spondyloarthropathy (HLA B27-associated arthritis, seronegative spondyloarthropathy)
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Introduction
A group of disorders that shares clinical features & an association the HLA B-27 allele.
Classification
These disorders include:
- ankylosing spondylitis
- reactive arthritis
- psoriatic arthritis & spondylitis
- enteropathic arthritis & spondylitis (inflammatory bowel disease)
- juvenile-onset spondyloarthropathy
Etiology
- reactive arthritis after gastroenteritis
- psoriatic arthritis, generally after 10 years of psoriasis
Epidemiology
- onset generally < 40 years of age
Genetics
History
- favorable response to NSAIDs
- family history of spondyloarthropathy
- family history of psoriasis
- diagnosis of psoriasis, inflammatory bowel disease, iritis, uveitis, or conjunctivitis
- symptoms of psoriasis, inflammatory bowel disease, iritis, uveitis, or conjunctivitis
- preceding infection
- urethritis
Physical examination
- spine &/or sacroiliac joint tenderness
- limited range of motion of the spine
- tenderness &/or swelling of joints
- dactylitis
- enthesitis, especially Achilles tendonitis & enthesitis
- rash or nail changes of psoriasis
- ocular inflammation (iritis, uveitis, conjunctivitis)
Clinical manifestations
- sacroiliitis
- spondylitis
- ectopic calcification, tendonitis, enthesopathy (enthesitis)[2]
- sausage digit
- predominantly lower extremity arthropathy
- asymmetric peripheral arthritis with tenosynovitis (large joints) (< 5)
- joint effusion
- extra-articular inflammation
- uveitis, iritis (commonly associated)
- inflammation of skin & mucosal surfaces is common
- inflammatory bowel disease
- inflammatory disease of the lung (ankylosing spondylitis)
- genitourinary inflammation (especially reactive arthritis)
- vasculitis, aortitis (rare)
- psoriasis
- insidious onset
- improvement with exercise
- no improvement with rest
- pain at night with improvement upon getting out of bed
Laboratory
- erythrocyte sedimentation rate & serum C-reactive protein may be elevated
- HLA B27 testing often positive (does not independently confirm or exclude)
- rheumatoid factor is negative
- anti-cyclic citrullinated peptide Ab is negative
- HIV testing in patients with reactive arthritis or psoriatic arthritis
Radiology
- conventional radiography generally adequate
- radiography of entire spine[2]
- can show axial erosions, new bone formation
- anteroposterior radiograph of the pelvis
- provides view of sacroiliac joints & hips
- identifies sacroiliitis
- radiography of entire spine[2]
- radiography of symptomatic peripheral joints for erosions & new bone formation suggestive of inflammatory arthritis &/or enthesitis
- CT of spine reserved for identifying occult fracture &/or erosions not seen on conventional radiography
- MRI is the most sensitive method for detecting early inflammatory changes in the sacroiliac joints (sacroiliitis) & in the spine (spondylitis)
- consider MRI only if plain radiographs negative & index of suspicion for spondyloarthropathy is high[2]
Management
- exercise to preserve strength & range of motion
- glucocorticoid joint injections for symptomatic relief
- NSAIDs reduce symptoms but do not affect disease course
- 1st line treatment of spondyloarthropathy
- immunosuppressive agents & DMARDs
- reduces inflammation
- prevents joint damage & functional loss[2]
- no role in management of axial manifestations[2]
- not useful for ankylosing spondylitis[2]
- TNF-alpha inhibitors are effective for axial skeletal disease
- see specific sponyloarthropathy
More general terms
More specific terms
- ankylosing spondylitis, axial spondyloarthritis; Marie Strumpell disease; Bechterew's disease (AS)
- enteropathic arthritis; inflammatory bowel-associated arthritis
- psoriatic arthritis
- reactive arthritis
Additional terms
- anterior uveitis (iritis, iridocyclitis)
- enthesopathy (enthesitis)
- inflammatory bowel disease
- sacroiliitis
- spondylitis
References
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1904
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Medical Knowledge Self Assessment Program (MKSAP) 11,15,16,17,18. American College of Physicians, Philadelphia 1998,2009, 2012, 2015, 2018.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Weiner S, In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ Rudwaleit M, van der Heijde D, Landewe R et al The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis. 2009 Jun;68(6):777-83 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19297344
- ↑ Maksymowych WP. Progress in spondylarthritis. Spondyloarthritis: lessons from imaging. Arthritis Res Ther. 2009;11(3):222 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19519927
- ↑ Sieper J. Developments in the scientific and clinical understanding of the spondyloarthritides. Arthritis Res Ther. 2009;11(1):208. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19232062
- ↑ van Tubergen AM, Landewe RB. Tools for monitoring spondyloarthritis in clinical practice. Nat Rev Rheumatol. 2009 Nov;5(11):608-15 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19806152
- ↑ Rudwaleit M, van der Heijde D, Landewe R et al The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011 Jan;70(1):25-31 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21109520
- ↑ Poddubnyy D, van der Heijde D. Therapeutic controversies in spondyloarthritis: nonsteroidal anti-inflammatory drugs. Rheum Dis Clin North Am. 2012 Aug;38(3):601-11 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23083758
- ↑ Stolwijk C, Boonen A, van Tubergen A, Reveille JD. Epidemiology of spondyloarthritis. Rheum Dis Clin North Am. 2012 Aug;38(3):441-76. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23083748
- ↑ Akdeniz O, Alayli G, Tosun FC et al Early spondyloarthropathy: scintigraphic, biological, and clinical findings in MRI-positive patients. Clin Rheumatol. 2008 Apr;27(4):469-74. Epub 2007 Sep 15 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17874171
- ↑ Sieper J, Poddubnyy D. Axial spondyloarthritis. Lancet. 2017 Jul 1;390(10089):73-84. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28110981
- ↑ Ehrenfeld M. Spondyloarthropathies. Best Pract Res Clin Rheumatol. 2012 Feb;26(1):135-45. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22424199