24 Questions
What is the recommended treatment approach for patients who fail to respond or cannot tolerate NSAIDs?
Biologic therapy with either TNF inhibitors or secukinumab
Which medication has no impact on spinal symptoms or disease progression in SpA?
Methotrexate
What is the typical age range and sex affected by Reactive arthritis?
Young men
What is the characteristic skin feature of Reactive arthritis?
Keratoderma blennorrhagica
What is the typical duration of the first attack of Reactive arthritis?
2 to 4 months
What is the likelihood of recurrent arthritis in patients with Reactive arthritis?
More than 60%
What is the primary method of diagnosis for ankylosing spondylitis?
MRI of the sacroiliac joints
What is the frequency of uveitis in patients with Reactive arthritis during the first attack?
Rare
What percentage of ankylosing spondylitis patients are usually positive for HLA-B27?
95%
What is the typical presentation of Reactive arthritis?
Acute-onset, inflammatory enthesitis, spinal inflammation and/or oligoarthritis
What is the most common extra-articular feature of ankylosing spondylitis?
Anterior uveitis
What is the primary reason for fatigue in ankylosing spondylitis patients?
All of the above
What is the characteristic radiographic feature of ankylosing spondylitis in the thoracolumbar spine?
Bridging syndesmophytes
What is the primary goal of management in ankylosing spondylitis?
All of the above
What is the recommended treatment for ankylosing spondylitis patients with pain and inflammation?
NSAID use once daily or slow release taken at bedtime
What is the primary role of physical therapy in ankylosing spondylitis management?
To improve mobility and prevent deformity
What is the characteristic feature of Axial Spondyloarthropathy (AxSpA) visible on MRI?
Inflammatory changes in the entire axial skeleton
What is the primary distinguishing feature of SpA compared to RA?
Non-synovial musculoskeletal inflammation
What is the percentage of association with HLA-B27 in ankylosing spondylitis?
95% or more
What is the typical symptom of Axial Spondyloarthropathy (AxSpA)?
Low back pain radiating to the buttocks or posterior thighs
What is the suggested pathogenesis of SpA?
An aberrant response to infection in genetically predisposed individuals
What is the characteristic feature of Axial Spondyloarthropathy (AxSpA) in its later stages?
Bony changes with syndesmophytes and ankylosis
What is the common feature of Reactive Arthritis (ReA)?
Enthesitis and dactylitis
What is the association between Reiter’s disease and bacterial dysentery or chlamydial urethritis?
Reiter’s disease is a consequence of bacterial dysentery or chlamydial urethritis
Study Notes
Spondyloarthropathies (SPA)
- A group of inflammatory musculoskeletal diseases with overlapping clinical features, associated with HLA-B27.
- Includes axial spondyloarthritis (AxSpA), ankylosing spondylitis (AS), reactive arthritis (ReA), psoriatic arthropathy, enteropathic arthritis, and others.
Pathogenesis
- Aberrant response to infection in genetically predisposed individuals.
- Triggering organism may be identified (e.g., bacterial dysentery or chlamydial urethritis) or remain obscure.
Axial Spondyloarthropathy (AxSpA)
- Includes classical ankylosing spondylitis (AS) as well as axial spondyloarthritis.
- Characterized by inflammatory changes in the entire axial skeleton (visible on MRI), bony changes with syndesmophytes and ankylosis develop later.
- Symptoms include low back pain radiating to the buttocks or posterior thighs, early morning stiffness, and musculoskeletal symptoms at entheses.
Clinical Features of AxSpA
- Low back pain radiating to the buttocks or posterior thighs.
- Early morning stiffness exacerbated by inactivity and relieved by movement.
- Musculoskeletal symptoms may be prominent at entheses.
- Sacroiliitis and structural spinal changes are seen on X-ray, eventually progressing to bony fusion of the spine.
Reactive Arthritis (ReA)
- Affects young men, following an episode of bacterial dysentery or nonspecific urethritis (formerly known as Reiter’s disease).
- Present with acute-onset, inflammatory enthesitis, spinal inflammation, and/or oligoarthritis affecting the lower limbs.
- Symptoms of urethritis and conjunctivitis may be present.
Clinical Features of ReA
- Insidious onset of single joint involvement, minimal features of urethritis and conjunctivitis, and no clear history of trigger illness.
- Achilles tendinitis or plantar fasciitis may occur.
Skin and Nail Features of ReA
- Circinate balanitis: causes painless vesicles on the glans of the penis.
- Buccal erosions.
- Keratoderma blennorrhagica: waxy, yellow-brown skin lesions, particularly on the palms and soles.
- Nail dystrophy identical to psoriatic nail dystrophy.
Course of the Disease (ReA)
- First attack is usually self-limiting, with spontaneous remission within 2 to 4 months.
- Recurrent arthritis develops in more than 60% of patients.
- Uveitis is rare in the first attack but occurs in 30% of patients with recurring arthritis.
Investigations
- Diagnosis is made by MRI of the sacroiliac joints.
- X-rays show sacroiliitis with irregularity, sclerosis, joint space narrowing, and fusion.
- Ultrasound detects entheitis at the enthesis.
- ESR and CRP are usually raised in active disease but may be normal.
- HLA-B27 is usually positive in 95% of AS patients.
Management and Prognosis
- Patient education, NSAID use, and physical therapy with mobilizing exercises.
This quiz introduces spondyloarthropathies, a group of inflammatory musculoskeletal diseases with overlapping clinical features, including axial spondyloarthritis, ankylosing spondylitis, and psoriatic arthropathy.
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