Exam 2 - new material

Causes of sacroiliitis that are positive HLA-B27

(1) Ankylosing Spondylitis (AS)

(2) Enteropathic

(3) Psoriatic

(4) Reactive Arthritis

Causes of sacroiliitis that are HLA-B27 negative

(1) HPT (calcium levels)

(2) Gout (uric acid levels)

(3) DJD

(4) Infection

(5) Trauma

(6) Pregnancy

(7) DISH

(8) OCI

Which two seronegative spondyloarthropathies primarily affect the axial skeleton? Which two affect the appendicular skeleton?

Axial = AS and enteropathic arthritis

Appendicular = psoriatic and reactive arthritis

PEAR (keep the first two together and then the second two together)

Which is less common: AS or Enteropathic Arthritis?

Enteropathic Arthritis

Enteropathic Arthropathies

Group of rheumatologic conditions that share a link to gastrointestinal pathology

Commonly associated with inflammatory bowel disease (IBD)

What infections are commonly linked to enteropathic arthritis?

Bacterial: shigella, salmonella, campylobacter, yersinia, clostridium difficile

Parasitic: Giardia lamblia, Ascaris lumbricoides, Cryptosporidium species

Enteropathic Arthritis: etiology

UNKNOWN

Inflammation in the GI tract may increase permeability, resulting in absorption of antigenic material, which may then localize to musculoskeletal tissues and elicit an inflammatory response

Alternate idea: autoimmune response through molecular mimicry

Additional clinical symptoms with enteropathic arthritis

— malaise

— anorexia

— weight loss

Arthropathy is self-limiting, but symptoms worsen with flare-ups of bowel disease

Enteropathic Arthritis: axial skeleton clinical presentation

Insidious onset of low back pain, especially in younger persons

— morning stiffness

— exacerbated by prolonged sitting or standing

— improved by moderate activity

— independent of GI symptoms

Is enteropathic arthritis more common with Crohn Disease or ulcerative colitis?

More common in Crohn Disease than ulcerative colitis

Enteropathic Arthritis: peripheral skeleton

Nondeforming and nonerosive

May precede intestinal involvement, but usually concomitant or subsequent to bowel disease

Common locations: heel (insertion of Achilles tendon and plantar fascia) and knee (tibial tuberosity and patella)

Enteropathic Arhtritis Management

Focused on the bowel disease with anti-inflammatory medications for arthropathy

Bowel resection may halt the peripheral arthropathy, but not axial arthropathy

Features of Enteropathic Arthritis

Looks the same as Ankylosing spondylitis! — same features!

Psoriatic and Reactive Arthritis Features

— soft tissue edema

— asymmetrical small joints (mostly DIP)

— peripheral erosions with periostitis ("mouse ears")

— central erosions ("pencil in cup")

— ankylosis and deformity

— normal bone density

— unilateral or bilateral AND Asymmetrical SI erosions and/or sclerosis

— unilateral or bilateral SI fusion

— syndesmophytes (asymmetrical, bulky, non-marginal, paravertebral)

Remember: primarily appendicular skeleton

Psoriatic Arthritis

Chronic inflammatory arthritis that develops in at least 5% of patients with dermatological psoriasis

Chronic disease of the joints and the entheses

Risk factors of Psoriatic Arthritis

— nail, inverse (immune-mediated disease that causes a rash in areas where skin rubs against itself), and scalp psoriasis

— family history

— severity of skin disease

Psoriasis precedes the onset of psoriatic arthritis in what percent of patients?

60-80%

Pathogenesis of psoriatic arthrits?

— genetics

— environmental factors

— immune-mediated inflammation

Prognosis of Psoriatic Arhtritis

As many as 40% develop erosive and deforming arthritis

Possible increased risk of: hypertension, obesity, hyperlipidemia, Type II diabetes, and cardivascular events

Types of Psoriatic Arthritis

(1) Distal Psoriatic Arthritis

(2) Spondylitis

(3) Arthritis Multilans

(4) Enthesis

(5) Dactylitis

Age of onset of psoriatic arthritis

30-50 years

Psoriatic arthritis mainly targets which joints?

Hands

Less common in feet

Does psoriatic arthritis commonly have a symmetrical distribution?

No >> asymmetrical

Proliferative synovitis with psoriatic arthritis results in what?

Pannus

Main features of Psoriatic Arthritis

— soft tissue edema

— asymmetrical small joints (mostly DIP)

— peripheral erosions with periostitis ("mouse ears")

— central erosions ("pencil in cup")

— ankylosis and deformity

— normal bone density*

— unilateral or bilateral and Asymetrical SI erosions and/or sclerosis

— unilateral or bilateral SI fusion

— syndesmophytes (asymmetrical, bulky, non-marginal, and paravertebral)

Extremity Findings of Psoriatic Arthritis: similar features as RA

— joint space narrowing

— soft tissue edema

— marginal erosions ("bare area") erosions

— ankylosis and deformity

Extremity Findings of Psoriatic Arthritis: distinctive features from RA

— mostly DIP (acro-osteolysis possible)

— normal bone density

— periostitis ("mouse ears")

— central erosions ("pencil in cup" appearance)

— less symmetrical within a joint and throughout the body (distribution may involve all joints of one digit - "ray pattern")

What is a key bone change that can be seen in Psoriatic arthritis but NOT in RA?

New bone formation

Occurs at the periarticular area owing to enthesitis

The surface of bone erosion and proliferation in psoriatic arthritis may appear "fluffy"

Psoriatic arthritis at the DIP joint of the hand

Psoriatic Arthritis in the hand with joint deformity

"Pencil in cup" deformity with Psoriatic Arthritis

Drawing Comparison between different types of arthritis in the hand

"Sausage Digit" from Psoriatic Arthritis

How is psoriatic arthritis in the spine similar to ankylosing spondylitis?

— erosions

— sclerosis

— possible ankylosis

— syndesmophytes (but different appearance)

How is psoriatic arthritis in the spine different from ankylosing spondylitits?

— unilateral or bilateral

— asymmetrical

— thick, bulky nonmarginal (don't come from just the endplate) syndesmophytes

Syndesmophytes in psoriatic arthritis of the spine

Psoriatic Arthritis on the SI Joints

Similar to AS, indistinct articulations

BUT...AP view identifies thick, nonmarginal syndesmophytes

For psoriatic arthritis, SI joint is usually not the first sign, and it is usually asymmetrical

Reactive Arthritis Etiology

Autoimmune condition

Usually caused by GI or GU infections (most commonly Shigella, Salmonella, Campylobacter, Chlamydia trachomatis)

What is the classic triad of reactive arthritis?

(1) Noninfectious urethritis

(2) Arthritis

(3) Conjunctivitis

"Can't see, can't pee, and can't dance with me"

Other S/S of reactive arthritis?

— malaise, fever, fatigue, myalgia

— diarrhea, sometimes abdominal pain

— asymmetrical oligoarthritis (MC lower extremity)

— about 50% have LBP

Reactive Arthritis Onset

Usually develops 2-4 weeks after GU or GI infection (about 10% have no preceding symptomatic infection

Classic triad is seen in only about 30% BUT has a specificity of about 99%

Physical Examination Findings of Reactive Arthritis

— asymmetric oligoarthritis (predominately LE)

— dactylitis ("sausage digits")

— toe or heel pain and/or other enthesitis

— cervicitis or urethritis

— conjunctivitis or iritis

— genital ulcerations

— skin lesions

Common locations for reactive arthrtitis

Weight-bearing joints

— Asymmetrical distribution in the knees, hips, and ankles

— Shoulders, wrists, and elbows can be affected

— Small joints of fingers and toes usually in severe cases

Joints are tender, warm, edematous, and sometimes red

Imaging Findings of Reactive Arthritis

Enthesopathy

— achilles insertion is most common site

— ischial tuberosities, iliac crest, tibial tuberosities, and ribs

Sacroilitis also can occur

Reactive Arthritis Management

No curative treatment exists

— Treatment aimed at relieving symptoms

— Includes corticosteroids, NSAIDs, antibiotics, and disease-modifying antirheumatic drugs (DMARDs)

About 2/3 are self-limiting BUT approximately 30% develop chronic symptoms

Reactive Arthritis Complications

— recurrent arthritis

— chronic arthritis or sacroiliitis

— ankylosing spondyliyis

Reactive Arthritis: similarities of Psoriatic Arthritis at the extremity

— joint space narrowing

— soft tissue edema

— normal bone density

— periostitis ("mouse ears")

— less symmetrical within a joint and throughout the body

Reactive Arthritis: distinctions from psoriatic arthritis at the extremity

— Reactive arthritis is more common in the lower extremity vs psoriasis is more common in the upper extremity

— Lack of nail pitting and psoriatic scaling

— Central erosions ("pencil in cup") are less common

— ankylosis and deformity are less common

Reactive Arthritis: SI similarities to psoriatic arthritis

— thick, bulky nonmarginal syndesmophytes

— unilateral or bilateral

— asymmetrical

Reactive Arthritis: SI distinctions from psoriatic arthritis

Nearly identical!

Reactive Arthritis of the foot

Normal bone density, but shaggy periosteum

What are the seropositive inflammatory joint diseases?

— Rheumatoid arthritis

— Systemic Lupus Erythematosis (SLE)

— Jaccoud Arthropathy

— Scleroderma

RA diagnosis

Diagnosis is clinical, serological, and radiological

— requires the presence of several criteria

— signs and symptoms usually begin as insidious and may be proceeded by emotional or physical stress

What are the most common articular complaints of RA?

— pain

— tenderness

— swelling

— stiffness especially in the morning ("jelling phenomenon")

Most common symptoms begin in the PIP and MCP and proceed proximally

What are some other possible clinical abnormalities with RA?

— Raynaud

— osteopenia (joint capsule)

— cervical spine subluxations/dislocations

— vasculitis with skin ulcerations

— ocular complications

— lacrimal gland atrophy leading to dry eyes

What is the checklist for Rheumatoid Arthritis Diagnosis? How many do you need for diagnosis?

(1) Morning stiffness for at least 6 weeks

(2) Pain on joint motion for at least 6 weeks

(3) Swelling of at least 1 joint for at least 6 weeks

(4) Swelling in at least 1 other joint for more than 6 weeks

(5) Bilateral symmetrical joint swelling

(6) Subcutaneous nodules

(7) Radiographic changes

(8) Laboratory

Need 4 or more to qualify for RA!

RA prognosis

Most patients will experience periods of remission and exacerbation with gradual deformity and disability

Minority of patients will experience complete remission

Poor prognosis is associated with subcutaneous nodules, high titer levels of RH factor, sustained disease for one year or more, onset before 30, and extra-articular manifestations

What is the common distribution of RA at the hands/wrist?

— MCP

— PIP

— ulnar aspect of the wrist

Rheumatoid Arthritis (RA)

Generalized multi-system connective tissue autoimmune disease involving synovial tissue and resulting in polyarticular joint inflammation

Antibodies directed against Fc fragments of IgG = Rheumatoid Factors (RFs)

Usually composed of IgM and are used as a marker for rheumatoid arthritis and other autoimmune conditions

Rheumatoid Factor (RF) is positive in approximately how many of those diagnosed with RA?

75%

Note: 5% of the general population is RF positive without RA diagnosis

Higher RF titers indicate what?

Poorer prognosis

Tends to have a more severe disease

What is the most common inflammatory arthritis? Who does this usually affect?

RA

Age 20-60 = F > M (3:1)

Age >60 = F=M

RA targets what?

Synovial tissue

Particularly of the hands, feet, and cervical spine

Other systems: heart, lungs, small blood vessels, nervous system, eyes, and reticuloendothelial system

RA is marked by what?

Inflammatory hyperplastic synovitis = synovial tissue proliferation = pannus

Pannus = late, inactive and irreversible manifestation of RA

How does pannus affect the bones?

Proliferating pannus erodes and narrows the cartilage as the pannus releases chondrolytic collagenase enzymes and interferes with nutrition (to the region/joint)

Proliferating synovium results in marginal erosions in the bare area = window for pannus to intrude into subchondral region, which produces cysts

Eventually the entire joint is filled with proliferating panus and undergoes progressive fibrosis and eventually ankylosis

What is arthritis mutilans?

Severe joint deformity/destruction

What is a Baker's cyst?

Enlargement of the gastrocnemius bursa

What is Felty's Syndrome?

Leukopenia, splenomegaly, and RA together

What are Haygarth's Nodes?

Soft tissue swelling at the MCP

What is the jelling phenomenon?

Stiff joints after inactivity

What is a rheumatoid nodule?

Accumulation of inflammatory cells with necrotic area and fibrosis seen on extensor surfaces

What is Boutonniere deformity?

PIP flexion and DIP extension

Swan neck deformity

PIP extension and DIP flexion

Radiographic features of RA

(1) Marginal erosion ("rate bite erosions") = localized loss of intraarticular cortex adjacent to the capsular insertion due to pannus erosion at the anatomical bare area

(2) Dot-dash appearance = intermittent absence of the articular cortex (due to erosions)

(3) Periarticular soft tissue swelling

(4) Juxta-articular osteopenia (lateral generalized osteopenia)

(5) Uniform narrowed joint spaces

(6) Erosions (beginning in bare areas)

(7) Subchondral Geodes

(8) Joint deformity

(9) possible ankylosis

Bare Area with RA

Unprotected area that is usually the first site of erosions

"Rat Bite" Erosions from RA

Periarticular Osteoporosis from RA

RA Soft tissue nodes

What area should you check with RA?

WRIST! Loves to attack the carpals and may see ankylosis of the carpals

What can happen to long bones with RA?

Erosions can cause narrowing of the long bones

Boutonniere Deformity on X-ray

Swan Neck Deformity on X-ray

What is a common early location of RA in the wrist?

Ulnar styloid process erosions

RA causes deviation of the fingers in which direction?

Ulnar deviation

RA at the hip can cause what?

Axial migration or acetabular protrusion

Arthritis mutilans can be caused by what?

Psoriatic or rheumatoid arthritis

RA at the knees

Symmetric loss of joint space (vs osteoarthrosis = more at medial side)

Erosions and Baker Cyst

RA at the feet causes what kind of deviation?

Fibular deviation

What joint in the shoulder is common for RA

AC joint

NOTE: take other side image to ensure not from trauma (RA is systemic so most likely bilateral changes)

RA at the shoulder image

Erosions, misalignment, and the humerus head is higher (most likely due to supraspinatus tendon erosion)

RA of the cervical spine impacts how many RA patients?

About 50% within 10 years of diagnosis

Where does RA mainly attack in the cervical spine?

Upper cervical

Review: anterior and posterior ADI measurements

Anterior ADI = 3mm or less

Posterior ADI = 14 mm or greater

What can happen to axis with RA?

Odontoid erosions could lead to "whittled dens"

Atlanto-axial impaction is the most common cause of upper cervical neurological symptoms in patients with RA

RA presentation in the cervical spine

— apophyseal joint disease

— decreased disc height

— spinous process erosions

— malalignment/subluxation

— osteopenia

Odontoid Erosions with RA can occur where?

(1) Between the dens and anterior arch

(2) Between the dens and transverse ligament

(3) Tip of the dens

Cranial Settling from RA

Occ-C1 and/or C1-C2 facet erosions

Risk of basilar invagination and potential neurological compromise

Juvenile Chronic Arthritis (Aka JRA or JIA)

RA onset younger than 16 years of age

Can be seropositive (like adult type RA) or seronegative (MC)

Seropositive = more aggressive and poorer prognosis (but only about 10% of cases)

Polyarticular Form of JRA

Most common variety

Females > males

Bilateral and symmetrical involvement with systemic signs (mild fever, lymphadenopathy, and rash)

Radiological signs of JRA

Similar to adult RA:

— soft tissue swelling

— osteopenia

— loss of joint space

— articular erosions

— malaignments/subluxations

Characteristic to children:

— growth disruptions (potential growth plate closure)

— periostitis (lifting periosteum)

— ankylosis