction of interphalangeal joints

Answer 33

Peripheral arthritis (caused by subset of enteropathic arthritis caused by IBD)

Question 34

treatment of Peripheral Arthritis (IBD arthritis)

Answer 34

• NSAID – pain control • Non biologics – used for peripheral arthritis • Methotrex, sulfasal, hydroxychloro • Biologics - TNF inhibitors prevent progression of joint damage/psoriasis • Combine methotrex with TNF inhibitor, infliximab, etanercept

Question 35

What two GI diseases are associated with Enteropathic Arthritis?

Answer 35

IBD, Crohn's and UC

Question 36

Describe Enteropathic Arthritis- peripheral involvement

Answer 36

– Large joints lower extremity | – Small joints upper extremity

Question 37

**Extra-articular manifestations of EA caused by CD

Answer 37

* Skin: **Pyoderma Gangrenosum, Erythema Nodosum** * Eyes – Uveitis * GI – CD/UC * GU – Nephrolithiasis * CV – Thrombolism * Bones – fx, low bone density, vitamin D deficiency

Question 38

Tx of EA

Answer 38

NSAID, steroids (short relief), MTX, TNF alpha

Question 39

Tx of summary for SpA

Answer 39

* Exercise – maintain mobility, flexibility (swimming, stretching) * NSAID – helpful * Glucocorticoids * Methotrexate - Peripheral arthritis: Not for axial disease or AS * Sulfasalazine – PsA * DMARD’s – PsA * Antibiotics – Chlamydia urethritis

Question 40

What symptom does AS have that RA does not?

Answer 40

anterior uveitis (Iritis)