Term
Spondyloarthropathies(SpA) |
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Definition
•Ankylosing Spondylitis (AS)
•Reactive Arthritis (ReA) – Reiter Syndrome
•Psoriatic Arthritis/Spondylitis (PsA)
•Enteropathic Arthritis (EnA)
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Term
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Definition
•Inflammation of axial spine (sacroiliitis and spondylitis)
•Asymmetric peripheral arthritis
•Enthesopathy
•Inflammatory eye disease
•Mucocutaneous features
•Absence of rheumatoid factor
•Familial aggregation – HLA-B27
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Term
Ankylosing Spondylitis (AS) –
Definition |
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Definition
•Chronic inflammatory disease of sacroiliac joints and spine (Spondylitis).
•Extraspinal manifestations in some patients.
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Term
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Definition
•Young adult onset common – Average 26 years old.
•Males > Females – 5:1
•Caucasian and Native American > African, African-American, Eskimo populations.
•Ethnic frequency of AS generally but not exclusively reflects prevalence of HLA-B27.
- Haida Native Americans – 6%
- Caucasian (UK and USA) – 0.5-1.0 (B27 9%)
- African and Eskimo – 0.1% (B27 2%)
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Term
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Definition
•SPONDYLITIS – Inflammatory pain and stiffness in buttock (sacroiliitis) and lower back (spondylitis)
- Worse in morning and with inactivity
- Improved with activity
- Calcification of spinal ligaments gradually ascends spine over years.
- Costo-vertebral joint involvement manifested by decreased chest expansion.
- May involve lumbar, thoracic and cervical spine.
•ENTHESITIS – Entheses are attachments of tendons and ligaments to bone
- Spine – pain and “squaring” of vertebrae
- Calcaneus – Plantar fascia and Achilles’ tendonattachments causing heel pain and bone spurs
•SYNOVITIS – Inflammation of synovial joint lining.
- Lower extremity most common
- Inflammatory, oligoarticular, asymmetric.
- Often episodic rather than persistent like RA.
- May have joint erosions.
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Term
AS – Clinical Features SYSTEMIC / EXTRA-ARTICULAR
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Definition
SYSTEMIC / EXTRA-ARTICULAR
•EYES – Acute anterior uveitis; Conjunctivitis
•CARDIOVASCULAR – Aortitis and aortic regurgitation (1%).
•PULMONARY – Fibrosis in upper lobes (1%); Shortness of breath from costovertebral involvement.
•NEUROLOGIC – Cord and nerve root lesions after spinal fracture with subluxation.
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Term
AS – Physical Examination |
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Definition
•Tenderness over sacroiliac joints
•Decreased mobility of spine
- Schober’s Test
•Kyphosis
- Increased Occiput-Wall Distance
•Decreased chest expansion
- Less than 2.5 cm is abnormal
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Term
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Definition
Non-specific indicators of chronic inflammation may be detected:
- Elevated ESR
- Elevated C-reactive protein
- Elevated platelet count
- Anemia
Rheumatoid factor may be positive in up to 15% of patients with “seronegative spondyloarthropathy” (SNSA) but is probably just a coincidence.
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Term
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Definition
-HLA-B27 is positive in 95% of white patients with Ankylosing Spondylitis (A-A 50%).
-HLA-B27 Is present in ~9% of the U.S. white population, and back pain occurs in most people at some point in their lives.
-Therefore, HLA-B27 neither specific nor diagnostic for either the etiology of back pain or the diagnosis of AS or other SpA.
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Term
AS – Radiographic Features |
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Definition
Radiographic characteristics of SpA (AS in particular):
Sacroiliitis
Syndesmophytes
Bamboo spine
Spinal Fusion
Enthesitis
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Term
Reactive Arthritis/Reiter Syndrome (ReA/RS) |
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Definition
Triad of
Arthritis (asymmetric oligoarthritis)
Conjunctivitis
Non-gonococcal Urethritis
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Term
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Definition
Typically follows Gastrointestinal or Genitourinary infection with:
Campylobacter
Shigella
Salmonella
Yersinia
Chlamydia
The arthritis represents an autoimmune reaction to the bacteria and does NOT necessarily represent persistent active infection.
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Term
ReA- Spondylitis and Arthritis |
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Definition
•Peripheral arthritis
- Inflammatory asymmetric oligoarthritis
- Lower extremity predominance
• Enthesitis - Common
•Sacroiliitis – less common
- 20 % by radiographs
- 50% low back pain
•Spondylitis with ankylosis – uncommon
- 10 to 12 % of patients
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Term
Reiter Syndrome :
Mucocutaneous manifestations |
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Definition
Conjuctivitis
Keratoderma blennorhagica
Circinate balanitis
Painless oral ulcers
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Term
Psoriatic Arthritis (PsA) |
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Definition
5 Types of Joint Involvement in PsA
•Predominant DIP involvement
•Arthritis Mutilans
•Symmetric polyarthritis similar to RA
•Asymmetric oligoarthritis
•Spondyloarthropathy – 20 - 40%
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Term
PsA – Peripheral Arthritis |
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Definition
•Inflammatory, asymmetric oligoarthritis
•Arthritis occurs in 7-42% of psoriatic patients vs 2-3% of general population
•“Sausage swelling” from enthesitis
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Term
PsA – Extra-articular Manifestations |
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Definition
•Cutaneous Psoriasis
•Nail Involvement
- 90% of psoriatics with PsA
- 41% of psoriatics without PsA
•Ocular Manifestations
- Conjunctivitis or iritis in 7 - 33%
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Term
Distinctive Features of Each SpA |
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Definition
AS: Sacroiliitis, axial arthritis, rarely peripheral arthritis
ReA: Follows infection; Triad of arthritis, urethritis and conjunctivitis in classic form Mucocutaneous lesions prominent
PsA: Silvery scaly plaques on skin, nail changes
EnA: Inflammatory Bowel Disease (IBD) or similar history
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Term
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Definition
1. Continued activity and Physical Therapy with special emphasis on postural training (sleep without a pillow).
2. Drug therapy - Similar to other non-crystalline inflammatory arthropathies such as rheumatoid arthritis:
NSAIDs
TNF inhibitors – adalimumab, etanercept,
inflixamab – demonstrated to modify AS disease course.
Sulfasalazine – main benefit to peripheral arthritis.
Methotrexate – no conclusive evidence of benefit.
Leflunomide – no conclusive evidence of benefit.
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