| What is reactive arthritis? | Aseptic arthritis occurs 1 month of a primary infection, acute, assymetric oligoarthritis
Extra-articular (ocular inflammation, enthesitis/mucocutaneous lesions [Balanitis circinata ring shaped skin on glans of penis/ keratoderma blennorhagia], Urethritis, Rarely Carditis)
Duration 4-5 months of arthritis, recurrent attacks, chronic/recurrent peripheral arthritis, sacroilitis, or spondylitis. |
| What is spondyloarthritits? | Heterogenous group of chronic inflammatory arthropathies affecting mainly the spine with some peripheral symptoms in enthesis and certian extra-articular sites.
Enthesis is distiguishing feature of SPA, associated with HLAB27.
Sero - for RF and ANA.
Important priniciple if pt comes with pain waking him/ at morining we have inflammatory pain, if we have a swollen finger either arthritis, dactylitis or spondyloarthritis.
Here we have spine involvement |
| What are the types of spondyloarthropathies? | Ankylosing spondylitis, Juvenile chronic arthritis, Psoriatic arthritis and reactive arthritis (these are the most common)
We also have arthritis associated with IBD, and undifferentiated SpA |
| What are clinical aspects of SpA? | According to subgroup (axial or peripheral, Psoriatic or reactive (infection))
Manifestations (Rheumato: axial involvement, peripheral arthritis, enthesopathy.
Extra-articular: Acute anterior uveitis (eye inflammation) and cardiac involvement
We have a genetic background: HLAB27 and family hx, and specific manifestations: psoriasis and IBD... |
| How do different subgroups of SpA differ in prevalence of clinical manifestations? | . |
| How is epidemiology of SpA? | Most common one is ankylosing spondylitis (AS) 60% have + HLAB27 (except undifferentiated only 25%) however chance of pt w/ + HLAB27 to get SpA is 1-5% could get to 20% if a relative has it.
More common in males (except psoriatic where equal proportions)
Mean age 26 years from late adolescence to 40 years, we usually have delay in dx in HLAB27 - pt. |
| How is pathogenesis of SpA? | Genetics (very tricky, first degree relatives increase risk, HLAB27 role in MHC I, microbes which can cross react with B27 Ab to bacteria this is known as molecular mimickery, role of gut >50% have ileal disease microscopic, breakdown of gut blood barrier can be inciting event of SpA)
Inflammation (Most important is Enthesis, typical Sacroiliac joint, vertebral bodies, peripheral joint synovium, GI and eye, limited histopathology.
Starts with early sacroilitis, then synovitis with myxoid bone marrow then destroyed bone replaced and endochondral ossification results in bone ankylosis) |
| How are clinical features of SpA? | Inflammatory back pain (IBP, first manifestation 75% of axSpA, lumbosacral junction, inactivity aggrevates and NSAIDs relieve, prolonged morning stiffness (>30min), nocturnal pain wakening, sacroilitis/spondylitis dx by expert criteria 4/5 improve w/exercise, pain at night, insidious onset, age <40, no improvement with rest)
Ankylosis (Ossification of ligaments, costovertebral, sternocostal joints. Loss of lumbar lordosis, thoracic hyperkyphosis, forward stooping of neck, restricted spinal movement muscle spasms, respiratory failure decreased vital capacity and increased residual if hip involved we have bending forward)
Osteoporosis fracture (spinal osteoporosis increase risk of fracture with lack of mobility and inflammatory cytokines, IBD higher risk)
Peripheral Arthritis (Assymetric, oligoarticular, lower limbs, mechanical microtrauma, upper limb if PsA bilateral symmetrical polyarticular presentation. DIP joints see dactylitis sausage fingers))
Dactylitis (Very characteristic, ReA, PsA and undiff., sausage fingers/toes due to synovitis, enthesis, tenosynovitis, soft tissue swelling)
Anterior chest wall pain (axial, 15% of pt, stero/clav/manubr, reduced chest expansion, can involve hips more than shoulders see hip pain, early bilateral for juvenile destruction and disability |
| How is enthesis clinical manifestation of SpA? | DIstinguishing feature, most typical is heel pain (posterior/inferior), in morning as soon as pt sets foot on floor and improves with ambulation, can be disabling and resist std anti-rheumatic tx, typically at achilles tendon plantar pain/ fasculitis
Number of swollen joints is 44, 0-44 grading |
| What are comorbidites associated with SpA? | Cardiovascular (atherosclerosis), Osteoporosis/fracture, and MR 2 fold increased |
| What are lab findings in SpA? | No specific lab tests
Seronegative disease
ESR and CRP elevation (in only 40% of the cases CRP Elevation -> structural progression, CRP predictor of good response to treatment)
HLAB27 (Found in 90% of patients with SPA (not in Lebanon)
8% in healthy subjects Not diagnostic value) |
| What are conventional image findings in SpA? | Conventional Radio (not helpful early, structural changes reflect changes by inflammation not inflammation itself, we may get radiographic sacroilitis [blurring of cortical margins of subchondral bone, erosions and sclerosis, joint space appears wider than fibrous, bony ankylosis]
X ray has a New York grading system [ I sus, II evidence of erosion/sclerosis, III erosions and early ankylosis, IV total ankylosis, sensitivtiy first year 0%, after 10 years 60%, in spine we see squaring of vertebra secondary to erosions, vertebral enthesitis may cause sclerosis of upper and lower vertebra appear shiny corners romanus sign, syndesmophyte formation, bamboo spine |
| What are MRI findings in SpA? | Early detection, Axial SpA ASAS criteria include inflammation in SI joints seen on MRI, It can produce excellent evidence of sacroilitis and enthesitis.
T2 weighted fat suppressed fast spin-echo and short Tao inversion recovery (STIR) sequences. Assessment of bone marrow edema (BMO) represents a sign of inflammation.
Positive MRI put by ASAS/OMERACT MRI working group (active inflammation lesion of SI, BMO/osteitis clear located in typical anatomical sites (subchondral/periarticular), solitary BMO there should be 2 consecutive slices, if more BMO lesions on one slice, if we see inflammation it is sufficient, presence of inflammation alone is not enough |
| What is axial SPA/ AS? | Spinal pain resulting in limitation of spinal mobility, radiologic evidence of structural changes in SI joints and spine, enthesitis (40-60%) acute anterior uveitits (30-50%), disease course highly variable (axial inflammation + restricted spine mobility and decreased function), starts early adulthood, lifetime impact of stiffness, fatigue, limitation of social activities and participation |
| What are the new york criteria for AS? | Diagnosis (Clinical [low back pain and stiffness for more than 3 months improves with exercise not relieved by rest, limitation of spinal motion both saggital and frontal plane, and limitation of chest expansion relative to normal values]
Radio [Sacroilitis grade >2 bilaterally/ grade 3-4 unilaterally])
Grading (definite dx if radio finding + 1 clinical, probable if three clinical , or radio alone) |
| What are signs and symptoms of AS? | Peripheral manifestations (enthesitis, peripheral arthritis, dactylitis)
Extra-articular (anterior uveitis, subclinical inflammation of gut, lung abnormalities, bone abnormalities, renal, cardiac, psoriasis, and IBD.) |
| How is ASAS criteria for peripheral SpA? | Peripheral Arthritis/ Enthesitis/ Dactylitis + either >1SpA feature [uveitis, psoriasis, Crohn's, infection, HLAB27, Sacroilitis] or >2 SpA feature. |
| What is Psoriatic Arthritis? | Prevalence among caucasians 1-3%, female=male, 10-30% have PsA and psoriasis (Skin before most, simultaneous 20% and arthritis before 15%), arthritis onset 30-50 years, no correlation between skin and joints
Manifestations (peripheral assymetrical oligoarticular, polyarticular symmetrical, assymetrical with DIP involvement and dactylitis, predominant spondylitis 5%, arthritis mutilans (pencil in cup on Xray)
Juxta-articular new bone formation, absence of peri-articular osteopenia, and preservation of the joint space.
We have nail involvement |
| What is SAPHO classification of PsA? What is caspar classification? | Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis.
Dermato entity (acne and pustulosis), synovitis of anterior chest wall and SI joint, spondylodiscitis, enthesopathy, aseptic osteomyelitis / hyperostosis.
7 criteria, more than 3 points gives PsA. |
| What is enterohepatic arthritis? | occurrence of inflammatory arthritis in patients with IBD UC or CD
The prevalence of arthritis 17% to 20%, with a higher prevalence in Crohn’s disease
Peripheral arthritis (Oligoarticular , usually transient, migratory and non-deforming generally self-limiting, but recurrences)
Axial involvement and enthesitis may become chronic and destructive. Intestinal symptoms usually before with or after joint involvement |
