Rheuma Lecture 5 - Seroneg Spondylarthropathies

what diseases are part of seroneg spondylarthritides (SpAs)

undifferentiated SpA, psoriatic arthritis, ankylosing spondylitis, acute uveitis, reactive arthritis, crohn’s/UC, juvenile SpA

SpAs are often associated with which marker

HLA B27 and TNFa

clinical manifestations SpAs

inflammatory lumbar pain, spinal stiffness, butt pain, sacroilitis, enthesis, oligoarticular arthritis, dacylytis (sausage digits), uveitis, psoriasis, nail changes, aortic insufficiency

clinical manifestations reactive arthritis

conjunctivitis, nail changes, infectious diarrhea, urethritis/cervicitis, oral ulcers, sterile pyuria, circinate balanitis, keratoderma blennorhagicum, aortic insufficiency

how to define active inflammatory lesions (positive MRI) of sacroiliac joint

subchondral bone marrow edema/osteitis (hyperintense on T1)

synovitis on MRI of sacroiliac joints

hyperintense signals on T1 in synovial part of joint

capsulitis vs synovitis on MRI

capsulitis involves ant and post capsule, may extend far medially and laterally into periosteum

MRI enthesitis

hyperintense on T1 where ligaments and tendons attach to bone

what do STIR images NOT detect concerning active inflammatory lesions

synovitis

chronic inflammatory signs on MRI

subchondral sclerosis (low intense), erosions (bony defects at joint margin, low intense), periarticular fat depots (high intense), ankylosis (low intense, bone bridges across joints),

tests for spinal mobility in SpAs

chest expansion, Schober, lat. spinal flexion, occiput/tragus to wall, cervical rotation, intermalleolar distance, ext + int rotation hip

drugs ttt ankylosing spondylitis

nsaids first line

steroid injections?

when should we give anti-TNF therapy in ankylosing spondylitis

persistently high disease activity + failure of other treatments

when should we give sulfasalazine in patients with ankylosing spondylitis

peripheral arthritis/disease

erythema nodosum and pyoderma gangrenosum are present in which diseases

CD, UC

when are ESR and CRP elevated

in active disease

what is an evolution factor in PsA

anti-CCP Ab

imaging to ask for in SpAs

ant-post xrays of sacro iliac joints

in which diseases do we have bilateral/asymmetrical sacroilitis

bilat - AS, CD, UC

asymmetrical - PsA, ReA

xray gradings in SpAs

1. suspicious

2. minimal abnormality (erosions, sclerosis)

3. mod-advanced sacroiliitis (erosions, sclerosis, partial ankylosis)

   1. severe - total ankylosis

imaging findings of spine in SpAs

ankylosis of spine with syndesmophytes (bamboo appearance)

imaging findings of joints in PsA

pencil in cup erosions, new bone growth at enthesitis sights and in distal joitns

terminal phalanges lysis, periostitis

imaging findings in joints in reactive arthritis

fluffy erosions

terminal phalanx lysis, periostitis, new bone growth in distal joints

active vs chronic MRI findings in SpAs

active - osteitis (bone marrow edema), capsulitis, synovitis, enthesitis

chronic - sclerosis, erosions, fat depots, ankylosis

axial vs peripheral spondylarthritis

axial - sacroillitis and inflammatory lumbar pain

peripheral - polyarthritis/oligoarthritis

asymmetric oligoarthritis

5+ joints involved

spondyloarthropathy

sacroiliitis, spondylitis

arthritis mutilans

destructive arthritis

reactive arthritis

sterile inflammatory disorder characterized by arthritis, uveitis and conjunctivitis

reactive arthritis can be caused by

chlamydia, shigella, salmonella, yersinia

manifestations reactive arthritis

acute, asymmetrical oligoarthritis, conjunctivitis, enthesitis, urethritis → spondylitis and sacroiliitis

types of enteropathic arthtiis (CD and UC)

type 1. peripheral pauciarticular arthritis - asymmetrical migratory, associated w/ active bowel disease

type 2. peripheral, polyarticular arthritis (not associated with active bowel disease)

type 3. axial - inflammatory low back pain and sacroiliitis (not associated with active bowel disease)

ttt axial SpAs

NSAIDS first line

TNFa

IL 17,17a

ttt peripheral SpAs

sulfasalazine, mtx - first line

azathioprine if PsA

ttt limited joint involvement

intra-articular and topical steroids

ttt circinate balanitis and keratoderma blenorrhagicum

topical steroids

what is the predictor of worse outcome of SpAs

smoking