Spondyloarthropathies - November 2023 PDF

Spondyloarthropathies November 2023 Emmanuel Katsaros, DO, FACR SPONDYLOARTHROPATHY Non-radiographic axial Spondyloarthroapthy Ankylosing spondylitis Reactive arthritis Psoriatic arthritis Inflammatory Bowel Disease (IBD) associated with arthritis or spondylitis Juvenile Onset Spo...

Spondyloarthropathies November 2023 Emmanuel Katsaros, DO, FACR SPONDYLOARTHROPATHY Non-radiographic axial Spondyloarthroapthy Ankylosing spondylitis Reactive arthritis Psoriatic arthritis Inflammatory Bowel Disease (IBD) associated with arthritis or spondylitis Juvenile Onset Spondylitis  Objectives Formulate differential diagnoses based on different demographic characteristics of the seronegative spondyloarthropathies (SSpA) Distinguish the different SSpAs’ clinical features and compare to other types of arthritis Distinguish the unique laboratory and x-ray features Develop a basic treatment plan for each of the SSpAs  Spondyloarthropathy A group of disorders characterized by inflammation of the spine Seronegative because they are rheumatoid factor negative ANKYLOSING SPONDYLITIS Ankylosing Spondylitis-What are the key symptoms? Ankylosing spondylitis (AS) is a chronic inflammatory disease of the axial skeleton manifested by back pain and progressive stiffness of the spine. It also affects joints and extraarticular structures.  AS Pathology Sacroiliac joint: subchondral granulation tissue, marrow edema, synovitis and pannus formation followed by erosions. Also enthesitis, scattered areas of new cartilage formation, and osteitis. Eventually eroded joint margins are replaced by fibrocartilage regeneration and ossification. The joint then is obliterated (ankylosed/fused). AS Pathophysiology – What type of treatment should I use? HLA-B27 is an MHC Class I Molecule – Found in 8% of Whites and 4% of Blacks Antigen presented by HLA-B27 is recognized by reactive CD8+ T Cells to cause inflammation The B-27 heavy chain of HLA-B27 has an unusual tendency to misfold, which has been thought to be proinflammatory, producing IL-23. IL-23 stimulates Th-17 cells to produce IL-17. IL-17 stimulates macrophages and neutrophils to produce TNF-a Increased IL-12 has also been found  AS Demographics- Can women get AS? U.S. Prevalence is from 0.2 to 0.5 percent More common among whites than blacks Males more than females: 2-3:1 A peak age of onset between 20 and 30 years Symptoms are first noticed at late adolescence and early adulthood. Median age is 23 In only 5% of patients does the first manifestations occur after the age of 40.  Clinical Manifestations- Inflammatory back pain/stiffness improves with exercise? Onset less than 40-45 Symptoms of AS usually start insidiously with dull low back pain or in the gluteal areas and or posteriorly the knees. Greatly improved with NSAIDS. Back complaints are the first symptoms in approximately 75 percent of patients Morning stiffness which improves with exercise Pain at night  AS Symptoms and Signs Bony tenderness may accompany back pain or stiffness. – Sites of pain include the costosternal junctions, spinous processes, iliac crest, greater trochanters, ischial tubercles and tibial tubercles and heels 25-30% of patients have hip and shoulder arthritis 30% have an asymmetric peripheral arthritis excluding the hips or shoulders  EXTRAARTICULAR INVOLVEMENT Anterior Uveitis Aortitis, Aortic regurgitation, cardiac conduction delays Up to 15 percent have apical pulmonary fibrosis IgA nephropathy Colitis -60% are subclinical  More AS Exam Findings SI tenderness +/- The chest expansion is usually 5 cm or more – An expansion of less than 2.5 cm is abnormal – Impairs pulmonary function Positive Schober test  Laboratory Studies- Does HLA- B27 and back pain make the diagnosis of AS? Laboratory studies are nonspecific. Erythrocyte sedimentation rate (ESR) & C- reactive protein: often elevated Mild normocytic normochromic anemia HLA-B27 positive (90%), but 6% of general population is positive. – 30% chance of getting AS if first degree relative has AS & you are HLA-B27 positive  HLA-B27 Disease Association Ankylosing Spondylitis >90% Reactive Arthritis >50% Psoriatic Arthritis – With Spondylitis >50% – With Peripheral Arthritis >15% AS Radiographic Findings Blurring of the corticial margins Erosions Sclerosis Pseudowidening of joint space Fibrous and bony ankylosing Symmetric  Radiographic findings Straightening Loss of lordosis and scoliosis Reactive sclerosis (osteitis at the corners of the vertebral bodies with subsequent erosions) leading to… Squaring Syndesmophyte (ossificaction) REACTIVE ARTHRITIS  Reactive Arthritis (ReA) What should I look for? An arthritis associated with an infection or previous infection elsewhere in the body Classically: Uveitis, urethritis, and arthritis The peripheral arthritis in spondyloarthropathy is of acute onset and predominantly involves the lower extremities, especially the knees, ankles, and feet. It is typically asymmetrical and often affects only one to three joints  Reactive Arthritis (ReA) Urethritis (Chlamydia Trachomatis, Ureaplasma) Infectious diarrhea (Shigella, Salmonella, Campylobacter, C.Difficile ) Pneumonia (Chlamydia Pneumoniae)  ReA Pathogenesis Bacterial antigens, DNA and RNA have been detected in synovial fluid suggesting the presence of the organism. – However, the specificity of these findings is not clear because similar finings have been found in other rheumatic diseases  ReA Epidemiology What age? What gender? Does HLA-B27 help? The prevalence of HLA –B27 in ReA is over 50% Ages 18-40 year-old, but it can occur in children over 5 and in older adults. Male:Female. 1:1 ReA Clinical Features -What makes this arthritis unusual? Symptoms range from isolated transient monoarthritis or enthesitis to a severe multisystem disease Symptoms are common 1-4 weeks after infection. However, pts may have no clinical or lab evidence of infection Arthritis is usually asymmetric and additive  ReA – Arthritis Features Joints involved: knee, ankle, subtalar, metatarsalphalangeal and to ips, but the wrists and fingers can also be involved. Tendinitis and faciitis ReA Clinical Features: How would the SI arthritis of ReA differ from AS? Constitutional features are common and can include fatigue, malaise fever and weight loss. Spondylitis occurs in 10% of cases – Spinal low back pain, muscle spasms and sacroiliitis (unilateral)  ReA Urogenital Prostatitis Cervicitis Salpingitis Circinate Balinitis: occurs on the glans penis – Vesicles that rupture into painless superficial erosions  Onycholysis – Does my patient have a nail fungus? Onycholysis: nail changes with distal yellowish discoloration  ReA Labs and X-rays- What should I order? ESR and CRP are elevated Half of pts are HLA B-27 positive With long standing disease, marginal erosions and loss of joint space can be seen. Periostitis can be seen, new bone formation, Spurs at the insertion of plantar fascia Sacroiliitis is asymmetric Syndesmophytes are coarse and nonmarginal and asymmetric ReA Prognosis- Do I need to treat indefinitely? Most have self-limited course of 3-12 months. However, some have minor residual symptoms beyond 12 months Relapses occur in up to 15% of cases Chronic cases occur in another 15% -20% of cases PSORIATIC ARTHRITIS  Psoriatic Inflammatory arthritis associated with arthritis (PsA) psoriasis Affects women and men equally Incidence of approximately 6 per 100,000 Prevalence of about 100 per 100,000 The prevalence among those with psoriasis is 5-30 per 100 patients PsA – Does joint pain and psoriasis constitute PsA? The presence of an inflammatory arthritis in a patient with psoriasis makes the diagnosis likely. Not all patients with psoriasis and arthritis have psoriatic arthritis Patients with psoriasis may have coexistent rheumatoid arthritis, osteoarthritis, arthritis of inflammatory bowel disease, and gout PsA Clinical Presentation- What two types of arthritis can involve the DIPs? Morning stiffness lasting more than 30 min Stiffness is accentuated with immobility, and is alleviated by physical activity Less tender DIP’s & spine can be affected.  Why isn’t this RA with a rash? It is seronegative (rheumatoid factor negative) Often involves the DIP’s PsA can involve the spine and sacroiliac joints Distinctive radiographic findings  Patterns of PsA Asymmetric oligoarthritis 30% Symmetric polyarthritis 40% Arthritis mutilans