Scribed for Hire: J. Morgan

March 12 (Mon.)

ICM 8am

Dr. Ratnoff

Rose / Eckerman

I031208.doc

Scribed for hire: J. Morgan

Seronegative Spondyloarthropathies - 1

Arthritis II

Note: I apologize for the timing of this scribe, but thanks to those who still want to hire me when I am out of town! Also, to get these out ASAP, I have made them a little more “outline-ish.”

General Information

1. HLA-B27 is normally positive in a lot of the population (it is just overly elevated in the above diseases), so cannot use this as a diagnostic test. Must use in addition to other disease characteristics. (reasoning: if brown eyes are assoc. with RA, we don’t Dx RA b/c they have brown eyes).

Seronegative Spondyloarthropathies

-Spondylo = involves the spine (usually sacroiliac joint); Arthropathy = peripheral neuropathy (that’s what he said)

I.Non-vertebral Sx

1.Peripheral Arthritis

a.usually asymmetric

b.Large joints like shoulders, elbows, hips, knees, ankles.

c.IP joints of the toes (different than OA)

1)“sausage digit” = entire digit is swollen like a sausage.

2)inflammation is in a ray pattern (like the rays of a sun – the sun being your palm and the rays are the fingers) - 1+ joints involved/digit

2.Enthesopathy = tendonitis at insertion of bone.

a.Achilles’ Tenosynovitis

b.Plantar Fasciitis

3.Non-arthritic manifestations

a.Costochondritis

4.May be mucocutaneous lesions (depends on syndrome)

5.Iritis / Uveitis (inflammation of anterior chamber of eye) = Hallmark of these diseases (esp. in Ankylosing Spondylitis and Reiter’s)

II.Ankylosing Spondylitis (prototypic Seronegative Spondyloarthropathy)

A.Clinically

1.Onset almost always before 40, usually by age 20. (like gouty arthritis)

a.Insidious (Gout has an abrupt onset)

2.Duration of Sx must be > 3 mos

3.Associated w/ morning stiffness/pain

a.May involve the spine and decreases (stiffness and pain) with exercise (in contrast with other causes of back pain where exercise worsens the pain.)

b.Not relieved by rest.

4.Reduced chest wall expansion (check with tape measure; NL = 5 cm)

5.Uni/Bilateral Sacroiliitis

a.subchondral bone resorption and irregularity = “Rosary Bead” appearance

-apparent pseudo-widening with increased sclerosis

6.Iritis / Uveitis

a.adhesions b/t iris and lens

B.Dx (must have these 3 criteria)

1.Limited lumbar motion

a.tested by the “Shover Index” (?). Take tape measure and arrange to measure expansion of lumbar spine.

b.Lumbar back pain that goes away with exercise.

2.Uni/Bilateral Sacroiliitis = classic for Ankylosing Spondylitis (but can be found in other HLA-B27 arthropathies)

a.X-Ray

-fusion of sacroiliac joints (can’t bend spine)

-“bamboo” spine - b/c of fusion, looks like bamboo

-spurs snuggly follow the contours of the discs (vs. 90º spurs of OA)

-inflammation is generally the cause of sclerosis of the joint

3.Reduced chest wall expansion

C.Slides

1.Frontal view: Flexion deformity of the neck causes pt to presents with an upward gaze of their eyes when looking straight ahead.

2.Lateral view: Shows the forward protrusion of the head, flattening of the anterior chest wall, thoracic kyphosis, protrusion of the abdomen, and flattening of the lumbar lordotic curvature. Slight flexion at the hips is also present.

3.Photographic series of the progression of Ankylosing Spondylitis showing over a 26-year period. At the end of the series, a bilateral hip arthroplasty was performed to relieve some of the difficulties of the disease.

D.Complications include swallowing and problems with the lungs and heart.

III.Psoriatic Arthritis

A.Clinically

1.Inflammatory Arthritic Changes

a.DIP joints involved (MIP, PIP sometimes also)

-vs. DIP not involved in RA, but involved in OA (Heberden’s Node)

-Characteristic “ray” pattern of involvement (all 3 joints)

-Inflammation of DIP contributes to “Sausage Digits”

b.Usually asymmetric (vs. RA which is usually symmetric)

2.Non-arthritic manifestations include psoriatic nail and skin changes.

a.Pitting of nails (important)

b.Onycholysis

c.Accumulation of sub-ungual keratotic material

d.Peri-ungual scaly lesions

3.Erosive arthritis occurs w/o periarticular osteopenia (vs. RA)

4.Asymptomatic Sacroiliitis (X-ray anyway to support Dx)

5.Paravertebral Ossification

6.Enthesopathy

7.So, 5 clinical patterns of Arthritis in Psoriasis

a.Spondylitis

b.DIP arthritis

c.Oligoarticular asymmetrical arthritis

d.Polyarticular symmetrical arthritis (mimics RA)

e.Arthritis Mutilans (deformity of the hands)

1)With or with out Telescoping Digits.

2)Both Arthritis Mutilans and Telescoping Digits are also seen in Severe Gouty Arthritis and sometimes RA

8.May or may not have or develop psoriasis.

9.RF test = negative

IV.Reiter’s Syndrome

A.Seronegative asymmetric arthritis following:

1.Urethritis (men) or Cervicitis (women)

2.Infectious diarrhea

B.Often associated with:

1.Inflammatory eye disease (uveitis or iritis)

2.Balanitis (inflammation of the skin of penis), oral ulceration, or keratodermia

a.Keratoderma on the sole of the foot - you may see grouped vesicles or pustules

-or can have scaly plaques (resemble 2º syphilis or psoriasis)

-or can have both

b.Balanitis – erythematous, painless, moist, well circumscribed lesion (early)

-or dry in late Reiter’s

c.Tongue erosion is asymptomatic

-can be palatal (most common oral manifestation of Reiter’s – also seen in Lupus)

3.Enthesopathy

a. Calcaneal Tendonitis especially

4.Sacroiliitis

5.Hallmark = Iritis / Uveitis

C.Other clinical stuff

1.Nail changes

a.Onycholysis

b.Accumulation of sub-ungual keratotic material

c.Peri-ungual scaly lesions

From here it got he jumped around a little.

V.To exam the lower extremities, get them to take their pants off (and wear a gown).

VI.Inflammatory Bowel Associated Arthropathies

A.Crohn’s or Ulcerative Colitis with low back pain, think Seronegative Spondyloarthritis.

VII.Treatment

A.Usually independent of any associated skin problem

B.Methotrexate is good for Psoriatic arthritis and skin disease.

C.Avoid Prednisone for Psoriatic arthritis.

VIII.Reactive Arthritis

A.Same clinical features of Reiter’s

B.More of an immunologic reaction that lasts long after the infection is gone. After the initial infectious stimulant, an immunologic reaction leads to the onset of the arthritis.

…Wisdom has built her house, she has hewn out her seven pillars; she has prepared her food, she has mixed her wine; she has also set her table; she has sent out her maidens, she calls from the tops of the heights of the city: “Whoever is naive, let him turn in here!” To him who lacks understanding she says, “Come, eat of my food and drink of the wine I have mixed. Forsake your folly and live, and proceed in the way of understanding.” He who corrects a scoffer gets dishonor for himself, and he who reproves a wicked man gets insults for himself. Do not reprove a scoffer, or he will hate you, reprove a wise man and he will love you. Give instruction to a wise man and he will be still wiser, teach a righteous man and he will increase his learning.

Seronegative Spondyloarthropathies - 1