part 4 spcon module 3

WHAT CONDITION IS THIS?

● Group of disorders that share certain clinical features associated with HLA B27 allele

● Ankylosing spondylitis

● Reiters syndrome

● Psoriatic arthritis

SPONDYLOARTHROPATHIES

WHAT CONDITION IS THIS?

● Inflammatory disorder of unknown cause

● Primarily affects the axial skeleton, including sacroiliac joint, costovertebral joints

● Asymmetric involvement of large peripheral joints

● 2nd to 3rd decade of life

● Prototype of the spondyloarthropathies

● Aka Marie Strumpell Disease; Behcet’s Disease

ANKYLOSING SPONDYLITIS

In Ankylosing Spondylitis,

PATHOGENESIS : AS

● Incompletely understood

● Chronic non-granulomatous inflammation at the sites of cartilage, tendons and ligaments attachment to bone

● Due to immunomodulated mechanism

○ Increase level of _____ and acute phase reactants

○ Close association with _____

● Bacterial invasion (_____)

In Ankylosing Spondylitis,

PATHOGENESIS : AS

● Incompletely understood

● Chronic non-granulomatous inflammation at the sites of cartilage, tendons and ligaments attachment to bone

● Due to immunomodulated mechanism

○ Increase level of IgA and acute phase reactants

○ Close association with HLA B27

● Bacterial invasion (Klebsiella pneumoniae)

In Ankylosing Spondylitis,

PATHOLOGY: AS

_____

• One of the earliest manifestation of AS

• Subchondral granulation tissue containing lymphocyte, plasma cells, macrophage and chondrocytes

• Thinner iliac cartilage is eroded first then the sacral cartilage

Spine

• Initial lesion consists of inflammatory granulation tissue at the junction of the _____ of disk cartilage and margin of vertebral bone

• _____ are eroded and eventually replaced by bone forming the beginning of bony excresence (_____)

• Eventually grows bridging adjacent vertebral bodies to ascending progression leading to a “_____”

  • _____ (occurs as a result of the VB fusion by marginal syndesmophyte)

  • Other lesions

    • Erosion of vertebral body

    • Diffuse osteoporosis '

    • Squarring of vertebrae

In Ankylosing Spondylitis,

PATHOLOGY: AS

SACROILITIS

• One of the earliest manifestation of AS

• Subchondral granulation tissue containing lymphocyte, plasma cells, macrophage and chondrocytes

• Thinner iliac cartilage is eroded first then the sacral cartilage

Spine

• Initial lesion consists of inflammatory granulation tissue at the junction of the annulus fibrosus of disk cartilage and margin of vertebral bone

• Outer annular fiber are eroded and eventually replaced by bone forming the beginning of bony excresence (SYNDESMOPHYTES)

• Eventually grows bridging adjacent vertebral bodies to ascending progression leading to a “bamboo spine” appearance '

  • Bamboo-spine (occurs as a result of the VB fusion by marginal syndesmophyte)

  • Other lesions

    • Erosion of vertebral body

    • Diffuse osteoporosis '

    • Squarring of vertebrae

In Ankylosing Spondylitis, what is being defined?

• One of the earliest manifestation of AS

• Subchondral granulation tissue containing lymphocyte, plasma cells, macrophage and chondrocytes

• Thinner iliac cartilage is eroded first then the sacral cartilage

SACROILITIS

In Ankylosing Spondylitis, fill in the blanks

• One of the earliest manifestation of AS

• Subchondral granulation tissue containing lymphocyte, plasma cells, macrophage and chondrocytes

• Thinner iliac cartilage is eroded first then the sacral cartilage

Spine

• Initial lesion consists of inflammatory granulation tissue at the junction of the _____ of disk cartilage and margin of vertebral bone

• _____ are eroded and eventually replaced by bone forming the beginning of bony excresence (_____)

• Eventually grows bridging adjacent vertebral bodies to ascending progression leading to a “_____”

  • _____ (occurs as a result of the VB fusion by marginal syndesmophyte)

  • Other lesions

    • Erosion of vertebral body

    • Diffuse osteoporosis '

    • Squarring of vertebrae

Spine

• Initial lesion consists of inflammatory granulation tissue at the junction of the annulus fibrosus of disk cartilage and margin of vertebral bone

• Outer annular fiber are eroded and eventually replaced by bone forming the beginning of bony excresence (SYNDESMOPHYTES)

• Eventually grows bridging adjacent vertebral bodies to ascending progression leading to a “bamboo spine” appearance '

  • Bamboo-spine (occurs as a result of the VB fusion by marginal syndesmophyte)

  • Other lesions

    • Erosion of vertebral body

    • Diffuse osteoporosis '

    • Squarring of vertebrae

Ankylosing Spondylitis has 4 terms under its Pathology. What are these?

Enthesis

Peripheral Arthritis

Acute Anterior Uveitis

Aortic insufficiency

In Ankylosing Spondylitis, which among the 4 terms under pathology is being described?

• Site of ligamentous or tendinous attachment to the bone

• Common site of pathology especially at sites localized around spine and pelvis

Enthesis ○

In Ankylosing Spondylitis, which among the 4 terms under pathology is being described?

• Synovial hyperplasia

• Pannus formation

● Peripheral arthritis

In Ankylosing Spondylitis, which among the 4 terms under pathology is being described?

• 20%

• Iris shows non-specific inflammatory changes, scarring, vascularity and pigment laden macrophage

• Most common extra-articular manifestation of AS which can antedate spondylitis

● Acute Anterior Uveitis

In Ankylosing Spondylitis, which among the 4 terms under pathology is being described?

○ Thickening of the aortic valve cusp

● Aortic insufficiency

In Ankylosing Spondylitis, fill in the blanks

CLINICAL MANIFESTATIONS: AS

• PHYSICAL EXAMINATION

  • _____ – most specific finding

  • Limit in anterior and lateral flexion and extension of lumbar spine and chest expansion

• _____ – useful measure of the flexion of lumbar spine

  • _____ or more: normal

  • _____: decrease mobility

• _____

  • most serious complication ( spine is rigid)

  • most common involved: cervical spine

In Ankylosing Spondylitis, fill in the blanks

CLINICAL MANIFESTATIONS: AS

• PHYSICAL EXAMINATION

  • Loss of spinal mobility – most specific finding

  • Limit in anterior and lateral flexion and extension of lumbar spine and chest expansion

• SCHOBER TEST – useful measure of the flexion of lumbar spine

  • 5cm or more: normal

  • <4cm: decrease mobility

• Spinal fracture

  • most serious complication ( spine is rigid)

  • most common involved: cervical spine

In Ankylosing Spondylitis, the is the most specific finding

Loss of spinal mobility

In Ankylosing Spondylitis, this is a useful measure of the flexion of lumbar spine

SCHOBER TEST

In Ankylosing Spondylitis. this is the procedure of choice

MRI

In Ankylosing Spondylitis, this medication is considered most effective agent in AS

Phenylbutazone –

In Ankylosing Spondylitis, this medication is useful in reducing peripheral joint symptoms

Sulfasalazine –

WHAT CONDITION IS THIS?

● Type of Reactive arthritis (most common form)

● Refers to acute non purulent arthritis complicating an infection elsewhere in the body

● Recent yrs refers to spondyloarthropathies following an enteritis or a urogenital infection

● Occurs with HLA B27

● Clinical syndrome triggered by specific etiologic agent (Chlamydia, Salmonella)

● Triad: arthritis, urethritis, conjunctivitis

REITERS SYNDROME

What is the triad of reiter’s syndrome

arthritis, urethritis, conjunctivitis

WHAT CONDITION IS THIS?

● Seronegative inflammatory joint disease affecting people who have psoriasis

● Associated with radiographic evidence of periarticular bone erosions and occasional significant bone destruction

PSORIATIC ARTHRITIS

What are the 3 major types of Psoriatic Arthritis?

1. ASYMMETRIC INFLAMMATORY ARTHRITIS

2. SYMMETRIC ARTHRITIS

3. PSORIATIC SPONDYLITIS

What type of Psoriatic Arthritis is this?

● 47%

● M =F

● Psoriasis precedes the arthritis by years

● PIP/DIP commonly involved (sausage shaped digit)

● Onychodystrophy (ridging and pitting of nails)

● Prognosis is good

1. ASYMMETRIC INFLAMMATORY ARTHRITIS

What type of Psoriatic Arthritis is this?

● 25%

● 2x frequent in females

● Psoriasis and inflammatory arthritis develops simultaneously

● Morning stiffness

● Onychodystrophy

2. SYMMETRICAL PsA

What type of Psoriatic Arthritis is this?

● 23%

● Psoriasis tends to precede arthritis by few yrs

● With or without peripheral joint involvement

● Lower back pain with morning stiffness

● Can also manifest with SI

● Enthesopathy (inflammation of tendons and ligaments attached to bone)

3. PSORIATIC SPONDYLITIS

Anatomical Distribution:

Symmetrical; most frequent MCP, wrist, PIP

Disease: ?

RA

Anatomical Distribution:

Asymmetrical; most frequent knee, hip, DIP, 1st CMC

Disease: ?

OA

Anatomical Distribution:

Asymmetrical; most frequent sacroiliac joint vertebral column, hip

Disease: ?

Spondyloarthropathies AS

Anatomical Distribution:

Asymmetrical; 1st MTP, small jts. knee

Disease: ?

Gout

Anatomical Distribution:

Asymmetrical; knees, ankle, hip

Disease: ?

Septic Arthritis

Anatomical Distribution:

Symmetrical; small jts of hands and knees

Disease: ?

SLE