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Seronegative Spondyloarthropathies (Ankylosing Spondylitis (Symptoms…
Seronegative Spondyloarthropathies
Shared Features
(-) RF
(+) HLA-B27
- not diagnostic
Clinical Features
Axial involvement (back, SI)
Peripheral arthritis (asymmetric, LE)
Dactylitis
Enthesitis
Inflammatory eye and bowel disease
Ankylosing Spondylitis
Peak onset 20-30 y.o.
Male predominant (9:1)
Primarily white people
Delay to dx ~5-7 yrs
Symptoms
Inflammatory back pain (<40 y.o.)
better w/ exercise, worse w/ rest and @ night
SI joint pain
Enthesitis (40-70%)
Peripheral arthritis (30-50%)
Extra-axial
Eye (25-40%):
acute anterior uveitis
Cardiovascular (6-10%):
aortic insufficiency, aortitis
Pulmonary:
restrictive lung disease (decr TLC), apical fibrosis
Renal:
IgA nephropathy, amyloidosis
GI (50-60%):
asymptomatic ileal/colonic mucosal ulceration
Physical Exam
Schober Test
Forward flex as far as possible
Flexion should increase to >15 cm b/w two marks (originally at 0 cm and 10 cm from LS junction)
Occiput Test
Lose natural curvature of neck
Stand back against wall, cannot put head flush against wall.
Imaging
AP Pelvis
Sacroilitis
Hip arthritis
Spinal Radiograph
Squaring of vertebral bodies
Syndesmophytes
Calcification of anterior spinal ligament
MRI
More sensitive
BM edema
Endplate edema (esp anteriorly at ligament attachments)
"Corner inflammatory lesions"
Treatment
NSAIDs
Improve back pain/stiffness in 70-80%
DMARDs
MTX
Sulfasalazine
Great for peripheral symps, less so for axial
Biologics
Anti-TNF Inhibitors
Great for axial symptoms
Reactive Arthritis (aka "Reiter's Synd)
Preceding infection
Enteric (e.g. Salmonella, Shigella, Yersinia, Campylobacter, C. diff)
GU (e.g. Chlamydia trachomatis)
Symps (1-3 wks after infxn)
Can't see (Conjunctivitis)
Can't pee (Urethritis)
Can't climb a tree (Arthritis - asymm, LE - enthesitis, dactylitis)
Extra-Articular
Mucosal lesions
Cutaneous eruptions (e.g. keratoderma blennorrhagica)
Genital lesions (e.g. circinate blanitis)
Labs
Elevated acute phase reactants
(+) HLA-B27 (30-50%)
Inflammatory synovitis
Diagnosis
Clinical
Hx preceding infxn
Supported by labs
Treatment
ABX if
Chlamydia trachomatis
[+ treat partner(s)]
Arthritis
Initial: NSAIDs +/- steroids
Chronic: MTX, Sulfasalazine
Psoriatic Arthritis
Symptoms
Arthritis
Asymm oligoarthritis:
<5 joints (40%)
Symm polyarthritis:
resembles RA (25%)
Arthritis mutilans
: deforming, destructive (<5%)
Spondyloarthropathy:
sacroilitis, spondylitis (20%)
Distal arthritis:
DIP joints (15%)
Dactylitis
Enthesitis
Nail pitting
Psoriasis
Imaging
Pencil-in-cup
(DIPs)
Periostitis (new bone formation)
Soft tissue swelling
Treatment
MTX
Anti-TNF
Ustekinumab (IL-17, IL-23 inhib)
Apremilast (PDE4, less immunosuppressive)
IBD
Arthritis
Pauciarticular, asymmetric, transient, migratory
Large & small joints
Axial symptoms
Can precede or follow GI symp onset
Typically non-destructive
Correlate w/ disease activity
Peripheral joint activity parallels bowel activity
Axial involvement does not correlate w/ bowels
Extraarticular symps
Enthesitis
Uveitis
Pyoderma gangrenosum
Treatment
Symptomatic (b/c non-destructive process)
NSAIDs/COX-2 Inhibs (unless flares IBD)
AZA/6-MP
Anti-TNF agents