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27 Cards in this Set

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What does ankylosis mean? What does spondylo- refer to?

What is entheses?
Ankylosis= bony fusion. Spondylo- refers to the spine

Entheses= point where tendon, ligaments, or muscle attach to bone (includes bone, fibrocartilage, etc.)
Common features of Spondyloarthropathies-

Age of onset? Gender predominance?
Pattern?
Associated conditions?
Age= young
Male predominance (M>F)
*In women, diagnosis may be delayed. Tend to have less severe involvement.

Reactive pattern

Asymmetric peripheral arthritis
Enthesopathy
Ankylosis
What are common laboratory features of patients with Spondyloarthropathies?
- Seronegative (no RF or ANA)
- moderate ESR and CRP elevation
- association with HLA-B27
What is the pathology of ankylosis in patients who have these spondyloarthopathies?
Inflammation > fibrosis > scarring > bony fusion
----------------
1. Low grade inflammation in joints at the entheses
2. Inflammation --> fibroblast and collagen proliferation
3. fibrotic scars result becoming calcified/ossified
4. bony bridges --> ankylosis
What is shown on the right?
What is shown on the right?
Enthesitis of the achilles tendon (severe inflammation). Involves the fibrocartilage, tendon, bone, etc.
What do you notice at the top of this disk? Describe the steps of this process.
What do you notice at the top of this disk? Describe the steps of this process.
Ankylosis process occurring at top of disk.

1) inflammation
2) fibrosis
3) scarring
4) bony fusion

*note: this is a growth within the ligament of the spine, i.e. a syndesmophyte
There is a genetic association between _____ and ankylosing spondylitis.
Associated with HLA-B27

*studies also show that there must be some microbial/antigen exposure for condition to arise. NOTE: ~10% of the population is normal and has HLA-B27
In what scenario would you test a patient with A.S (ankylosing spondylitis) for the HLA-B27 mutation?
Consider ordering test if they have a positive family history. Otherwise, A.S. in those with HLA-B27 is not that common (~2%).
What does this individual have? What is the sine qua non for diagnosing this condition?

What else might this person have?
What does this individual have? What is the sine qua non for diagnosing this condition?

What else might this person have?
Ankylosing spondylitis (prototypic hunched position)

Sacroiliac inflammation = seals the deal.

This person likely has peripheral arthritis as well. Extra-articular manifestations: uveitis, aortic problems, chest wall restriction (from costovertebral arthritis)
What condition might this person have if you are told that they have been having burning upon urination and pain in their left knee upon exercise?

How is it triggered?
What condition might this person have if you are told that they have been having burning upon urination and pain in their left knee upon exercise?

How is it triggered?
Reactive Arthritis or Reiter's syndrome 

Trigger is typically diarrhea or GU (4 wks prior). Can cause classic quadrad: conjunctivitis, iritis, urethritis, and arthritis (i.e. "can't see, can't pee, can't climb up a tree")
Reactive Arthritis or Reiter's syndrome

Trigger is typically diarrhea or GU (4 wks prior). Can cause classic quadrad: conjunctivitis, iritis, urethritis, and arthritis (i.e. "can't see, can't pee, can't climb up a tree")
This characteristic skin lesion is found in relation to what condition?

What agents might initiate this condition?
This characteristic skin lesion is found in relation to what condition?

What agents might initiate this condition?
Keratoderma blennorrhagica (skin lesion of Reactive arthritis)

- Enterics (Shigella, Yersinia, etc.)
- GU infection (Chlamydia, Neisseria)
- HIV infection
A patient comes in with arthritis of righ lower knee which is extremely painful. Years of work up has revealed nothing but recently she had bad GI episodes and was diagnosed with Crohn's disease. Does this change your diagnosis?

What is her genetic profile like?
Yes--> Enteropathic (colitic) Arthritis (asymmetric migratory oligoarthritis of lower extremities)

Can be presenting feature of colitis! NO HLA association (she would be negative for HLA-B27)
Spondylitis that results from Enteropathic arthritis differs from the Peripheral arthritis in what major way?

What will the genetic profile of people with spondylitis in the setting of Enteropathic arthritis be?
Spondylitis--> HLA-B27+. In addition, course of spondylitis is NOT related to colitis (i.e. unlike peripheral arthritis variant, curing the colitis typically DOES NOT CURE the colitis).

*thought to be related to molecular mimickry
What is Psoriatic Spondylitis? Is it related to the gene mutation seen in other Spondyloarthropathies?
Spondylitis seen with Psoriasis and HLA-B27 Positive
What symptoms might a person with Spondyloarthropathy present with?

What test would you want to conduct?
Sxs: insidious onset of back pain before 40
- morning stiffness
- daily back pain, lower back especially
- improves with exercise

Look for SI tenderness, Shober test, and reduced chest expansion (VC and RV decreased)
What is the Shober test?
What is the Shober test?
Test for spondyloarthropathy. Make 2 marks 10cm apart on lower back (at iliac crest). Have patient flex (touch toes). If this distance remains the same- could have spondylitis.

*normally, distance should increase with flexion
What lab values would you expect in patients with SpA?

What about on MR imaging?
- mild anemia
- RF and ANA is negative (SERONEGATIVE)
- ESR is normal, CRP is elevated (typically not severely elevated). 

Sacroilitis is seen. (sclerosis on both sides of SI joint) 

M
- mild anemia
- RF and ANA is negative (SERONEGATIVE)
- ESR is normal, CRP is elevated (typically not severely elevated).

Sacroilitis is seen. (sclerosis on both sides of SI joint)

M
What radiologic sign is seen here that is associated with Ankylosing spondylitis? 

What other radiographic signs (seen on the vertebrae) are associated with this condition?
What radiologic sign is seen here that is associated with Ankylosing spondylitis?

What other radiographic signs (seen on the vertebrae) are associated with this condition?
Radiologic sign- Bamboo spine (also square appearing vertebral bodies).

Others= Dagger sign (fusion of vertebral spines) and Trolley-Track sign (spinous process fuse with facet joint)
Radiologic sign- Bamboo spine (also square appearing vertebral bodies).

Others= Dagger sign (fusion of vertebral spines) and Trolley-Track sign (spinous process fuse with facet joint)
What did treatment of AS involve (in the pre-biologic era)?
- Patient education
- Stretching exercise (EXTENSION)
- NSAIDs (indomethacin- potent prostaglandin inhibitor)
- Methotrexate
- Patient education
- Stretching exercise (EXTENSION)
- NSAIDs (indomethacin- potent prostaglandin inhibitor)
- Methotrexate
Compare and contrast the following three therapies:

- Infliximab
- Etanercept
- Adalimumab
ALL are Anti-TNF therapy (biologics)

1. Infliximab: monoclonal antibody against TNFa (given IV)
2. Etanercept: protein that binds soluble TNF (self SC injection)
3. Adalimumab (Humira): human monoclonal antibody against TNF (injection every other week)
What is Psoriatic Arthritis and how does it differ from Psoriatic Spondylitis?
Psoriatic Arthritis: Arthritis precedes skin disease, correlates with presence of NAIL changes. No RF, nodules, or extra-articular manifestations. NOT HLA-B27 related. 

Psoriatic Spondylitis: HLA-B27+, similar to AS
Psoriatic Arthritis: Arthritis precedes skin disease, correlates with presence of NAIL changes. No RF, nodules, or extra-articular manifestations. NOT HLA-B27 related.

Psoriatic Spondylitis: HLA-B27+, similar to AS
What is the pattern of psoriatic arthritis seen in this man (who has arthritis of the lower knees)?
What is the pattern of psoriatic arthritis seen in this man (who has arthritis of the lower knees)?
Oligoarthritis (<4 joints involved). MOST COMMON!!
What is the pattern of psoriatic arthritis seen in this person?
What is the pattern of psoriatic arthritis seen in this person?
Psoriatic dactylitis (cocktail sausage look to toe)
What pattern of Psoriatic Arthritis?
What pattern of Psoriatic Arthritis?
Arthritis mutilans (destructive form)
What do you see here? What does it suggest?
What do you see here? What does it suggest?
Nail pits (if >15 likely to have Psoriatric Arthritis)
What three nail conditions are seen here?
What three nail conditions are seen here?
Onycholysis
Oil staining
Ridging and Pitting

*Nail changes- think PSORIATIC ARTHRITIS
How does the course of Psoriatic arthritis differ from Psoriatic spondylitis?
Peripheral arthritis- related to cutaneous activity
Spinal arthritis- unrelated to cutaneous activity

Better prognosis than RA