Cardinal feature of spondylarthropathies:

-inflammation of sacroiliac joints (sacroilitis), spine (spondylitis, tendon insertion sites (enthesis), and uveitis

-seronegative (no RF), no ANA, or other autoimmune antibodies 

Epidemiology of Spondylarthropathies:

-ankylosing spondylitis: much more common among adolescent boys and young men; may be that women just get it milder and are not diagnosed

-reactive arthritis: common in men when following GU Chlamydia infection, but after dysentery, equal sex distribution 

-inflammatory arthritis (psoriatic) affects approx. 5-8% of those w/ psoriasis; 10-15% of those w/ UC or Crohn's; these usually come about in adulthood

-prevalence increases w/ HIV 

HLA-B27

-frequency among whites is low (6-8%)

-90% of pts. with ankylosing spondylitis are (+)

-80% of pts. with reactive arthritis or juvenile spondyloarthropathy are (+)

-50% of pts. with inflammatory arthritis are (+) but spondylitis HAS to be present 

Common pathogens to reactive arthritis

-Chlamydia trachomatis (GU infection)

-Shigella, Salmonella, Campylobacter, Yersinia (diarrheal infections)

-Klebsiella (pneumonia)

-HIV

Common clinical presentations of spondylarthropathies 

-sacroilitis and spondylitis are hallmark and NOT seen in any other rheumatic diseases 

-may develop insidiously with low back or gluteal pain or cause severe pain

-significant morning stiffness (hours of duration), pain with inactivity 

-sacroilitis may mimic sciatica 

-joint become still and painful with increasing reduced ROM as bony fusion occurs 

Extra-articular manifestations - Uveitis 

-commonly seen; especially HLA-B27+

-disease of anterior chamber of eye

-presents acutely, is painful and accompanied by redness and blurred vision

-can lead to blindness

-may be only sx assoc. with spondylarthropy, so pts. need to be checked for this!

Extra-articular: lung and others

-results from involvement of spine and costovertebral joints, mimics restrictive lung disease

-fusion on spine increases risk of fracture

-may increase risk of kyphosis 

-aortitis

-pulmonary fibrosis

-spinal cord compression

Peripheral arthritis assoc. w/ spondylarthropathies

-begins as episodic, asymmetrical, oligoarticular

-often involves lower extremities 

-can progress and become chronic and disabling 

*unique feature is fusiform swelling of entire finger or toe, referred to dactylitis or "sausage digits"

Radiographic features

-sacroilitis is usually the earliest sign and results in sclerosis and erosions of the sacroiliac joint w/ eventual fusion

-bony erosions and osteitis may occur at sites of enthesis 

-secondary changes such as ossification of annulus fibrosis, calcification of spinal ligaments, bony sclerosis and squaring of vertebral bodies 

-**last know as "shiny corner sign"

Specific Clinical Features of Reactive (Reiter's) Arthritis

-urethritis, conjunctivitis (distinct from uveitis), dermatological problems

-keratoderma blennorrhagicum: papulosquamous rash on palms and soles of feet

-circinate balanitis: rash appearing on penile glans or shaft of men 

-80% positive for HLA B27

Specific Clinical Features of Psoriatic Arthritis

Five identifiable clinical patterns:

1. DIP involvement w/ nail pitting

2. asymmetrical oligoarthropathy of both large and small joints

3. arthritis mutilans: severe, destructive form

4. symmetrical polyarthritis: identical to rheumatoid

5. spondyloarthropathy 

-spondylitis or sacroilitis can occur with any of these as well

-50% HLA B27 + if spondylitis or sacroilitis is present 

-little or no temporal association b/w skin disease and arthritis 

Specific Clinical Features of Enteropathic Arthritis 

-IBD, Crohn's, and UC are frequently assoc. with spondylarthopathy and peripheral arthritis 

-arthritis is usually nonerosive and oligoarticular

Treatment of Spondylarthropathies 

-patient education is essential and helps with identifying uveitis 

-PT including daily stretching program, postural adjustments, strengthening useful in maintaining proper bony alignment, reducing deformities and maximizing function

-orthopedic surgery may be useful in correcting deformities 

-NAIDS** - most important medical therapy 

-intra-articular glucocorticoid injections may provide temporary relief 

-TNF blockers