Please enable JavaScript.
Coggle requires JavaScript to display documents.
Seronegative Spondyloarthropathies (Reactive arthritis (Clinical features,…
Seronegative Spondyloarthropathies
Inflammatory back pain
requires 4 of these 5 criteria (serves as a screening tool for AS)
– Young onset (< 40 years)
– Morning stiffness (> 30 minutes)
– Chronic (> 3 months)
– Activity improves the pain (rest does not) – Insidious (not acute)
group of inflammatory joint diseases affecting the axial skeleton (spine and sacroiliac joints) and peripheral joints.
Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA)
Reactive Arthritis (ReA), Enteropathic Arthritis (EA)
Etiology
association with HLA-B27, mechanism unclear
infection in genetically predisposed persons:
Reactive arthritis: bacterial dysentery, chlamydial urethritis
AS – Klebsiella
Psoriatic arthritis – Streptococcus
human leukocyte antigen (HLA)-B27
Class I MHC, important in antigen presentation --> CD8 T cells
Risk developing AS in HLA-B27(+) person is only 1-2%.
normal gene found in 8% of Caucasians, 3-4% of African-Americans, 1% of Orientals.
Over 95% of patients with AS are HLA-B27(+)
increases risk of SPONDYLITIS and UVEITIS
Clinical features common to SpA
inflammatory back pain: sacroilitis, spondylitis
peripheral joints arthritis: lower >upper limb, asymmetrical
enthesitis:
pain, stiffness and tenderness of
insertions
Common areas of involvement
Achilles tendon insertion (calcaneus)
Plantar fascia insertion (calcaneus), Patellar tendon insertion
Costochondral junctions, Sternoclavicular joints
Spinal ligament insertion (vertebral body)
Tenderness at these and other entheseal sites is suggestive of enthesitis.
Pathology
synovitis often indistinguishable from RA
resolution of inflammation leads to extensive fibrosis
tendency for resultant scar tissue to calcify and ossify
Common differential diagnoses for SpA
Back or buttock pain: mechanical back pain, other casues (non-skeletal, infection, and malignancy)
Enthesitis: mechanical soft tissue problems
Monoarthritis: septic arthritis, crystal arthritis, trauma
Polyarthritis (rare): rheumatoid arthritis, other chronic inflammatory arthropathies
Spinal mobility measures
Cervical rotation
Lateral spinal flexion
Modified Schober: tests for range of motion loss at lumbar spine
Occiput to wall distance
Chest expansion
sacroiliac joint inflammation:
-Gaenslen, FABER / Patrick's test, yeoman's tests
Arthritis associated with IBD
acute inflammatory oligoarthritis
12% of patients with ulcerative colitis
20% with Crohn’s disease
asymmetrical: large lower limb joints, wrists and small joints of the fingers and toes
coincides with exacerbations of the bowel disease: remission after total colectomy in ulcerative colitis
symptoms
aphthous mouth ulcers, iritis, erythema nodosum
sacroilitis (16%), ankylosing spondylitis (6%)
Axial arthritis
sacroiliitis and spondylitis in IBD has the following characteristics:
Insidious onset of low back pain,
Morning stiffness
Exacerbated by prolonged sitting or standing,
Improved by moderate activity,
More common in Crohn disease (CD) than in ulcerative colitis (UC)
Peripheral arthritis
Nondeforming and nonerosive
More common in CD than in UC
May precede intestinal involvement
Type 1 (pauciarticular [< 5 joints]) - Acute, self-limiting attacks, lasting less than 10 weeks; asymmetrical and affecting large joints, such as the knees, hips and shoulders; strong correlation to IBD activity, most frequently with extensive UC or colonic involvement in CD; associated with other extraintestinal manifestations of IBD
Type 2 (polyarticular [>5 joints]) - Chronic, lasting months to years; more likely symmetrical, affecting small joints of the hands; independent of bowel activity
Treatment
treatment of the inflammatory bowel disease.
Paracetamol, NSAIDs and/or cyclooxygenase-2 (COX-2) inhibitors can be given to relieve pain and swelling.
Steroids can be injected into the affected joint.
More resistant peripheral arthritis in patients with IBD can be treated with sulfasalazine and tumour necrosis factor α (TNFα) inhibitors.
Ankylosing spondylitis (AS)
Chronic inflammatory arthritis
Sacroiliac joints and spine
Progressive stiffening and fusion of the axial skelton
common in M.
-onset: 15-30 years
Clinical features
Onset usually extremely insidious (months, years)
-Morning stiffness
Anorexia, malaise, low grade fever
Low back pain:
radiation to the buttocks or posterior thighs
relieved by exercise, provoked by prolonged inactivity or lying down
worse in the morning
Thoracic
anterior chest pain - costochondral junction inflammation
pleuritic chest pain – costovertebral joints
reduction of chest expansion
Neck symptoms (problems with driving a car)
Large joint involvement:
asymmetrical, rarely (monarthritis, oligoarthritis)
hips, shoulders, knees, ankles
Heel pain:
Achilles tendon insertion at calcaneus
Plantar fascia insertion at calcaneus
Extra-articular
Eyes - Anterior uveitis (irydocyclitis) in 25%, recurrent in 15%, Conjunctivitis in 20%
Microscopic colitis (often asymptomatic!)
Cardiac: aortic incompetence, aortitis, conduction defects, pericarditis
Pulmonary: restrictive lung disease, apical lobe fibrosis
Prostatitis (80% men), usually asymptomatic
Amyloidosis
Complications
Spinal fracture:
may be very difficult to detect with standard radiographs
spinal rigidity and secondary osteoporosis predispose
Neurologic involvement: cauda equina syndrome, atlantoaxial subluxation, may result in cervical myelopathy
Severe Complications:
Spinal stiffness/ankylosis in kyphotic position
Severe uveitis (25-40%)
Heart: AI, Heart Block
Lung: ILD, apical Fibrosis
kidney: amyloidosis, nephritis
Diagnosis
Blood: ESR and CRP – usually raised, serum RF is negative, anemia
X-rays
Modified New York Criteria for AS
Clinical criteria:
Low back pain and stiffness for >3 months, which improves with exercise, but is not relieved by rest
Limited lumbar spine motion: in sagittal and frontal planes
Limitations of chest expansion (age/sex standardized)
Radiographic criteria: EITHER: Bilateral sacroiliitis ≥ Grade 2 OR Unilateral sacroiliitis ≥ Gr 3
Definite AS = ≥1 clinical plus 1 radiographic criteria
Probable AS = 3 clinical criteria and no radiologic criteria or 1 radiologic criterion and no clinical criteria
Radiographic evaluation:
Grade 0 =Normal
Grade 1 =Suspicious changes
Grade 2 =Minimal abnormality – small localized areas with erosion or sclerosis without alterations in joint width
Grade 3 = Unequivocal abnormality – moderate or advanced sacroiliitis with ≥ 1 of the following: erosions, sclerosis, widening, narrowing, or partial ankylosis
Grade 4 = Severe abnormality – total ankylosis
Radiologic changes
Bilateral sacroilitis:
-sclerosis, narrowing and fusion (ankylosis)
-erosions, widening of the joint space
Lumbar Spine:
„squaring” of the vertebrae,
syndesmophytes (bony bridging between the vertebrae)
calcification of the anterior longitudinal ligament and facet joint fusion
leads to a ‘bamboo’ spine
Loss of normal spinal curvatures
Enthesitis – erosions and bony spurs
Treatment
Non - pharmacologic
exercise, Erect posture, Firm mattress, Range of Motion exercises, physical therapy
pharmacologic
NSAIDs:
first line of treatment for all symptomatic AS patients, unless contraindicated
can relieve pain and stiffnes
sulfasalazine or methotrexate: help peripheral arthritis, never in axial form, only traditional DMARD regarded as potentially useful in AS is sulfasalazine.
local steroid injections: for plantar fascitis, enthesopathies
anti-TNF-alpha: Infliximab, mab, mab, Etanercept
surgery
total joint replacement (hips)
treatment of spinal fracture
worse prognosis: severe hip, knee or shoulder disease
Outcome measure
BASDAI (Bath AS Disease Activity Index).
BASFI ( bla bla Functional Index)
BASMI ( metrology index)
ASAS AS Assessment Study)
Bath AS Disease Activity Index: measures disease activity based on 6 self-administered questions relating to:
Fatigue, Spinal pain, Peripheral arthritis, Enthesitis, Morning stiffness : 2 questions range 0-10
Psoriatic arthritis
in patients with current or previous psoriasis (70%)
severity of the skin disease and the arthritis usually do not correlate with each other.
Nail disease is commonly found in patients with PsA especially those with distal interphalangeal (DIP) joint involvement.
20-40 years of age, F=M
Etiology
genetic: family, HLA B13, B17, DR 4 (peripheral arthritis), HLA-B 27 - sacroilitis
infectious: bacteria -Group A streptococcal bacteria and viruses-HIV
immunologic
Clinical features
oligoarthritis (40%): assymetric, one or two large joints (knees)
symmetrical polyarthritis (25%): may strongly resemble RA
distal interphalangeal joint (DIP) arthritis (15%)
psoriatic spondylitis (15%): similar to AS, tendency to less severe involvement
arthritis mutilans (5%), „sausage digit” or dactylitis, enthesitis (Achilles tendon), nail changes ( commonly in psoriatic arthritis (85%) than in uncomplicated psoriasis (30%), skin lesions ( over extensor surfaces), conjunctivitis (most common) and uveitis
Classification of Psoriatic Arthritis (CASPAR)
Inflammatory articular disease (joint, spine or entheseal With ≥ 3 points:
1.Current psoriasis, a personal history, or a family history of psoriasis.
2.Typical psoriatic nail dystrophy including onycholysis, pitting and hyperkeratosis.
3.A negative rheumatoid factor.
4.Current dactylitis or a history of dactylitis.
5.Radiographic evidence of juxtaarticular new bone formation, ill-defined ossification near joint margins (exclude osteophyte formation) on plain radiographs of the hand or foot.
imaging
radiographic features of PsA can be grouped into destructive and proliferative changes.
Erosions are a typical destructive feature
Erosions with accompanying increased bone production are typical in PsA and may become extensive enough to give the appearance of a widened joint, rather than a narrowed joint space.
Widespread erosive changes may lead to the characteristic ‘‘pencil in cup’’ phenomenon
Marked osteolysis may be observed in severely destroyed joints, such that the whole phalanx may be destroyed.
Ankylosis of joints may also be observed.
spinal and sacroiliac radiograph: similar to AS but: unilateral or asymmetrical sacroilitis is more common, thicker syndesmophytes, asymmetric
peripheral joints: erosions (usually mild), subluxation, ankylosis – less commonly, destruction of phalanges: „pencil in cup” deformity
Radiological changes
Soft tissue swelling (sausage digit)
Preserved bone density
Periarticular erosions
“Pencil in cup” deformity
Bone proliferation
Adjacent to erosions, tendon insertions
Periosteal new bone formation
Sacroiliitis
Treatment
mild cases:
NSAIDs topical/oral
sulfasalazine
Intra-articular injections of glucocorticoids
severe disease:
methotrexate
biological therapies (blocade TNF, blocade Tcells)
exercise, surgery for joint replacement or stabilization
Reactive arthritis
infectious induced systemic illness characterized by an aseptic inflammatory joint involvement occurring in a genetically predisposed patient with a bacterial infection localized in a distant organ/system.
1-4 weeks after non-specific urethritis/gastroenteritis
lower limb mono/oligoarthritis
dactylitis
in susceptible individuals sacroilitis and spondylitis may develop
arthritis
conjunctivitis
urethritis
predominantly young men.
most common cause of inflammatory arthritis in men aged 15-35
Etiology
bacterial diarrhoea: Salmonella, Shigella, Campylobacter or Yersinia, Clostridium difficile
sexually acquired infection (SARA)
non-gonococcal urethritis: Chlamydia trachomatis, Ureaplasma urealyticum, cervicitis
respiratory infection: Chlamydia pneumoniae
HLA-B27 in >66% of patients
Reactive Arthritis may be initial presentation of HIV
Clinical course
first attack is usually self-limiting, with spontaneous remission of symptoms within 2-4 months
sacroilitis and spondylitis may develop (15-20%)
anterior uveitis in severe disease
Clinical features
acute, asymmetric, lower-limb arthritis (oligoarthritis)
dactylitis, enthesitis, fever, weight loss
Genitourinary tract symptoms: dysuria, pelvic pain, urethritis, cervicitis, prostatitis, salpingo-oophoritis, or cystitis
extra-articular:
circinate balantitis 20-50%
skin: keratoderma blennorrhagica in palms and soles
nail dystrophy
buccal erosions
eye: uveitis, conjunctivitis
Investigations
ESR, CRP, anemia
synovial fluid
bacterial culture – urethra, high vaginal swabs, stool
serum agglutinin tests
HIV test
radiographic changes
acute attack: soft tissue swelling
chronic or recurrent: periarticular osteopenia, joint space narrowing, marginal proliferative erosions, calcaneal spurs
asymmetrical: sacroilitis, syndesmophytes
Treatment
First attack
treatment of persisting infection with antibiotics
symptomatic NSAIDs
local steroid injections for large knee effusions
Ralapsing cases
sulfasalazine or methotrexate