Psoriatic Arthritis, Ankylosing Spondylitis, Reactive Arthritis, and Enteropathic Arthritis

Psoriatic Arthritis

• Affects males and females equally.
• 14-30% of patients with psoriasis develop psoriatic arthritis.
• Most patients with psoriatic arthritis have psoriasis first.
• Increased risk with smoking if no underlying psoriasis, but decreased risk if psoriasis is already present (smoking paradox).

Clinical Symptoms

• Nail pitting
• Onycholysis
• Dactylitis (sausage digit)
• Enthesitis: inflammation at tendon/ligament insertion into bone.
• Synovitis
• Most common: Psoriatic arthritis (35% of patients).

Radiographic Changes

• Pencil and cuff deformity (most common at distal interphalangeal joints).
• Ivory phalanx: sclerosis of distal phalanx, most commonly at the hallux, associated with nail changes of the same digit.
• Arthritis mutilans: severe, advanced condition.
  • Telescoping of digits: end-stage disease, osteolysis, pencil-in-cup deformities, fusion of joints.

Treatment

• Depends on severity.
• Escalates from oral NSAIDs to DMARDs (methotrexate, sulfasalazine) and anti-TNF medications (etanercept/Enbrel, infliximab/Remicade, Humira).

Case Study

• 39-year-old female with pain in right distal eyelids, history of psoriasis.
• X-ray shows erosions of central trochlea and lunula with periostitis and ivory phalanx.
• Likely diagnosis: psoriatic arthritis.
• IV phalanx → changes to nail.

Case Study

• 49-year-old female with painful bilateral feet, progressive hammering of digits, skin condition treated with topical steroids.
• ESR = 50, CRP = 5 (elevated).
• Rheumatoid factor negative (seronegative).
• X-rays show pencil-in-cup deformity at IPJs.
• Diagnosis: psoriatic arthritis.

Ankylosing Spondylitis

• More common in males.
• Stiffness, worsens throughout the day.
• Symptoms develop over >3 months.
• Bilateral sacroiliitis (most commonly associated).
• Pain and stiffness worse with rest, better with movement.
• Flattening of lower spine.

Extra-Articular Manifestations

• Restrictive pulmonary disease: vertebral inflammation restricts movement.

Schrober's Test

• Measures lower back flexibility.
• Patient flexes lower back. Measure distance between L5 vertebrae and 10 cm above, 5 cm below.
• Normal: >20 cm with flexion.
• Ankylosing spondylitis: Less than 20 cm

Wall Test

• Occiput to wall distance: Have patient stand against wall.
• Normal: Head touches wall.
• Abnormal: Increased distance from wall. For example 31 cm or 24 cm.

Other Tests

• Cervical rotation test: Decreased motion.
• Lateral spinal flexion test: Move less than 10 cm.

Disease Progression

• Decreased lumbar lordosis
• Kyphosis
• Flattening of Lumbar Lordosis

Radiographic Changes

• Buzzword: bamboo spine.
• Romanus lesions.
• Shiny corners on MRI.
• Vertebral fractures are more likely.

Diagnostic Testing

• Elevated ESR and CRP.
• >90% positive HLA-B27.
• Sacroiliitis necessary for diagnosis (spinal and/or mastoid).

Treatment

• Oral NSAIDs, steroids, anti-TNF medications.

Case Study

• Patient undergoing foot/ankle surgery with history of ankylosing spondylitis.
• Pulmonary function testing required to evaluate lung disease.
• Scoliosis and Ankylosing Spondylitis Reduces Functional Residual Capacity And Vital Capacities so Pulmonary Function Test is Necessary.

Case 2

• 45-year-old male with ankylosing spondylitis undergoing ORIF of right ankle.
• Besides pulmonary tests, need cervical spine X-ray.
• Patients With Spine Disease Should Be Adequately Assessed For Problems With Neck and Jaw.
• Assess neck and jaw for intubation problems with neck movement

Reactive Arthritis

• Also known as Reiter’s syndrome.
• Classic triad: "Can't see, can't pee, can't climb a tree".
• More common in young males.
• Typically follows an infection.
• Most common bacteria: Chlamydia trachomatis. Treatment: tetracycline (doxycycline).
• Also associated with Neisseria gonorrhea.

Symptoms

• HLA-B27 association.
• Joint arthritis: Most commonly affects knee joint, no infection within joint.
• Enthesitis, dactylitis, conjunctivitis, urethritis.

Keratoderma Blennorrhagica

• A hyperkeratotic squamous rash of the palms and soles
• Highly associated with reactive arthritis.

Diagnosis

• Clinical diagnosis.
• Inflammatory markers, HLA-B27.
• Check for leukocytosis.

Treatment

• Treat underlying infection (e.g., tetracycline for chlamydia).
• Usually self-limiting, resolves within 3-5 months.

Case 1

• 26-year-old male with right ankle pain, plantar and posterior heel pain, history of recent unprotected sexual encounter.
• X-ray shows enthesophytes, calcaneal spur both superiorly and plantarly, and keratoderma blennorrhagica.
• Diagnosis: Reactive Arthritis.
• The scenario described above is a classic example of reactive arthritis.

Case 2

• Which of the following is associated with reactive arthritis and is associated with inflammatory bowel disease?
  HLA-B27.
• (A) Symmetric: Small Joints. (E) Is best Answer

Enteropathic Arthritis

• Joint pain and history of ulcerative colitis and/or Crohn’s disease.
• 5-20% of patients with inflammatory bowel disease develop seronegative spondylarthropathy.
• Can present with axial and/or peripheral involvement.
• Joint pain may or may not coincide with IBD flares.
• IBD-associated arthritis is non-destructive of joints.

Extraintestinal Manifestations of IBD

• Erythema Nodosum
• Pyoderma Gangrenosum
• Aphthous Stomatitis
• Episcleritis Uveitis

Treatment

• Graded.
• Treat underlying IBD.
• Avoid NSAIDs.

Case Study

• Patient with sore ankle joints and wrists, history of chronic recurrent skin papules and plaques, pustular eruptions on face and arms with erythoderma.
• Erythoderma - high risk factors for disease

Case 2

• Patient presents with acute monoarthritis of the left ankle. He has a family history of psoriasis, but no skin lesions. Joint aspiration reveals monosodium urate crystals. What other tests should be done?
  x-ray showing cigar shape digits
• Gout confirmed by monocentric Uric Acid Crystals of Microsoft exam; Don't study scout specin in formalin.
• Bony cirrhosis is most commonly associated with Zorasis.