Rheumatology Lecture Notes

Rheumatology Lecture Notes on Seronegative Spondyloarthropathies (SPA)

Overview of Spondylarthritis

• Spondylarthritis: Family of disorders with similar clinical features

• Disorders Included (PEAR):

  • P: Psoriatic Arthritis

  • E: Enteropathic Spondyloarthropathies

  • A: Ankylosing Spondylitis

  • R: Reactive Arthritis

Clinical Features of SPA

• Seronegative for Rheumatoid Factor

• Inflammatory Back Pain: Lasting over 3 months

• Sacroiliitis: Inflammation of sacroiliac joints

• Peripheral Joint Inflammation

• Extra-Articular Symptoms:

  • Eye inflammation

  • Skin disease, particularly psoriasis

  • Potential bowel mucosa inflammation

Ankylosing Spondylitis (AS)

• Prevalence: Most common form of seronegative spondyloarthropathy

• Typical Onset: 3rd/4th decade of life (often in 20s), rare beyond 45

• Conditions Affected:

  • Sacroiliac joints

  • Intervertebral discs and peripheral joints

• Types:

  • Primary: No associated disorder

  • Secondary: Associated with reactive arthritis, psoriasis, ulcerative colitis, Crohn's

• Symptoms:

  • Chronic back pain and progressive spinal stiffness

• Pathophysiology:

  • Genetic predisposition (HLA-B27)

  • Environmental triggers

  • Inflammatory responses lead to joint erosion and fusion

• Clinical Presentation:

  • Inflammatory back pain with significant stiffness and pain

  • Pain worsens with inactivity; morning stiffness lasting over 1 hour

  • Typical sacroiliac joint involvement

  • Extra-articular symptoms include systemic issues (e.g., fever, weight loss) and eye issues (e.g., uveitis)

Physical Examination for AS

• Spine Assessment:

  • Loss of normal lumbar lordosis

  • Restricted mobility in all planes

• Chest Expansion Test:

  • Measured by tape around the chest at nipple level; normal increase at least 5 cm

• Tenderness:

  • SI joints and other insertion sites

• Evaluation for Extra-Articular Manifestations

Diagnostics for AS

• Lab Findings: Generally nonspecific

• Imaging:

  • Key for diagnosis - pelvic and spine X-rays for evidence of sacroiliitis

  • Look for syndesmophytes, leading to the characteristic 'bamboo spine' appearance

Management of AS

• Treatment Goals:

  • Relieve symptoms, maintain mobility, prevent complications, minimize extra-articular effects

• Management Strategies:

  • NSAIDs: First line treatment

  • Biological Agents and DMARDs: For moderate to severe disease

  • Glucocorticoids: Not recommended for long-term use

• Referrals:

  • Rheumatology for diagnosis and management

  • Other specialties as needed (GI, Dermatology, Ophthalmology)

Reactive Arthritis (Reiter Syndrome)

• Definition: Arthritis developing post-infection, frequently with GI or GU origins

• Symptoms:

  • Classic triad: arthritis, urethritis, conjunctivitis

  • Symptoms arise 1-4 weeks post-infection

Clinical Presentation of Reactive Arthritis

• Extra-Articular Symptoms include systemic manifestations (fatigue, weight loss) and dermal issues (e.g., keratoderma blennorrhagia)

Diagnostics for Reactive Arthritis

• Laboratory Findings:

  • Elevated inflammatory markers, negative RF

  • Stool culture and specific swabs for infections as needed

Management of Reactive Arthritis

• Treat underlying infection

• NSAIDs: Initial treatment for pain

• Corticosteroids: Intra-articular for refractory cases

Psoriatic Arthritis

• Overview: Chronic inflammatory arthritis associated with psoriasis

• Symptoms:

  • Joint pain worsening with immobility

  • Nail changes and ocular inflammation

Diagnostics and Management of Psoriatic Arthritis

• Imaging: Particular changes in hands and feet

• Medication: NSAIDs as first-line, DMARDs when needed

Polymyalgia Rheumatica and Giant Cell Arteritis

• PMR: Characterized by stiffness and aching, especially in shoulders and pelvic girdle

• GCA: Age > 50; headache, jaw claudication; associated with blindness risks

• Treatment: Corticosteroids are standard; careful monitoring needed

Raynaud Phenomenon

• Definition: Episodic vasospasm causing color changes (white, blue, red) in fingers/toes

• Types: Primary (no underlying condition) vs. Secondary (associated with autoimmune disorders)

Rheumatoid Arthritis (RA)

• Overview: Autoimmune disease causing symmetric inflammatory polyarthritis

• Pathophysiology: Features include synovial lining inflammation leading to joint destruction

• Presentation: Swollen, tender joints, morning stiffness lasting >1 hour

• Diagnostics: Positive RF and anti-CCP with a score of ≥6 according to diagnostic criteria

• Management: DMARDs as first-line, managing complications from RA therapy

Systemic Lupus Erythematosus (SLE)

• Pathophysiology: Autoantibodies lead to systemic issues

• Clinical Features: Varied, including fatigue, rashes, arthralgias

• Management: Avoid sunlight; immunosuppressive therapy may be required

Vasculitis

• Definition: Inflammation damaging blood vessels, often serious

• Key Types: Large vessel (GCA), medium vessel (Polyarteritis Nodosa), small vessel

• Management: Depends on type and severity; rheumatology referral is generally recommended

Sjogren’s Disease

• Overview: Exocrine gland dysfunction leading to dryness

• Symptoms: Ocular and oral dryness, increased risk of dental caries

• Management: Artificial tears, sugar-free gum; monitor for associated conditions

Fibromyalgia

• Definition: Characterized by chronic widespread pain

• Symptoms: Fatigue, cognitive disturbances, and mood disorders

• Management: Education, cognitive behavioral therapy, medications like SSRIs or TCAs

Sarcoidosis

• Overview: Granulomatous disease impacting multiple systems

• Key Symptoms: Pulmonary issues, potential for systemic involvement

• Management: Corticosteroids for severe cases; many resolve spontaneously

Juvenile Idiopathic Arthritis (JIA)

• Overview: Common childhood arthritis requiring persistent symptoms for diagnosis

• Management: Early intervention with NSAIDs; specialized pediatric care recommended.